Urinary system

Methods of investigation

X-ray Plain abdominal radiographs Urogram –Excretory urography (intravenous pyelography, IVP) –Retrograde urography –Cystography & urethrography –Abdominal aortography & Selective renal arteriography

Plain abdominal radiographs (KUB) Bowel preparation A full-length film including: –Th11 to bladder base –The prostatic urethra (in the male) Investigation : –calcification –The position, shape, size of the kidneys

Normal KUB

Excretory urography Purpose: –Showing the anatomical shape of renal pelvis, ureter, bladder –An indication of renal function Method: –Normal dosage –Double dosage Dosage:300 mg-600mg I kg−1 body weight

Normal IVP To know the principle and applications of IVP To observe the pelvicaliceal system, the renal calices and the ureter

Retrograde urography Applications: In the patients whom excretion urography is failure Contraindications: the lower urinary tract infection Method: Cystoscopic-guided catheterize into the selected ureter Contrast media: 10-25% Iodinated contrast media 5-10ml, the dosage can be increase when hydronephrosis presents.

Bilateral retrograde urography To observe the pelvicaliceal system, the renal calices and the ureter

Air retrograde urography To know the applications and method of air retrograde urography To observe the pelvicaliceal system and the ureter after injected negative contrast medium

Cystography Applications: Bladder mass, Diverticulum, compression of adjacent organ Method: Antegrade and Retrograde Contrast media: 3-5% Iodinated contrast media ml, air, or both of them (Double contrast cystography)

Normal cystography Upper: normal Iodinated contrast media cystography Lower: air cystography

Urethrography Applications: Stenosis of Urethra Method: Antegrade and Retrograde Contrast Media: 15-25% Iodinated contrast media

Normal antegrade urethrography, a oblique view and a A-P view

Abdominal aortography & Selective renal arteriography Method: Digital Subtraction angiography Applications: Renovascular disease, tumor disease (combine with interventional therapy)

Normal abdominal aortography Showing the bilateral renal arteries (red arrow)

Stenosis of the left renal artery (green arrow)

Selective renal digital subtraction arteriography

CT

MR

Ultrasound

Image observing and analysis (X-ray)

Normal Plain abdominal radiographs (KUB) Kidney –From the superior line of Th12 to the inferior line of L3 –The right kidney is usually located more inferiorly than the left. –Size: 5-6 ×12-13cm –The axis of kidney: degree –The movement of kidney is less than the height of one vertebra.

Kidney Renal parenchyma –Cortex –Medulla (Pyramides renales) Collecting cave –Calyces –Pelvis IVP: –1-2min nephrographic phase –2-3min calyces and pelvis begin to be shown –15-30min calyces and pelvis are been shown well. (pyelographic phase)

Different form of pelvis renales –A normal form –B branch form (without pelvis) –C ampullae form (without calyx major)

Normal pelvis and calyces –Observe the position, shape, borderline and density of them

Ampullae form –The pelves is directly connected with minor calyces –The shape of pelves are full Branch form –The major calyces are directly connected with ureter, without pelvis

Reflux A.tubular reflux B.sinus reflux C.intravenous reflux D.Lymphatic reflux

Tubular reflux: it is like sector in the upper pole of left kidney

Reflux: tubular reflux (red arrow), sinus reflux (blue arrow), Lymphatic reflux (black arrow)

tubular reflux and sinus reflux

Lymphatic reflux

Ureter 25cm long 3 physiological narrowings Peristalsis

Dual retrograde pyelography Anatomical detail of the pelvicaliceal system is demonstrated.

Normal Cystography (fill with Iodinated contrast media (left) and air (right)) The normal Capacity of bladder is about 250ml. The size and shape of bladder is determined on filling.

Urethra The male urethra is divided into two parts: the anterior and the posterior urethra. It has 2 curvature and 3 physiological narrowing.

Normal male urethra (AP and Oblique position)

Normal female urethra

Disease Diagnosis

Calculus disease Urinary calculus can occur in every part of urinary tract. Plain abdominal radiograph is the first choice. Calculi are divided into negative (radiolucent) and positive stones. Calculi in different part of urinary track have different form. Urinary calculi should be distinguished with biliary calculus, calcification of lymph nodes, Intestinal contents and phlebolith.

Renal Tuberculosis Renal tuberculosis results from hematogenous dissemination from a distant site, usually in the lung or bone. Characteristics of renal tuberculosis: –Parenchymal calcification –Parenchymal scar –Papillary necrosis –Infundibular strictures –Nonfunction (autonephrectomy)

Ureter Tuberculosis: presents strictures and calcification. Tuberculous cystitis: presents contracted and irregular and reflux

Renal Tuberculosis A: Infundibular strictures B: Papillary necrosis C: autonephrec tomy

Renal Tumer Renal carcinoma –Twice as common among men than women –The incidence peaks in the fifth to seventh decade –Usually in one kidney –Painless gross hematuria –Internist ’ s tumer

Renal carcinoma renal cell carcinoma may cause displacement, compression, distortion, stretching, invasion, or amputation of calices and infundibula.

CT finding May have calcification Heterogeneous mass Diffuse margin with normal parenchyma Enhances with intravascular contrast media

MR finding MRI can be used to detect and stage renal cell carcinoma. The signal characteristics of renal carcinoma are variable –isointense or hypointense compared to the renal cortex on T1 sequences –slightly hyperintense on T2-weighted sequences. Contrast: Heterogeneous enhancement occurs immediately, decreasing on delayed images.

Bladder Tumors Transitional cell carcinoma –X-ray finding: Filling defect ( Iodinated contrast media ) Soft tissue mass (air)

Urinary obstruction Cause: calculus, tumor, inflammation, reflux, etc. Classification: –Grade I: the most minimal dilatation appreciable, characterized by slight blunting of the caliceal fornices. –Grade II: obvious blunting of the caliceal fornices and enlargement of the calices, but the intruding shadows of the papillae, although flattened, are still easily seen. –Grade III: caliceal ballooning

Congenital Anormalies

Benign Prostatic Hypertrophy X-ray finding: –BPH elevates and indents the bladder base –Stricture of prostatic urethra –Obstructive cystitis