DIAGNOSTIC IMAGING OF URINARY TRACT Radiology Department of Ruijin Medical College Affiliated to Shanghai Jiaotong University Medical School

骨关节系统影像学 瑞金临床医学院 医学影像学教研室

INTRODUCTION Including both kidney, ureter, bladder and urethra. Lack of natural contrast. Need various kinds of contrast examination. Use of CT, USG,MRI.

METHODS OF EXAMINATION Plain Film of the Abdomen (KUB) Including both sides of kidney, area of ureter and bladder. To show contour, size, shape of the above organs and psoas muscles margin. To demonstrate stone and calcification of urinary tract

KUB

METHODS OF EXAMINATION Intravenous Urography (IVU) Preparation: 1. sensitivity test of iodine. 2.preparation of intestinal tract (fast 8~12h, catharsis) Contrast medium: 1.Urografin (泛影葡胺) 2. Iopamidol (碘必乐) 3. Iopromide (碘普罗胺)

METHODS OF EXAMINATION Intravenous Urography (IVU) Technique: 1.intravenous instillation of contrast medium (100ml) should be over in 5~10minutes 2. films are taken at 3,5,10,15,25(KUB) minutes Display: 1.excretory function of kidney 2.morphology of urinary tract

-C +C I.V.U.

I.V.U.

METHODS OF EXAMINATION Retrograde Urography To be used when IVU has been unsatisfactory or inconclusive. To show the morphology of urinary tract only.

Retrograde Urography

METHODS OF EXAMINATION Renal Angiography abdominal aortography. Selective renal arteriography.

Renal Angiography

Renal Angiography

METHODS OF EXAMINATION CT Plain Scans patient preparation : ⑴ oral contrast mediun administration for bowel and bladder filling ⑵ 1~2%, 500ml of urografin for kidney CT ⑶ 1~2%, 1000ml of urografin for bladder CT ⑷ the bladder must be fully distended Slice thickness and intervals: 5~10mm Scanning method: sequential CT scans Scanning ranges: upper pole of kidney→ureter→bladder

CT Plain Scans

METHODS OF EXAMINATION CT Contrast enhanced Scans Contrast medium: 60~100ml, 1.5~2.5ml/s Intravascular administration: bolus injection Scanning: ⑴Sequential CT scans: start at 15~20s after injection ⑵Delayed CT scans: can be performed at 5~10min. after injection to show filling the pelvis, ureter and bladder with contrast medium

CT Contrast enhanced Scans

METHODS OF EXAMINATION MRI Plain Scans: ⑴ transverse T1WI (T1-Weighted imaging) + T2WI (T2-Weighted imaging) with SE (spin-echo sequences) ⑵ coronal T1WI with SE Contrast enhanced scans: ⑴ contrast medium: Gd-DTPA, 0.1~0.2mmol/kg ⑵ scanning sequences: T1WI with SE MRU (MR urography): to demonstrate the obstruction of urinary tract

KUB I.V.U. R.U. US Angio CT

NORMAL IMAGING OF URINARY TRACT KUB & IVU Kidney 1. position: T11~12 to L1~2 2. size: 11~13×5~6×2~3cm (3×6×12cm) Contour: smooth Minor calyces: 10~14 Major calyces: 2~4 Pelvis: trumpet , branch, ampulla

NORMAL IMAGING OF URINARY TRACT KUB & IVU Ureter long: 25~30cm width: 3~5mm physiological narrowings: ⑴ pelvi-ureteral junction ⑵ iliac vessels ⑶ entry of bladder

NORMAL IMAGING OF URINARY TRACT KUB & IVU Bladder shape: round or oval capacity: 200~350ml

I.V.U.

NORMAL IMAGING OF URINARY TRACT Plain Scans Kidney ⑴ renal parenchyma: soft tissue density, 30~50Hu ⑵ pelvis: water density, 10~20Hu ⑶ renal sinus: fat density, -60~-100Hu Ureter soft tissue density Bladder water density when fully distended

NORMAL IMAGING OF URINARY TRACT Contrast Enhanced Scans Kidney: ⑴ 1′after injection: cortical enhancement ⑵ 2′after injection: medullary enhancement ⑶ 5~10′after injection: parenchyma enhancement and filling the pelvis with contrast medium

NORMAL IMAGING OF URINARY TRACT Contrast Enhanced Scans Ureter and Bladder: ⑴ bladder wall enhanced on early scans ⑵ filling with the contrast medium on delayed scans

NORMAL IMAGING OF URINARY TRACT MRI Plain Scans The signal intensity of renal cortex on T1WI is higher than that of renal medulla The signal intensity of renal cortex and medulla on T2WI are all higher The signal intensity of ureter and bladder are low on T1WIand higher on T2WI

NORMAL IMAGING OF URINARY TRACT MRI Contrast Enhanced Scans Renal parenchyma and bladder wall show enhancement

CALCULUS OF URINARY TRACT Radiopaque(calcium) in 90% of patient Radiolucent(urate) in 10% of patient

CALCULUS OF URINARY TRACT Renal Calculus round, horny, morula lie in the calyces or pelvis hydronephrosis CT: high density, 200~1000Hu

CALCULUS OF URINARY TRACT Ureteral calculus grain of rice size, jujube core shaped long axis parallel to the ureter often stay in the sites of narrowness hydroureter or hydronephrosis above the stone CT: high density, 200~1000Hu

Ureteral calculus

CALCULUS OF URINARY TRACT Calculus of Urinary bladder round, oval, laminited, concentric circles shaped CT: high density MRI: low signal on T1WI and T2WI

Calculus of Urinary bladder

TUBERCULOSIS OF URINARY TRACT Secondary infection Hematogenous dissemination

TUBERCULOSIS OF URINARY TRACT Pathology TB bacilli renal cortex infection medullary destruction caseous necrosis abscess (calcification) pelvicalyceal destruction ureter and bladder TB

TUBERCULOSIS

TUBERCULOSIS OF URINARY TRACT Auto-resection of kidney Diffused calcification of caseous foci, or whole kidney + loss of renal function

Auto-resection of kidney

TUBERCULOSIS OF URINARY TRACT Renal Tuberculosis KUB: ⑴ normal (early stage ) ⑵ calcification

TUBERCULOSIS OF URINARY TRACT Renal Tuberculosis IVU: ⑴ calyceal destruction ⑵ abscess and cavity formation ⑶ pyonephrosis ⑷ diffuse fibrotic contraction and calcification ⑸ auto-resection of kidney

Renal Tuberculosis

TUBERCULOSIS OF URINARY TRACT Renal Tuberculosis Plain CT scans: ⑴ high density (calcification) ⑵ low density areas (abscess or cavity) ⑶ CT values: 20~40Hu(abscess)

TUBERCULOSIS OF URINARY TRACT Renal Tuberculosis Contrast-enhanced CT scans: ⑴ low density areas without enhancement. ⑵ contrast media is demonstrable within the abscess. ⑶ pelvicalyceal enlargement

TUBERCULOSIS OF URINARY TRACT Renal Tuberculosis MRI: ⑴ low signal on T1WI ⑵ high signal on T2WI

TUBERCULOSIS OF URINARY TRACT Ureteral Tuberculosis KUB: calcification IVU: ⑴ stricture ⑵ shorten ⑶ beading

TUBERCULOSIS OF URINARY BLADDER IVU: Small bladder Contracted bladder

TUMORS OF URINARY TRACT Renal Carcinoma KUB: ⑴ kidney enlarged, local protrusion ⑵ calcification in 10% of patients IVU: ⑴ renal contour: bulging ⑵ calyces and pelvis: compression narrowing dissociation destruction

Renal Carcinoma

TUMORS OF URINARY TRACT Renal Carcinoma Plain CT scans: ⑴ mass (20~50Hu) ⑵ calcification ⑶ the tumor may be hypodense or isodense in comparison to the surrounding structures

TUMORS OF URINARY TRACT Renal Carcinoma Contrast-enhanced CT scans: ⑴ inhomogeneous enhancement ⑵ peripheral enhancement ⑶ non-enhanced necrotic areas in the tumor

Renal Carcinoma

TUMORS OF URINARY TRACT Renal Carcinoma MRI: (1) Plain scans: inhomogeneous signals on T1WI and T2WI (2) Contrast-enhanced scans: inhomogeneous enhancement

Angioleimyolipoma Benign tumor of the kidney The tumor is histologically comprised of blood vessels, smooth muscle, and fat tissue. The proprtions of the conponents in the tumor are variable

Angioleimyolipoma KUB and IVU kidney enlarged pelvicalyceal compression calcification in 20% of patients

Angioleimyolipoma CT Fatty components of the tumor: ⑴ much lower dentisy ⑵ CT values:-40to-120Hu ⑶ non-enhancement The vascular and muscular structeres of the tumor: enhancement Calcification: high density

Angioleimyolipoma MRI Fatty components: ⑴ high signal on T1WI and T2WI ⑵ much lower signal on STIR Other components: inhomogeneous signal on T1WI and T2WI

Renal Pelvic Carcinoma Transitional cell carcinoma (80~90%) KUB: normal IVU : filling defect within the pelvis CT: ⑴ mass of renal sinus ⑵ enhancement ⑶ filling defect on delayed contrast CT imaging MRI: ⑴ mass of renal sinus

Renal Pelvic Carcinoma

Carcinoma of the Urinary Bladder Papillary carcinoma of the epithelium of the urinary tract Mass protruding on the bladder wall KUB: normal IVU: filling defect within the bladder CT and MRI: ⑴ mass in the bladder ⑵ enhancement ⑶ invasion of surrounding structures ⑷ demonstrate metastatic lymph nodes

Carcinoma of the Urinary Bladder

RENAL CYST Simple Renal cyst Single or multiple KUB: normal or bulging contour IVU: pelvicalyceal compression

RENAL CYST Simple Renal cyst CT: ⑴ round ⑵ clear margin ⑶ homogeneous low density ⑷ CT values: 6~18Hu ⑹ nonenhancement MRI: ⑴ low signal on T1WI ⑵ high signal on T2WI ⑶ nonenhancement

Simple Renal cyst

Polycystic Renal Disease in Adults Genetic disease Accompanied with polycystic hepatic disease in 30~60% of patients KUB: enlargment of both kidney IVU: pelvicalyceal compression, shift, dissociation-- “spider feet” CT and MRI: ⑴ multiple cysts in various sizes ⑵ nonenhancement

RENAL AND URETERAL DYSPLASIA Double pelvis and ureter Solitary kidey Horse-shoe kidney Ectopic kidney

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