1. URORADIOLOGY Bengi Gürses M.D. Assistant Professor Of Radiology

2. Radiological Modalities Ultrasound Ultrasound Intravenous Pyelography Intravenous Pyelography Computed Tomography Computed Tomography Magnetic Resonance Imaging Magnetic Resonance Imaging Radionuclide Scanning Radionuclide Scanning

3. Ultrasound Ultrasound CT  Anatomical info. CT  Anatomical info. MRI MRI Radionuclide  Functional info. Radionuclide  Functional info. IVP  Anatomical + Fnx.

4. ULTRASOUND First line investigation !!! First line investigation !!! Provides anatomical information without ionizing radiation Provides anatomical information without ionizing radiation No need for intravenous contrast !!! No need for intravenous contrast !!!

5. INDICATIONS (USG) İnvestigate patients with symptoms thought to arise from UT İnvestigate patients with symptoms thought to arise from UT Size of the kidneys Size of the kidneys Presence of hydronephrosis Presence of hydronephrosis Renal tumors, cysts, abcesses Renal tumors, cysts, abcesses Assess bladder and prostate Assess bladder and prostate

6. Normal Findings Kidneys; smooth in outline Kidneys; smooth in outline Central echogenic region (renal sinus) Central echogenic region (renal sinus) Renal cortex (hypoechoic) Renal cortex (hypoechoic) Pyramids (triangular hypoechoic areas) Pyramids (triangular hypoechoic areas) Size : 90-120 mm Size : 90-120 mm Urinary Bladder : examined in distended state, imperceptible walls, anechoic lumen Urinary Bladder : examined in distended state, imperceptible walls, anechoic lumen

10. Intravenous Pyelography Largely replaced by US Largely replaced by US 50-100 ml of contrast is injected intravenously 50-100 ml of contrast is injected intravenously Carried via blood to the kidneys, passes through the glomerular filtrate  collecting systems Carried via blood to the kidneys, passes through the glomerular filtrate  collecting systems Main indications: Main indications: Detailed demonstration of PCS and ureters Detailed demonstration of PCS and ureters Acute ureteric colic Acute ureteric colic Invstigation of renal calculi Invstigation of renal calculi Investigation of hematuria Investigation of hematuria

11. First step: Plain film First step: Plain film Look at renal contour Look at renal contour Identify all calcifications !!! Identify all calcifications !!! Urinary calculi (kidney,ureter,bladder) Urinary calculi (kidney,ureter,bladder) Nephrocalcinosis Nephrocalcinosis Prostatic calcification Prostatic calcification

15. Kidneys: position, length, contours Kidneys: position, length, contours Calices: should be symmetrical, cup-shaped. Calices: should be symmetrical, cup-shaped. If dilated  club-shaped (due to obstruction or destruction of papilla) If dilated  club-shaped (due to obstruction or destruction of papilla) Renal pelvis and ureters: normal pelvis is funnel- shaped, ureters are seen in only part of their length due to peristaltism. Renal pelvis and ureters: normal pelvis is funnel- shaped, ureters are seen in only part of their length due to peristaltism. Bladder:centrally located, smooth outline, should be empty after micturition Bladder:centrally located, smooth outline, should be empty after micturition

17. Computed Tomography Indications: Indications: To characterize renal masses and stage tumors To characterize renal masses and stage tumors To diagnose or exclude renal trauma To diagnose or exclude renal trauma To demonstrate stones To demonstrate stones To assess acute ureteric colic To assess acute ureteric colic To delineate renal vascular anatomy To delineate renal vascular anatomy

18. Normal Findings Renal sinus ; low attenuation in the center Renal sinus ; low attenuation in the center There should not be any calcification There should not be any calcification Ureters are seen as dots in cross section lying on the psoas muscles Ureters are seen as dots in cross section lying on the psoas muscles Bladder has a smooth outline, thin wall, anechoic urine. Bladder has a smooth outline, thin wall, anechoic urine. Axial images may be reformatted in the coronal and sagittal planes Axial images may be reformatted in the coronal and sagittal planes

19. MRI Used in selected circumstances Used in selected circumstances (renal artery stenosis, IVCal extension of renal tumors) (renal artery stenosis, IVCal extension of renal tumors)

20. Voiding Cystourethrogram Bladder is filled with contrast medium through a catheter and films are taken during voiding Bladder is filled with contrast medium through a catheter and films are taken during voiding Observed fluoroscopically to identify reflux f contrast medium from bladder to upper UT. Observed fluoroscopically to identify reflux f contrast medium from bladder to upper UT. Risk of urinary tract infection, chronic pyelonephritis and renal scarring is increased in VUR. Risk of urinary tract infection, chronic pyelonephritis and renal scarring is increased in VUR.

21. Grading of VUR Grade 1 reflux of urine only into the ureter Grade 2 reflux into the pelvis and calices, no dilatation Grade 3 mild to moderate dilatation of the ureters and renal pelvis Grade 4 moderate dilatation and tortuosity of the ureters,pelvis,calices Grade 5 gross dilatation and tortuosity of the ureters,pelvis and calices

24. UPPER URINARY TRACT DISORDERS Urinary Calculi Urinary Calculi Urinary Tract Obstruction Urinary Tract Obstruction Renal Parenchymal Masses Renal Parenchymal Masses Urothelial Tumors Urothelial Tumors Acute Pyelonephritis, Perinephric abscess Acute Pyelonephritis, Perinephric abscess Chronic Pyelonephritis Chronic Pyelonephritis Congenital Anomalies Congenital Anomalies

25. Urinary Calculi Most calculi are calcified and can be seen as radiodense on plain x-ray. Most calculi are calcified and can be seen as radiodense on plain x-ray. Only pure uric acid and xanthine stones are radiolucent on plain radiography, and they can be identified at CT or US. Only pure uric acid and xanthine stones are radiolucent on plain radiography, and they can be identified at CT or US. US ; hyperechoic with posterior acoustic shadowing US ; hyperechoic with posterior acoustic shadowing CT ; hyperdense CT ; hyperdense

28. UPPER URINARY TRACT DISORDERS Urinary Calculi Urinary Calculi Urinary Tract Obstruction Urinary Tract Obstruction Renal Parenchymal Masses Renal Parenchymal Masses Urothelial Tumors Urothelial Tumors Acute Pyelonephritis, Perinephric abscess Acute Pyelonephritis, Perinephric abscess Chronic Pyelonephritis Chronic Pyelonephritis Congenital Anomalies Congenital Anomalies

29. Urinary Tract Obstruction (USG) The main feature is dilatation of the pelvicaliceal system and ureters The main feature is dilatation of the pelvicaliceal system and ureters Main causes : Main causes : Calculi Calculi Blood clot Blood clot Sloughed papilla Sloughed papilla Tumors Tumors US, IVP and CT US, IVP and CT

30. US : dilatation of PCS is seen as multiloculate fluid collection in the central echo complex (caused by pooling of urine within the distended pelvis and calices). Proximal ureteric dilatation can also be demonstrated but overlying bowel gas obscures dilatation of the mid and distal ureter. US : dilatation of PCS is seen as multiloculate fluid collection in the central echo complex (caused by pooling of urine within the distended pelvis and calices). Proximal ureteric dilatation can also be demonstrated but overlying bowel gas obscures dilatation of the mid and distal ureter.

32. IVP Plain films may be helpful to demonstrate the calculus Plain films may be helpful to demonstrate the calculus Delayed films are essential Delayed films are essential Filling of the pelvicaliseal system with contrast medium is greatly delayed. Filling of the pelvicaliseal system with contrast medium is greatly delayed. görüntü görüntü

33. CT In acute obstruction, non-contrast CT demonstrates the calculi. In acute obstruction, non-contrast CT demonstrates the calculi.

34. UPPER URINARY TRACT DISORDERS Urinary Calculi Urinary Calculi Urinary Tract Obstruction Urinary Tract Obstruction Renal Parenchymal Masses Renal Parenchymal Masses Urothelial Tumors Urothelial Tumors Acute Pyelonephritis, Perinephric abscess Acute Pyelonephritis, Perinephric abscess Chronic Pyelonephritis Chronic Pyelonephritis Congenital Anomalies Congenital Anomalies

35. Renal Parencymal Masses Causes: cyst, benign tumor (angiomyolipoma), renal cell carcinoma, metastases, abscess Causes: cyst, benign tumor (angiomyolipoma), renal cell carcinoma, metastases, abscess US US usually renal masses are first detected by US. usually renal masses are first detected by US. Cystic versus Solid Cystic versus Solid Simple cyst: common in elderly, solitary or multiple, unilocular or septated. Acoustic enhancement. Simple cyst: common in elderly, solitary or multiple, unilocular or septated. Acoustic enhancement.

37. Angiomyolipoma: small echogenic masses. Angiomyolipoma: small echogenic masses.

38. Renal Cell Carcinoma RCCs account for 86% of all primary renal parenchymal tumors. RCCs account for 86% of all primary renal parenchymal tumors. On US; solid tumors On US; solid tumors May be iso, hypo or hyperechoic. May be iso, hypo or hyperechoic. When a tumor is demonstrated, extension into the renal vein and inferior vena cava should be assessed. When a tumor is demonstrated, extension into the renal vein and inferior vena cava should be assessed.

39. CT Useful for diagnosis and staging of renal tumors Useful for diagnosis and staging of renal tumors Shows local direct spread, enlargement of lymph nodes, liver or other organ metastases, renal vein and IVC involvement. Shows local direct spread, enlargement of lymph nodes, liver or other organ metastases, renal vein and IVC involvement.

41. UPPER URINARY TRACT DISORDERS Urinary Calculi Urinary Calculi Urinary Tract Obstruction Urinary Tract Obstruction Renal Parenchymal Masses Renal Parenchymal Masses Urothelial Tumors Urothelial Tumors Acute Pyelonephritis, Perinephric abscess Acute Pyelonephritis, Perinephric abscess Chronic Pyelonephritis Chronic Pyelonephritis Congenital Anomalies Congenital Anomalies

42. Urothelial tumors are seen as filling defects in the renal pelvis and ureters Urothelial tumors are seen as filling defects in the renal pelvis and ureters Filling defects in the collecting system: calculi, blood clot, tumor Filling defects in the collecting system: calculi, blood clot, tumor They may obstruct the ureter and cause hyrdonephrosis. They may obstruct the ureter and cause hyrdonephrosis.

44. Congenital Anomalies Bifid Collecting System Bifid Collecting System Ectopic Kidney Ectopic Kidney Horseshoe kidney Horseshoe kidney Renal Agenesis Renal Agenesis

45. Bifid Collecting System Most frequent congenital variation Most frequent congenital variation Unilateral or bilateral Unilateral or bilateral Bifid pelvis................ureteric duplication Bifid pelvis................ureteric duplication

47. Ectopic Kidney During fetal development kidneys ascend in the abdomen During fetal development kidneys ascend in the abdomen Ectopic kidney results when this ascent is halted Ectopic kidney results when this ascent is halted In some cases kidneys lie on the same side and are fused (crossed fused ectopia) In some cases kidneys lie on the same side and are fused (crossed fused ectopia)

48. Horseshoe Kidney The kidneys may fail to seperate, giving rise to a horseshoe kidney The kidneys may fail to seperate, giving rise to a horseshoe kidney Lower poles are fused by parenchyma or fibrous tissue Lower poles are fused by parenchyma or fibrous tissue

50. LOWER URINARY TRACT DISORDERS Bladder Tumors Bladder Tumors Bladder Diverticula Bladder Diverticula Prostatic Enlargement Prostatic Enlargement

51. Bladder Tumor Most frequent site for neoplasms of the urinary tract Most frequent site for neoplasms of the urinary tract On US; bladder tumors are seen as soft tissue masses protruding into the bladder. On US; bladder tumors are seen as soft tissue masses protruding into the bladder. IVP; filling defect in the bladder IVP; filling defect in the bladder On CT and MRI; soft tissue mass projecting from the bladder wall On CT and MRI; soft tissue mass projecting from the bladder wall

55. LOWER URINARY TRACT DISORDERS Bladder Tumors Bladder Tumors Bladder Diverticula Bladder Diverticula Prostatic Enlargement Prostatic Enlargement

56. Bladder Diverticula May be congenital or secondary to chronic obstruction May be congenital or secondary to chronic obstruction Demonstrated by US, CT or MRI. Demonstrated by US, CT or MRI.

58. LOWER URINARY TRACT DISORDERS Bladder Tumors Bladder Tumors Bladder Diverticula Bladder Diverticula Prostatic Enlargement Prostatic Enlargement

59. Prostate Imaging Prostatic enlargement : benign prostatic hypertrophy, prostatic carcinoma Prostatic enlargement : benign prostatic hypertrophy, prostatic carcinoma Prostatic ultrasound; transducer introduced into the rectum Prostatic ultrasound; transducer introduced into the rectum TRUS guided biopsy TRUS guided biopsy MRI ; tumor is seen mostly in the peripheral zone as hypointense on T2 MRI ; tumor is seen mostly in the peripheral zone as hypointense on T2

63. Scrotal Swelling US, Color Doppler US, MRI US, Color Doppler US, MRI Testicular tumor, orchitis-epididymo-orchitis, testicular torsion, hydrocele...... Testicular tumor, orchitis-epididymo-orchitis, testicular torsion, hydrocele...... Doppler ; used in acute scrotum; to differentiate between epididiymo-orchitis and testicular torsion Doppler ; used in acute scrotum; to differentiate between epididiymo-orchitis and testicular torsion Epididiymo-orchitis ; medical treatment Epididiymo-orchitis ; medical treatment Torsion ; surgery Torsion ; surgery