Urinary tract

Radiological department of the first affiliated hospital, ZZU

Zhang YongGao
 Methods of examination
（ 1）
Plain film:

Intravenous urography or intravenous

pyelography(IVUorIVP)

Retrograde pyelography
Methods of examination
（ 2）

Cystography

Urethrography

Angiography

CT ,MRI and Ultrasonography

Intravenous urography or
intravenous pyelography
(IVU or IVP)
Dose
Type
After rapid intravenous
administration, radiographs of the
kidneys at 1,5,7,15,25 minutes are
obtained.
IVU will demonstrate most lesions
affecting the normal anatomy of the
pyelocalycal system. It can also give
some information of excretory function
of the kidney.
Normal X-ray Anatomy

Kidney

Ureters

Bladder

Urethra
 Kidney

Renal outline

Size of kidneys

Position of the kidneys

 Basic X-ray findings in
diseases of urinary tract
Change in density:

The normal kidney is homogeneous in

density. Increase of density might be
due to calcification as seen in renal
stone, TB of kidney and
nephrocalcinosis.
Renal stone
 Change in size, contour
and position of the kidney
Decrease in size of one kidney might
be due to hypoplasia, pyelonephritis
and renal ischemia.
Increase in size of one kidney might
be due to unilateral hydronephrosis,
tumor growth or renal cyst.
Change of position of the kidney

might be due to pressure of adjacent

tumor growth or ectopic kidney

Destruction, filling defect
and displacement

TB
Tumor
Pyelonephritis
Varieties of calculus

Calcium oxalate calculi

Phosphatic calculi
Urate calculi
Calcium carbonate calculi
Uric acid calculi
 Radiologic features

When you are going to make a

diagnosis of renal stone, the
following questions should be
considered:
If a shadow is present, is it intra or
extrarenal?
If it is intrarenal, is it due to a
calculus?
If no shadow is evident, is an
invisible calculus present?
THE EVIDENCE IS------
 Intrinsic characters

There are certain characteristics which

if present indicate a shadow to be cast
by a renal calculus. Some of these,
such as coral or staghorn shape, are
pathognomonic;
Site of the opacity--- within the renal shadow

The shape of the opacity--- mulberry ,round

The texture of the opacity--- homogeneous ,

laminated, stippling
 The second diagnostic
question

How do you work out that an

intrarenal opacity is due to calculus?

If the plain film fails to give any idea,

either intravenous or retrograde

urography will settle the problem.

 The third diagnostic
question
This unusual cases where a transparent
stone causes a negative shadow. Even then
it may be impossible to differentiate it from a
neoplastic filling defect. However, invisible
stone causing obstruction of ureter may
show hold-up or hold-down of the contrast
medium. This is a reliable sign.
Ureteric calculus

In the main, ureteric stone are formed in

the kidney. Therefore the varieties found

are similar to those found in the kidney,

with the limitation in size imposed by the

lumen or ureter.
 Intrinsic character of
ureteric calculi

Ureteric calculi, if recently descended

from the kidney, may be round, oval , or
angular, and the surface may be
smooth. Lamination is occasionally
visible.
If the calculus has been impacted for some

time in the ureter, it tends to become more

oval or considerably elongated in shape.

The long axis of the stone is always along

that of the ureter.

Coralliform
 Bladder stone
Etiology: the formation of bladder stone
may be primary or secondary.
True primary bladder stone may either
arise in aseptic or infected urine, by
deposition of salts on a nucleus, which may
be renal calculus, blood clot or foreign
body.
Infection an stagnation of the urine are
important causative factors.
Secondary calculi are merely calculi

which have passed down from the

kidney.
Tuberculosis of urinary tract

Renal tuberculosis more commonly arises

from the lungs.

Tuberculous ureteritis and cystitis are almost

always secondary to renal TB.
The initial focus of TB in the kidney is in

the region of the corticomedullary junction;

Several foci in the kidney sometimes can

be seen.
The initial lesion may be contain and go on to heal,
with no evidence of renal TB.

On the other hand, an initial TB may enlarge and

rupture into a nephron, producing TB bacilluria
without a radiographic lesion; or the tubercle may
enlarge, with destruction of parenchyma and
formation of a caseous mass(a tuberculoma), with
displacement of the calyces but not
communication with the pelvicalyceal system.
The enlarging initial tubercles may also form a
tuberculous abscess that ruptures into a
calyx, with destruction of the calyx and
formation of an open draining, active
tuberculous cavity.

Parenchymal calcification occurs in long-

standing renal TB, although only in about 20
percent of all patients.
Radiological
feature
Plain film

pyelography
 Plain film

Lobular opacities, sometimes described as

cumulus clouds, are found in caseo-cavenous
tuberculosis. They may replace the whole
kidney and ureter, this condition is then
known as tuberculous autonephrectomy.
Other form of calcification found in

tuberculosis of kidney are multiple small

deposit which may be streaky and faint

or punctate and well defined. They are

usually limited to one pole of the kidney.

Ulcero-cavernous and pyenephrotic types.

This will cause erosion and mouth-eaten

appearance of one or more calyces. In the

early stage of the disease it may show no

change at all.
Cortical abscess– if the cavity is empty or

partially empty the contrast medium may

collect within and produce a rounded

shadow lying in the cortical zone. The wall

is slightly irregular. It may communicate

with calyx.
 Non-functioning kidney.

Non-function of one
kidney might be
due to TB or
tumor growth.
Involvement of ureter may show

rigidity of ureter and irregular

outline.
With the development of tuberculous

cystitis, the bladder may contract and

become very small with irregular margins

due to ulceration and trabeculation.

The left kidney TB
Cyst and neoplasm of the
urinary tract

The cysts of the kidney may be classified

as:
Simple cyst.
Polycystic disease
hydatic cyst
Calyceal cyst
Cyst and neoplasm of the
urinary tract

The cysts of the kidney may be classified

as:
Simple cyst.
Polycystic disease
hydatic cyst
Calyceal cyst
Renal neoplasm may be
classified as:

Arising in renal parenchyma.

Arising in renal pelvis.
Arising in adrenals.
Arising in perirenal tissue.
Arising in prerenal tissue.
Radiological features

Plain film:
Deformity of renal outline
Enlargement of the renal outline
Displacement of adjacent viscera.
calcification.
 IVU signs of tumor growth may be
enumerated as follows
Obliteration, partial or complete, of calyces and
pelvis.
Elongation of calyces, with compression or
dilatation (so called “spider leg” deformity)
Displacement of calyces.
Encroachment on the renal pelvis.
Displacement of the renal pelvis and upper port
of the ureter.
Non-functioning kidney.
 Neoplasm of the renal
pelvis:

Comprising papilloma and papillo-

carcinoma are found in 15% of renal

neoplasm
Filling defect in pyelography.

May induce hydronephrosis depending

upon the amount of obstruction at the

pelvis-ureteric junction
When, in carcinoma of the renal pelvis, the
obstructive hydronephrosis becomes very
marked, it may be impossible to show the tumor
either by the intravenous or retrograde
pyelography, because in the former case the
contrast medium is not concentrated adequately
to demonstrate and in the latter the contrast
medium can not be injected into the pelvis.
 CT of kidney
Technique:

Patients are routinely given oral contrast

agent 30 to 60 min prior to the examination in
order to opacify all bowel segments.

The examination begins with the identification

of the renal margin on a preliminary digital
scout radiography of the abdomen.
Scanning with slice thickness of 8-10mm

in an adjacent slice sequence.

Every CT examination of the kidney

should include contrast-enhanced images

Disease of the kidney

Calculus of urinary tract

Solitary benign renal cysts

Renal cell carcinoma

Calculus of urinary tract

CT is a exquisite tool for the

detection of urinary calculus.

Urinary calculi are identified as high density
objects with the calcium-containing showing the
highest CT numbers (over 100HU). In order to
accurately exclude calculi, the area of
interesting should be carefully scanned with
helical CT or overlapping sections before the
administration of contrast material that might
easily obscure these high density objects.
Disease of the kidney

Calculus of urinary tract

Solitary benign renal cysts

Renal cell carcinoma

Solitary benign renal cysts
Benign renal cysts fulfill the following criteria:

Smooth border

Thin walls that are not recognized.

Density of the cystic contents near that of water

with attenuation coefficient no greater than 15HU

Absence of contrast enhancement

Disease of the kidney

Calculus of urinary tract

Solitary benign renal cysts

Renal cell carcinoma

CT is a superior tool for diagnosing the

presence of solid masses, of which

renal cell carcinoma is not only the most

common but is also the one of most

clinical concern.
Typically, carcinoma presents as a solid mass with
irregular infiltrating margins and with attenuation
coefficients similar of less than unenhanced renal
parenchyma (30 to 60 HU). A consistent feature of
these tumors however, is the presence of necrotic
or hemorrhagic areas within the tumor, which cause
considerable inhomogeneous density. Areas of
necrosis and hemorrhage produce lower CT values
(15 to 45 HU) than normal renal parenchyma,
although fresh hemorrhage may have higher CT
values (60 to 79 HU)
Calcification may also be present within

the mass.
 Bladder carcinoma
Bladder carcinoma is the most frequent
malignancy of the urinary tract.
Most patients range in age from 50 to 70
years.
Gross hematuria and bladder irritability, with
urinary frequency and dysuria, are the most
common signs and symptoms.
The tumor metastasizes either by a

lymphatic route to regional lymph nodes

or by a hematogenous route to liver,

lung, and bone.