radiology in urology

8/7/2019 radiology in urology

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PLAIN ABDOMINAL RADIOGRAPH[KUB]

y

it incorporates entire urinary tract-kidney,ureter,bladder

y Upper limit lies above adrenal gland while inferiorlimit lies just below symphysis pubis

indicationsy Diagnosis of calcium contianing renal tract calculi

y Control film prior to contrast admnistration

y Asses efficacy of stone Rx[eswl]

y Check status and position of ureteric stents andforeign bodies/devices in urinary tract

y It also demonstrate intestinal gas patterns and certainsoft tissue abnormalities


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technique and radiation

y AP full length view in full expiration

y

Bowel preparation improve image quality and yield butis not mandatory

y Effective radiation dose is 1.5msv[equiv.to 9 month ofbackground radiation or 3500 miles traveled by car ]

interpretationappropriate interpretation requires a systemic

approach.

y Firstly, renal tract and its anatomical markings are

scrutinized


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y Other intraabdominal and pelvic organs identified

y Abnormal intestinal gas pattern is usually obviously

apparenty Look for bony abnormality in the spine and bony

pelvis

Renal tract

y Kidneys-renal hilum moves with respiration but tendto lie at L2 lumbar vertebrae .size[11-13cm in adult]shape, and position of both kidney should be observed

y Ureter-ureteric line is traced inferiorly along tip of

transverse process of lumbar vertebrae, over thesacroiliac joint, then lateral within bony pelvis towardsischial spine before turning medially to enter thebladder Note any calcification


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Causesofcalcification-

y Renal tract calculi

y

Calcified lymph nodey Phleboliths

y Calcified costal cartilages

y Renal nephrocalsinosis

y Aortic calcification

y Prostatic calcification

y Adrenal calcification

y

Parenchymal calcificationy Calcified uterine fibroids

y TB of kidney


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Softtissue abnormalities-asses outline and shape, size,displacement of kidney, liver, spleen, bladder. Absence psoasshadow suggest retroperitoneal mass or fluid collection

Abdominal gas patternBonyabnormalities

Advantages

y cheap

y

Non invasivey Small radiation dose

y Information about abdominal organs and intestinalobstruction

drawbacks

y Misses up to 30% of stone.

y Difficult to diagnose b/w calcification within and outsiderenal tract

y Bowel gas and fecal loading can obscure small calcification


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INTRAVENOUS UROGRAPHYINTRAVENOUS UROGRAPHY

y Provides anatomical as well as functional information

y Iodine- containing iv contrast medium is filtered andexcreted by kidneys. Providing opacification of entirerenal tract.

y CT scan is replacing ivu in many urological condition

Indicationsy Investigation and surveillance of urinary stone disease

y Investigation of hematuria[upper tracttumor],obstruction [usg,radionucleotide scan]

y Assessment of anatomical abnormalities and renaltract disease

y Management of renal tract trauma [on table ivp]


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Technique and radiation

y Contraindicated in pregnant and pt with h/o ofcontrast allergy

y

Fluid restriction is not required with modern lowosmotic media

y Bowel preparation desirable not mandatory

y ControlKUB film is taken to know any area of

calcification which may obscured later by contrasty 50ml to 100ml of contrast [1ml/kg body weight of

300mg of iodine/ml of solution]


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y 15- min film : may be performed to show lower uretery Release film :may be performed after release of

compression to visualize whole urinary tract

y Post micturition film : allows assessment of bladderemptying but also useful in diagnosing bladder tumors,juxtavesical stones , and urethral diverticulum

y Delayed film : may be useful at interval of 1 ,4 ,12 ,and 24 hrfollowing contrast injection if obstructed

yOther film : oblique views may help clarify location ofcalcification . Prone film provide better ureteric filling .Erect films are best for showing renal ptosis and cystoceles

Effective radiation is 4.6 mSv [ =2.5 yr of backgroundradiation or 11500 miles traveled by car]


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Interpretation

y Check for functioning kidneys,size shape[horse-

shoe],contour[renal masses]and cortical thickness[ renalfunction].

y Renal pelvis and calyces must be examined for adequatefilling[fillingdefect],distortion[sol],dupliction,distention[obstruction].

y Features of obstructed urinary tract include.

1. Dense nephrogram

2. Delayed pyelogram

3. Distention of collecting system of ureter above level ofobstruction

4. Contrast extravasation.

y Dense neprogram may be seen in renal vein thrombosis andrenal artery stenosis but subsequent pelvicalyceal distensionseen in obstruction absent.


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IVU inchildren

y Largely replaced by uss, ct scan and nuclear scan.

y

Still used in children with complicated stone disease,abnormal /variant upper tract anatomy ,and hematuria

y Certain modification are required :

Limit amount of contrast [1ml/kg body wight]

Limit no. of film to three Avoid dehydration

Avoid bowel preparation

Avoid compression


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Advantages

y Prompt visualization of entire urinary tract with gooddemonstration ofanatomy

y Excellent demonstration of renal tract calculi[>90%]y Functional assessment of obstruction[high or low grade]

y Qualitative assessment of overall kidney function [degree ofopacification ,cortical thickness]

yCan be performed /interpreted by non radiologist

y Cheap

Drawbacks

y Require iv assess and contrast

y

Use of radiationy Dependent on renal function

y May miss renal masses if not in line of renal contour

y Unable to distinguish b/w cystic and solid masses

y Cannot provide accurate estimation of renal function


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URETHROGRAPHY

y Most common investigation for the evaluation of male andfemale urethra

y Provides superior anatomical information

y Performed via antegrade [mcug] or retrograde [ascending]aproach

y Antegrade approach is better for visualization of posterior

urethra where as retrograde is for anterior urethray Some pt. can be imagined using both techniques

y Dynamics technique provides most clinically pertinentdata


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Indication

y Strictures

y Urethral trauma

y Urethral diverticulum

y Fistulae

y Periurethral or prostatic abscess

y Congenital abnormalities

y Urethral tumors [to assess luminal patency]

mai c tr ai icati is rese ce f c c rre t ti

c trast st ies eferre f rat least 6 eeks st s rgery


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Interpretationy Congenital rethral valves: best demonstrated on MCUG as a

linear filling defects obstructing contrast flow with proximaldilation of prostatic urethrae

y Urethral ivertic lm : seen as contrast filled smooth , roundedsac attached to urethra by short neck

y Strict res :

1. Inflammatory stricture usually occurs at proximal bulbarurethra, may be multiple with varying length2. Truamatic stricture bulbomembranaous area, solitary,


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2.Posterior urethral injuries classified according to their

urethrographic appearances

Type Description Contrast pattern

1[mild]

3severe

Contusion or partial tear of urethra

Rupture of membranaous urethra belowUrogenital diaphragm atbulbomembranaousJunction

No extravasation

Contrast in perineum usually completeNo contrast in bladder

2 mc rupture just above urogenitaldiapragm[prostatic contrast extravasation in retropubiapex] bulbar urethra intact 2/3rd complete no contrast in bla


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Advantage

y Accurate visualization of urethral anatomy

drawbacksy Introduction of infection

y Catheter related injury

y Contrast allergic reaction [but rare]


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ULTRASOUND SCANNING

y USS is cheap ,easily available ,painless and safe .

y Provide real time anatomical as well functionalinformation

y It relies on a dual mode transducer and displays twodimensional gray scale image or as color doppler

y Frequencies used in medical sonography range from 2to 10 mhz


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Indications

1. Ki ney ,adrenalandureter

y Possible upper tract obstruction

y Suspected renal /adrenal mass

y Investigation of hematuria

y Investigation of renal failure

y Monitor renal cystic diseasey Diagnosis of urinary stone disease

y Aids access to kidneys for interventional procedure

y Colourdoppler to demonstrate vascular lesions

y Visualize peri renal area and retroperitoneum


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2. Bladder

y Bladder outflow obstruction measurement of residualurine

y Investigate intra vesical mass [clot ,stone ,tumor]y Aid suprapubic aspiration

3. rostrate andseminal vesical

y Suspected prostate cancer [+biopsy]

y Investigation for chronic pelvic pain4. Scrotum

y Lump ,pain ,trauma

5 Penis

y

investigation of erectile dysfunctiony Peyronies disease

y Diagnose high flow priapism

y Can aid visualization of urethral stricture


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Interpretation

1.Kidneys andadrenal

kidneys must be viewed in both sagittal and transverse planes

Size /contour

y 9-13 cm in length

y Difference of >1.5cm b/w two kidneys is suggestive of unilateralpathological process

Echogenicityy Cortex is homogenous [=or< to liver or spleen]

y Thickness of preserved renal cortex correlates renal function

y Central echogenic complex contains hilar vessels and intrarenal

collecting systemy Splaying of central echogenic complex is seen in hydronephrosis

Masses

y US is excellent at distinguishing b/w solid and cystic masses over 2cm


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Hydronephrosis

Diagnostic accuracy of uss for hydronephrosis is 90-100%Vasculature Renal artery stenosis ,renal vein thrombosis ,and AV fistula

can easily be demonstrated using color dopplerPerirenal Urinoma, ,hematoma ,perinephric abscess can be diagnosed

and in many instances treated using usg guided drainagetechniques

Retroperitoneum LN enlargement ,retroperitoneal tumor ,and aorta can be

seen using ussAdrenal Uss visualization is very useful , especially in childrenSmall lesion may be missed and a CT scan needed when

doubt


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2.Bladder

y Bladder can be scanned by transabdominal ,

transrectal , transurethral approaches.y Transurethral approach provide excellent definition

and can be useful in the evaluation of muscle invasionby tumors.

y Full bladder is anechoic. Stone ,tumors ,debris ,clots,and infection causes abnormal echoes

y Bladder urine volume can measured althoughinaccurately [vol. = height x width x depth/2].

y Absence of ureteric jets [color doppler] for >15 min issuggestive of ureteric obstruction.


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3.scrotum

Scrotum is scanned for abnormal masses, inflammatorycondition ,and blood flow .

Doppler flow measurement have 98% accuracy in diagnosis ofacute testicular torsion . But in most cases immediatesurgical exploration is recommended.

4.Penis

USG of penis used in following condition.

1. Impotence : doppler can demonstrate cavernosal andinternal pudendal blood flow

2. Peyronie s ds: area of fibroses or plaque formation is seen

on uss3. Priapism : uss help in differentiating b/w high flow [AV

fistula] and low flow priapism

4. Urethral stricture : distal urethra stricture and periurethral

structures easily seen by uss


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Advantages

y Safe no radiation involved

y Non invasive

y Cheap readily available

y No requirement of contrast

y Not dependent on function

y Excellent anatomical detail

y Occasional functional / physiological information

y Doppler studies excellent vascular / flow studies

y Useful adjunct for interventional procedures[nephrostomy ,abscess drainage]


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Drawbacks

y Operator dependent

y

Eqiupment dependenty Limited by patient body habitus presence of

intervening bowel gas ,bony structure ,surgical wound,and dressings can compromise image quality

y Image quality is inferior to ivu and ct scan

y Offer little functional information

y Difficulty in visualize retroperitoneal structure andureter


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CT SCANy CT scan revolutionized uroradiological imaging such that in many practices it

is first and only investigation performed for a variety of urological complaintsIndications

kidneys

1. Detection ,definition ,and staging renal masses2. Delineation complex renal stone3. Evaluation of renal vasculature4. Characterization of perirenal and bladder inflammatory masses5. Investigation of level and causes of hydronephrosis6. Investigation of filling defect in the collecting system

7. Extent and staging of renal tract trauma8. Evaluation of renal transplants9. Investigation of congenital renal malformations10. Adjunct to interventional procedure [renal biopsy ,puncture]


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Retroperitoneumy Investigation of choice for retroperitoneum LN , masses , abscess or

fibrosisuretery Suspected ureteric stones [>97% NCCT]Adrenaly Investigation of suspected mass

Bladdery Staging of invasive bladder tumors

Prostate andseminal vesicalsy Staging of prostate tumorsy Investigation of abscess ,congenital deformities ,and cystTestis

y Detection of metastasis from testis cancer


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Advantages

y Single technique for visualization of entire renal tract withexcellent anatomical detail

y Simultaneously detect non renal pathology [liver]y Identifies virtually all renal and ureteric calculi

y Increased sensitivity in detection of renal masses

y Allow accurate staging detected malignancies

y 3D reconstruction enable delineation of anatomy and aidssurgical planning

y CT angiography [non invasive] as accurate as conventional[invasive]


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Drawbacks

y Radiation risk

y Requires contrast with associated risksy Expensive

y Interpretation requires time expertise

y Poor accuracy luminal pathology


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MRIIndication

1. Kidneysy Assessment of indeterminate renal masses[it readily distinguish b/w

cysts and other benign or malignant neoplasm ]y Staging renal cell carcinomay Renal lymphoma [ct insufficient detection of renal involvement]y MRA allow excellent demonstration of renal vasculaturey Retroperitoneal fibrosis [ may help distinguish b/w benign or

malignant etiology]y

Assessment transplanted kidneyy MR urography performed to asses calculi or obstruction ifconventional iodinated contrast tech. contraindicated[ pregnancy,renal failure ]


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2.Adrenals

y Pheochromocytoma

y Distinguish b/w adrenal adenoma ,ca ,and mets3. Bladder

y Staging bladder tumor

4. Prostate

y Staging Prostate cancer


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Advantages

y Can image any plane

y No radiationy Excellent anatomical detail [soft tissue]

y Non invasive angiography [MRA]

y No bony artifact due to lack of signal from bone

y Contrast use is infrequent and safe


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Drawbacks

y High operating cost

y

Limited availability for emergenciesy Interpretation requires expertise

y Artifact produced pt movement ,scarring andinflammation

y

Inability to show renal tract calcificationy Tendency to over stage prostate and bladder cancers

y Fresh hemorrhage not as well visualized as by ct

y Can be noisy and claustrophobic


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