Questions in urologic radiology for

medical students

1.Role of Radiologist as specialist and consultant in

urologic pathology
2.What problems could require imaging of the urinary
tract
3.Contrast media used in the investigation of the urinary
system
4.Imaging methods used in the investigation of the
urinary system
5.General principles of ultrasound including doppler flow
6.General principles of X-ray plain films
7.Differences, utility and use of CT versus MRI
8.General principles of angiography
including
blockage
of urine
abdominal mass
indications, utility
blood in the urine
9.General principles of nuclear medicine
kidney failure
10.Radiodiagnostics of urinary system diseases:

What problems could require imaging

of
the urinary tract?
Imaging can help the doctor find the cause of:
1.urinary retentionthe inability to empty the bladder completely
2.urinary frequencyurination eight or more times a day
3.urinary urgencythe inability to delay urination
4.urinary incontinencethe accidental loss of urine
5.blockage of urine
6.abdominal mass
7.pain in the groin or lower back
8.blood in the urine
9.high blood pressure
10.kidney failure

Dysuria
refers to painful urination
Difficult urination is also sometimes
described as dysuria
It is one of a constellation of irritative
bladder symptoms, which includes
urinary frequency and haematuria

 This is typically described to be a

burning or stinging sensation. It is
most often a result of
1.urinary tract infection
2. STD
3. bladder stones
4. bladder tumours
5. prostate disorders
6. anticholinergic drugs

 Incontinence:
is any involuntary leakage of urine.
Common etiology are:
1.Polyuria
2.Prostate disorders (BPH and cancers)
3.Caffeine and Cola
4.Brain disorders (MS, spinal cord
injuries, Parkinson disease, stroke)

Abnormalities of Urine
Volume
Oliguria:
is the low output of urine, It is clinically
classified as an output below 400
ml/day
The decreased output of urine may be
a sign of dehydration, renal failure,
hypovolemic shock, multiple organ
dysfunction syndrome, or urinary
obstruction/urinary retention.

 Anuria:
absence of urine, clinically classified
as below 100ml/day
Anuria can be caused by
1. total urinary tract obstruction
2. total renal artery or vein occlusion
3.Shock
4.Cortical necrosis
5. severe ATN
6.Rapidly progressive
glomerulonephritis

 Polyuria:
urine>3 L/d
Polyuria results from two potential
mechanisms:
1. nonabsorbable solutes diuresis
2. water diuresis (DI)
If the urine volume is >3 L/d and
urine osmolality is >300 mosmol/L,
then a solute diuresis is clearly
present and a search for the
responsible solute(s) is mandatory

METHODS OF INVESTIGATION
ULTRASONOGRAPHY
RADIOLOGY
Simple abdominal X-ray
Intravenous urography
Retrograde/anterograde
pieloureterography
Cystography
Renal angiography
Uretrography

NUCLEAR MEDICINE
Static studies: static renal scintigraphy
Dynamic studies: renogram

CT
MRI

Plain Film of the Abdomen

The kidneys-ureters-bladder is often
the first imaging study performed to
visualize the abdomen and urinary tract
The film is taken with the patient supine
and should include the entire abdomen
from the base of the sternum to the pubic
symphisis
Can show bony abnormalities, calcification
and large soft tissue masses

Urography
Involves
instillation
of
contrast
material to better visualize the
collecting or lumenal structures of the
kidneys, ureters, bladder, and urethra
This can be done after IV injection or
direct instillation into the urinary tract
1)
2)
3)
4)

Intravenous urography
Cystography
Voiding cystourethroography
Retrograde urethrography

Intravenous Urography
IVU/ intravenous pyelogram is the
classic modality of imaging the entire
urethelial tract from pyelocalyceal
system trhough the ureters and bladder
Excellent for indentifying small urethelial
lesions as well as the severity of
obstruction from calculi
Provides anatomical and qualitative
functional information about the kidneys

Ectopic kidney

Tumors

Cystography
Permits imaging of an opacified urinary
bladder after retrograde instillation of
contrast media through a urethral or
suprapubic catheter
Imaging is performed to demonstrate a
suspected urine leak, either from traumatic
bladder rupture or after bladder surgery
Can also demonstrate a presence of a
fistula between the bladder and vagina or
to characterize bladder diverticuli

Tumors

Tumor

Voiding Cystourethrography
Can be used to evaluate for abnormal
anatomy and function of the lower
urinary tract in both children and adults
Similar to the cystogram, instillation of
contrast media into the bladder through a
urethral cahteter is also employed
After full distention of the bladder, the
patient is instructed to void either after
removing the catheter or around the
catheter

Retrograde Urethrography
Complete evaluation of the urethra
includes both antegrade and
retrograde urethrography
Allows visualization of the anterior male
urethra
Used for evaluating a suspected traumatic
urethral injury or urethral stricture
Can also be useful for diagnosis of a
urethral diverticulum in females

Normal RUG

Retrograde urethrogram

20mm stricture in the bulbous urethra.

Duplicated urethra

Urethrogram
confirmsduplicated
urethra.

ULTRASONOGRAPHY

ULTRASONOGRAPHY

ULTRASONOGRAPHY

ULTRASONOGRAPHY

RENAL ABSCESS

Doppler US

Doppler US

left image : hydronephrosis at

the LK
rigth image :lower ureteric
calculi

same patient has

prostate hypertrophy.

Testicular torsion

Presentation:
15 year old boy with acute left testicular pain.

Case Discussion:
US testes was performed which demonstrate the left testicle assuming an abnormal
orientation and lack normal color and power Doppler flow with maintained testicular
normal echogenicity, consistent with acutetesticular torsion. The right testicle is
within normal.

CT Scan
often
used
examine
structures in the abdomen
and pelvis (reproductive
organs, liver, pancreas,
gallbladder, spleen and
intestines). CAT Scans are a
diagnostic
tool
that
urologists use to detect and
diagnose: recurrent urinary
tract infections, sources of
blood
in
the
urine
(hematuria), kidney stones,
renal cysts and masses.
Moreover, it can help
urologists rule out prostate,
bladder and renal cancers

CT

No Contrast

CT

Contrast

Benign prostatic hypertrophy

Axial image, CT showing left ureteral

stone.

Urinary bladder diverticulum

Ectopic kidney

Ectopic kidney

Ectopic kidney

Ectopic kidney

Ectopic kidney

Renal hypoplasia

Cazul 2

Hipoplazia
renala
Renal
hypoplasia

Cazul 2

CT

Trauma

CT

Tumor

CT

Tumor

Hypervascular
process left
kidney

Hypervascular
process left
kidney

Hypervascular
process left
kidney

Hypervascular
process left
kidney

Parapelvical cyst

Bosniak renal cyst classification

The Bosniak classification system for CT evaluation of renal cysts is
helpful in determining both malignant risk and required follow-up and/or
treatment.
Bosniak 1
simple cyst, imperceptible wall, rounded
work up : nil
% malignant : ~ 0%
Bosniak 2
minimally complex, a few thin (< 1mm) septa, thin Ca++;nonenhancing high-attenuation (due to to proteinaceous or haemorrhagic
fluid) renal lesions of less than 3 cm are also included in this category;
these lesions are generally well marginated.
work up : nil
% malignant : ~ 0%
Bosniak 2F
minimally complex but requiring follow up.
increased number of septa, minimally thickened or enhancing septa or
wall
thick Ca++,
hyperdense cyst that is:

Bosniak 3
indeterminate, thick or multiple septations, mural nodule,
hyperdense on CT (see 2F)
treatment / work up : partial nephrectomy or RF ablation in
elderly / poor surgical risk
% malignant : ~ 54%6
Bosniak 4
clearly malignant, solid mass with large cystic or necrotic
component
treatment: partial / total nephrectomy
% malignant : ~100%

Polycystic kidney disease

Multi-Detector Computed Tomography

(MDCT)

Extrarenal
renal cyst
expansion

Extrarenal
renal cyst
expansion

Extrarenal
renal cyst
expansion

MRI
Can be generally used in place of a CT
scan when renal insufficiency or contrast
allergy prohibits the use of CT scan
The process by which the protons realign
themselves with the magnetic field is
referred to as relaxation. The protons
undergo 2 types of relaxation: T1 (or
longitudinal) relaxation and T2 (or
transverse) relaxation

MRI
In T1-weighted images (emphasizing the difference
in T1 relaxation times between different tissues),
water-containing structures are dark. T1-weighted
images do not show good contrast between normal
and abnormal tissues. However, they do
demonstrate excellent anatomic detail.
T2-weighted images emphasize the difference in
T2 relaxation times between different tissues.
Because water is bright in these images, T2weighted images provide excellent contrast
between normal and abnormal tissues, although
with less anatomic detail than T1-weighted images

MRI

Polycystic kidney disease

MRI

renal carcinoma

MR ANGIOGRAPHY

Left renal artery stenosis

Table1

Comparisonofadvantagesanddisadvantagesbetween
computedtomography(CT)
andmagneticresonance(MR)imagingmodalities

CT

MRI

Usesionizingradiation,highdose
procedure

Usesmagneticresonance,noionizingradiation

Excellent spatial resolution

Excellent contrast resolution

Actualscanningtimemeasuredinseconds
Actualscanningtimemeasuredinminutes(typically45min)
(typically<10s)
Rarelyrequiresgeneralanestheticin
children

Frequentlyrequiresgeneralanestheticinchildren,dependingonage

Excellent at showing calcification Pooratshowingcalcification(signalvoid)

Pooratshowingedemaorpathological
changesinspecifictissuetypes

Excellentatshowingedemaandpathologicalchangesinspecifictissue
types

Usuallyrequiresintravenouscontrast
Usuallyrequiresintravenousadministrationofcontrast(butcertain
(unlesslookingforcalcificationwhennot
sequencescanbetailoredifthisiscontraindicated)
required)
Noknownriskofnephrogenicsystemic
fibrosis(NSF)

RiskofNSF(rare,butrenalpatientsbelievedtobeatincreasedrisk)

Less expensive

Expensive

Usuallyavailableasanemergency
imagingtechnique

Notroutinelyavailableasanemergencytechnique

No significant contraindications

Contraindicatedinpatientswithanyinternalferrousobjects(pacemakers,
defibrillators,recentorthopedicmetalware,otherimplantedmetallic
devices,metallicforeignbodies)

Open-style scanners

Generallyquiteenclosedscannersriskofclaustrophobia

ANGIOGRAPHY

AORTOGRAPHY: LEFT RENAL ARTERY THROMBOSIS

Nuclear Medicine
uses the radiation released by radionuclides
(called nuclear decay) to produce images
A radionuclide, usually technetium-99m, is
combined with different stable, metabolically
active
compounds
to
form
a
radiopharmaceutical that localizes to a
particular anatomic or diseased structure
(target tissue).
tracer goes to the target organ and can then
be imaged with a gamma camera, which takes
pictures of the radiation photons emitted by
the radioactive tracer