1. UROGENITAL Clinical cases
Radiology course
UROGENITAL
Clinical cases

2. Various renal cysts morphologies, listed in order by their potential for malignancy, using the Bosniak classification system.  This classification help us to decide the management of the patient

3. Renal cyst, Bosniak I simple cyst, imperceptible wall, rounded

4. Renal cyst, Bosniak II
Minimally complex, a few thin (<1 mm) septa, thin calcifications; non-enhancing 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

5. Renal cyst, Bosniak IIF
minimally complex, increased number of septa, minimally thickened or enhancing septa or wall, thick calcifications. Hyperdense cyst, no enhancement

6. Renal cyst, Bosniak III
indeterminate, thick or multiple septations, septal nodularity, hyperdense on CT 

7. Renal cyst, Bosniak IV
clearly malignant, solid mass with a large cystic or a necrotic component

8. This diagram depicts various renal cysts morphologies, listed in order by their potential for malignancy, using the Bosniak classification system.  The cysts in the top row (1 and 2) do not need further evaluation or monitoring. The cysts in the bottom row (2F, 3 and 4) should be followed and require further evaluation and management

9. Acute flank pain No fever
Acute Onset Flank Pain
Case 1
Acute flank pain
No fever

10. Case 1 First study? X – ray intravenous urography
MRI abdomen and pelvis without and with
contrast
MRI abdomen and pelvis without contrast
US kidneys and bladder retroperitoneal
with Doppler
CT abdomen and pelvis without contrast
CT abdomen and pelvis without and with

11. Acute Onset Flank Pain
Case 1

12. US kidneys and bladder retroperitoneal with Doppler

13. Acute Onset Flank Pain

14. https://acsearch.acr.org/docs/69362/Narrative/

15. Acute flank pain No fever - Recurrent symptoms of stone disease
Acute Onset Flank Pain
Case 2
Acute flank pain
No fever
- Recurrent symptoms of stone disease

16. Case 2 First study? X – ray intravenous urography
MRI abdomen and pelvis without and with
contrast
MRI abdomen and pelvis without contrast
US kidneys and bladder retroperitoneal
with Doppler
CT abdomen and pelvis without contrast
CT abdomen and pelvis without and with

17. https:// radiopaedia.orgcasesbilateral-renal-stones
Acute Onset Flank Pain
Case 2
Patient with right sided renal colic and a history of renal stones
radiopaedia.orgcasesbilateral-renal-stones

18. Case 2
radiopaedia.orgcasesct-ivu-hydronephrosis-due-to-ureteric-stone

19. https://acsearch.acr.org/docs/69362/Narrative/

20. Case 3
- Bilateral flank pain
- Mild fever
- Burning micturation

21. Acute Pyelonephritis Case 3 First study? X – ray intravenous urography
X – ray abdomen and pelvis
- MRI abdomen and pelvis without and with
contrast
- MRI abdomen and pelvis with/without contrast
- US kidneys and bladder retroperitoneal
- CT abdomen and pelvis without contrast
- CT abdomen and pelvis with and without contrast
- Tc-99m DMSA scan kidney-

22. https:// radiopaedia.org/cases/acute-pyelonephritis-1

23. https://radiopaedia.org/cases/acute-pyelonephritis-5
Acute Pyelonephritis
Case 3

24. https://radiopaedia.orgcasesacute-pyelonephritis-4
Acute Pyelonephritis
Case 3

25. https://radiopaedia.org/cases/acute-pyelonephritis-2
Acute Pyelonephritis
Case 3
Right sided acute bacterial pyelonephritis
Note the absence of a cortical rim sign

26. https://radiopaedia.org/cases/acute-bacterial-pyelonephritis
Acute Pyelonephritis
Case 3
CT portal venous phase
At the right renal midpole is
a wedge-shaped, hypodensity with associated fat stranding.
No hydronephrosis.
No free fluid or free gas.
Prominent para- aortic lymph nodes.
Case Discussion:
Acute right-sided pyelonephritis.
Urine culture grew E. Coli.

27. https://radiopaedia.org/cases/acute-pyelonephritis-4
Acute Pyelonephritis
Case 3
Axial renal parenchymal phase
Alteration of perirenal fat. Signs of right hydroureteronephrosis. Small enlarged para-aortic lymph nodes.
Case Discussion:
Acute bacterial pyelonephritis

28. https://radiopaedia.org/cases/acute-suppurative-pyelonephritis
Acute Pyelonephritis
Case 4
Presentation:
Diabetic patient with left flank pain, fever and hematuria for 3 days duration, not responding to medical treatment.

29. https://radiopaedia.org/cases/acute-suppurative-pyelonephritis
Acute Pyelonephritis
Case 4
Excretory phase demonstrates a streaky linear bands of alternating high and low attenuation.
Case Discussion:
Acute suppurative pyelonephritis
in a diabetic patient.

30. Acute Pyelonephritis Case 4

31. https://acsearch.acr.org/docs/69489/Narrative/

32. Hematuria
Case 5
-Flank pain - Gross haematuria -Palpable flank mass (classical triad)

33. Hematuria Case 5 First study? X – ray retrograde pyelography
- MRI abdomen and pelvis without and with
contrast (MR urography)
- MRI abdomen and pelvis with/without contrast
US kidneys and bladder retroperitoneal
Arteriography kidney
CT abdomen and pelvis without contrast
- CT abdomen and pelvis with and without contrast

34. Hematuria Case 5 Presentation:
Right flank pain and hematuria in urine analysis test

35. Hematuria
Case 5

36. Hematuria
Case 5
Large mass at upper pole of the right kidney which after contrast injection, heterogeneous enhancement is seen on both parenchymal and excretory phase.
There is no evidence of collecting system or renal artery and vein involvement.

37. Hematuria Case 5 Discussion:
Renal cell carcinoma is classically present with hematuria, flank pain and palpable mass in 10-15% of patients.
CT is usually used to diagnose and stage renal cell carcinomas.

38. Hematuria
Case 5
At the midpole of the left kidney, there is a 6.4 cm x 5.8 cm x 7 cm sharply circumscribed mass that demonstrates avid contrast uptake bare in a star-shaped central scarlike lesion.
The left renal vein is normal.
The right kidney is normal.
There is no lymphadenopathy in the upper abdomen.

39. Hematuria Case 5 Conclusion:
7 cm left renal mass - has imaging characteristics suggestive of an oncocytoma but a renal cell carcinoma is considered most likely, especially given the size of the lesion. Renal biopsy under US control could be performed if clinically indicated.
Renal oncocytoma is a relatively benign tumour and the importance of this lesion is the difficulty in pre-operatively distinguishing it from renal cell carcinomas.

41. Hematuria
Case 6

42. Hematuria
Case 6
Contrast enhanced CT scan demonstrates a mass within the right renal pelvis.
The mass distends the renal pelvis (compare to the contralateral kidney) and shows relative high attenuation compared to the urine within the renal pelvis.

43. Hematuria Case 7 - Haematuria and urinary frequency for 4 months.
Lower abdominal fullness.
- On examination was found to have a lower abdominal mass.

44. Hematuria
Case 7

45. Hematuria
Case 7

46. Hematuria
Case 7
There is a large heterogenous mass in the right superolateral aspect of the bladder, causing obstruction of the right kidney. A right duplex system is evident, with hydronephrosis of both moieties.
A right ovarian cyst is also evident.
Case Discussion:
A transitional cell carcimoma of the urinary bladder was confirmed after cystoscopy and biopsy.
The right duplex system was in incidental findings in this case.

47. Case 8 Dysuria, haematuria.
Diverticule typically result from chronic outlet obstruction.

48. Case 8 Dysuria, haematuria.

49. Hematuria Case 9

50. Hematuria Case 9

51. Hematuria Case 9

52. Hematuria Case 9

54. Case 10 Diminished urinary stream retrograde urethrography

55. Retrograde Urethrography
HOW:
- Place a Foley catheter tip in the navicular fossa and gently inflate the balloon with sterile water until a seal is formed making sure not to cause the patient pain or damage the distal urethra
- Inject the contrast and image as soon as a major part of the contrast has been injected, taking a spot image when appropriate
- Ideal images demonstrate the entire length of the urethra with contrast beginning to fill the bladder

56. Retrograde Urethrography
INDICATIONS:
- pelvic trauma in the emergency department
- diminished urinary stream
- urethral strictures
- urethral diverticula
- urethral obstruction
- suspected urethral foreign bodies
- urethral mucosal tumors
- suspected urethral fistula

57. Retrograde Urethrography

58. Case 11 Male 25 years old Admitted for acute urinary retention.
Failed urethral catheterisation despite normal meatus
First study?

59. Case 11 Ascending (retrograde) and descending (antegrade) urethrograms
Normal calibre anterior urethra. Huge calibre change at the junction of the bulbous and membranous urethra with a dilated posterior urethra (poststenotic dilatation).