1. Urinary system: imaging diagnosis
唐光健

2. Questions to think of
Which diagnostic imaging modality is the most suitable for the urinary system and why?
What urinary diseases are suitable for imaging examination?
What imaging method should be chosen with different sort of disease considered clinically? What information we expect to get from the imaging?

3. Urinary System Characteristics: poor natural contrast
Luminal Structure
calyces, pelvic, ureter, bladder -UROGRAPHY
Parenchyma
Kidney-cortex, medulla -TOMOGRAPHIC IMAGING

4. Imaging modalities: plane film（KUB）-limited effective Urography
Intravenous pyelography IVP
Retrograde pyelography
Cystography
Urethrography show morphous of the lumen indirectly -overall view of the urinary tract -affected by the renal function & lumen construction
Ultrasonography USG real time, convenient, low cost, available -good characteristic of stone, fluid
CT Computed Tomography high resolution of high density & low density -contrast enhancement
MRI Magnetic Resonant Imaging -good contrast of soft tissues

5. Normal Manifestations
KUB: contour of kidney
-edge, density, size, position…

6. Normal Manifestations
IVP –compress the ureter, picture 15’-30’ after contrast administration
renal papilla
Vtx
body
formix
major calyx-neck
minor calyx
fundament
renal pelvic
ureter
bladder

7. Normal Manifestations
IVP –compress the ureter, picture 15’-30’ after contrast administration
renal papilla
Vtx
body
formix
major calyx-neck
minor calyx
fundament
renal pelvic
ureter

8. Normal Manifestations
IVP-normal variant
branching
ampullary

9. Normal Manifestations
retrograde pyelogram
back flow-collecting duct BF, renal sinus BF,
perivein BF, lymph duct BF

10. Normal Manifestations
B-mode sonography-
renal sinus, renal parenchyma, renal profile…

11. Normal Manifestations
CT– without/with contrast ~cortical phase, parenchymal phase, excrete phase ~profile, density, enhancement…
Parenchymal phase
cortical phase
plane scan

12. Normal Manifestations
CT– without/with contrast ~cortical phase, parenchymal phase, excrete phase ~profile, density, enhancement…
Parenchymal phase
excretive phase
cortical phase

13. Normal Manifestations
Angiography– ~no routine method, with interventional therapy ~arterial ph. parenchymal ph. Veinal ph.

14. Normal Manifestations
MRI- T1WI higher SI with cortex
T2WI homogeneous high SI (signal intensity)
T2WI
T1WI

15. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carcinoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

16. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

17. Renal solid malignant
renal carcinoma neoplasm, vascularity, necrosis

18. Renal solid malignant pathologic features correlate to imaging
neoplasm-mass effect
neoplastic vascularity
necrosis & bleeding in side the mass

19. Renal solid malignant
renal carcinoma neoplasm, vascularity, common with necrosis
plain film: profile change-helpless with diag.
urography: elongated & deformed pelvic- poor specification
BUS: substantial, hypo/inhomogeneous echoic
angiography: vessel shift, tumor flashing, neo-vessel Staging
CT high specific & sensitive Staging
MRI Seldom used

20. Renal solid malignant renal carcinoma
plain film: profile change-helpless with diag.

21. Renal solid malignant renal carcinoma
urography: elongated & deformated pelvic-poor specification

22. Renal solid malignant renal carcinoma
BUS: substantial, hypo/inhomog eneous echoic

23. Renal solid malignant renal carcinoma
CT high specific & sensitive Staging
plain scan
delay scan
With enhancemnet

24. Renal solid malignant renal carcinoma
CT high specific & sensitive Staging
delay scan
plain scan
with enhancement

25. Renal solid malignant renal carcinoma
angiography: vessel shift, tumor flashing, neo-vessel. Staging
parenchymal phase
post ia adrenalin
arterial phase

26. Renal solid malignant renal carcinoma
CT high specific & sensitive Staging
renal vein, IVC invaded by RCC

27. Renal solid malignant renal carcinoma
CT high specific & sensitive Staging
renal vein, IVC invaded by RCC

28. Renal solid malignant renal carcinoma
angiography: vessel shift, tumor flashing, neo-vessel. Staging
Arterial phase
Parenchymal phase

29. Renal s solid malignant
renal carcinoma
angiography: vessel shift, tumor flashing, neo-vessel. Staging
post embolizing of RA
IVC angiography

30. Renal solid malignant
renal carcinoma
MRI seldom use

31. Renal solid benign
Renal hamartoma (angiomyolipoma) - ratio of tree elements various, bleeding often

32. Renal solid malignant Angiomyolipoma
pathologic features correlate to imaging
neoplasm-mass effect
adipose tissue, smooth muscle, vessels
hypo-developed neoplastic vessels-bleeding

33. Renal solid benign renal angiomyolipoma
plain film: profile change-helpless with diag.
urography: elongated & deformed pelvic-poor specification
sonography: hyperechoic substantial mass mostly
CT: high specific with fat density, high sensitive, bleeding might be seen
MRI inhomogeneous signal, signal of fat & old bleeding

34. Renal solid benign renal angiomyolipoma
sonography: hyperechoic substantial mass mostly

35. Renal solid benign renal angiomyolipoma
CT high specific with fat density, high sensitive, bleeding might be seen
CT plain scan
with enhancement

36. Renal solid benign renal angiomyolipoma
CT high specific with fat density, high sensitive, bleeding might be seen
with enhancement
CT plain scan

37. Renal solid benign renal angiomyolipoma
CT high specific with fat density, high sensitive, bleeding might be seen
with enhancement
Coronal MPR

38. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

39. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

40. cystic, inside kidney-renal cyst
pathologic features correlate to imaging
with thin, even wall,
flat epithelium
clear fluid inside & no blood flow

41. cystic, inside kidney-renal cyst
plain film: profile changing
urography: pelvix & calix deforming, no specific
BUS： anechoic lesion, high specific
CT： clear appearance, high sen. & spe. for calcification of the wall or septation
MRI：cystic, signal of fluids, different diagnosis needed if signal be non-specific

42. cystic, inside kidney-renal cyst
Urography
deforming of pelvic & calculi, low specific

43. cystic, inside kidney-renal cyst C
BUS, high specific
anechoic lesion, echo enhancement post.

44. cystic, inside kidney-renal cyst C
CT： clear appearance, high sen. & spe. for calcification of the wall or septation
Waterlike, no enhancement, “no wall”

45. cystic, inside kidney-renal cyst C
CT： clear appearance, high sen. & spe. for calcification of the wall or septation

46. cystic, inside kidney-renal cyst C
CT： clear appearance, high sen. & spe. for calcification, differentiation with high density cyst
Enhancement scan
Plain scan

47. cystic, inside kidney-renal cyst C
MRI, atypical signal-differentiate
cystic, sig. of fluid

48. cystic, inside kidney-renal cyst
Multicystic kidney

49. cystic, inside kidney-multycystic kidney
plain film: enlargement & shift of renal shadow
urography: elongation/deformation of the pelvic
BUS: renal enlargement of both sides with multi-cyst ~ diagnosed
CT: manifest clear, with multi-cystic liver often

50. cystic, inside kidney-multycystic kidney
plain film: enlargement & shift of renal shadow
urography: elongation/deformation of the pelvic
BUS: renal enlargement of both sides with multi-cyst ~ diagnosed
CT: manifest clear, with multi-cystic liver often

51. cystic, inside kidney-multycystic kidney
urography: elongation/ deformation of the pelvic

52. cystic, inside kidney-multycystic kidney
BUS: renal enlargement of both sides with multi-cyst ~ diagnosed

53. cystic, inside kidney-multycystic kidney
CT: manifest clear, with multi-cystic liver often

54. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

55. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

56. cystic, outside-sub capsule hematoma
Imaging character: out of kidney, no blood perfusion, fluid inside, partial solid if clot inside
KUB: useless
BUS: crescent anechoic area outside kidney adjacent kidney deform echoic if clot in hematoma

57. cystic, outside-sub capsule hematoma
CT: crescent, low density, high density if clot within hematoma, no enhancement, kidney deform

58. cystic, outside-sub capsule hematoma
Angiography: renal vessel compressed & shifted find source of bleeding

59. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

60. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

61. pathologies of Urinary tract wall
carcinoma of renal pelvis

62. pathologies of Urinary tract wall
carcinoma of renal pelvis neoplasm, often small, seldom necrosis
plain film: helpless
urography: filling defect, high sensitive
sonography: hypoechoic substantial mass in pelvic/ureter
CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging
MRI equivalent SI in T1 & T2WI

63. pathologies of Urinary tract wall
carcinoma of renal pelvis neoplasm, often small, seldom necrosis
plain film: helpless
urography: filling defect, high sensitive
sonography: hypoechoic substantial mass in pelvic/ureter
CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging
MRI equivalent SI in T1 & T2WI

64. pathologies of Urinary tract wall
carcinoma of renal pelvis
urography: filling defect, high sensitive

65. pathologies of Urinary tract wall
carcinoma of renal pelvis
CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging
with enhancement
plain scan
delay scan

66. pathologies of Urinary tract wall
carcinoma of renal pelvis
CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging

67. pathologies of Urinary tract wall
carcinoma of renal pelvis
MRI equivalent SI in T1 & T2WI
T2WI
T1WI
STAGE

68. pathologies of Urinary tract wall
carcinoma of renal pelvis
urography: filling defect, high sensitive

69. pathologies of Urinary tract wall
carcinoma of ureter
CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging
delay scan
with enhancement
plain scan

70. pathologies of Urinary tract wall
carcinoma of ureter
MRI equivalent SI in T1 & T2WI, hydrography

71. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carinoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

72. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

73. pathologies of Urinary tract lumen- lithiasis
90% X-ray positive, diagnose considering clinical data
KUB: renal calculi-pelvic/calix (staghorn stone) ureter calculi-?
CT: high sensitive, exact positioning
USG: high specific but low sensitive with ureter calculi

74. pathologies of Urinary tract lumen- lithiasis
KUB: renal calculi-pelvic/calix (staghorn stone) ureter calculi-?

75. pathologies of Urinary tract lumen- lithiasis
Sonography: renal calculi-pelvic/calix (staghorn stone) ureter calculi-?

76. pathologies of Urinary tract lumen- lithiasis
CT: high sensitive, exact positioning
Enhancement scan
slab MIP
plane scan

77. pathologies of Urinary tract lumen- lithiasis
KUB:
Urography: renal calculi-pelvic/calix ureter calculi-?

78. pathologies of Urinary tract lumen- lithiasis
CT: high sensitive, exact positioning
Enhancement scan
MIP
plane scan

79. pathologies of Urinary tract lumen- lithiasis
MRI: no routine, low SI both T1WI & T2WI

80. pathologies of Urinary tract lumen- lithiasis
CT: high sensitive, exact positioning

81. pathologies of Urinary tract lumen- lithiasis
USG: high specific but low sensitive with ureter calculi

82. pathologies of Urinary tract lumen- lithiasis
CT: high sensitive, exact positioning
plane scan
Enhancement scan

83. pathologies of Urinary tract lumen- lithiasis
Soft tissue around cal., hydronephrosis proximately

84. pathologies of Urinary tract lumen- lithiasis
Soft tissue around cal., hydronephrosis proximately

85. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carinoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

86. Renal pathologies pathologies of Parenchymal
Solid -benign: angiomyolipoma -malignant: carninoma
Cystic inside kidney: renal cyst 　　　　 outside kidney: sub capsule hematoma
pathologies of Urinary tract
of the wall –transitional cell carcinoma
of the lumen –calculus
Inflammatory change-tuberculosis
Hydronephrosis –differentiate diagnosis

87. Inflammatory change-renal tuberculosis
nephropyelitis  renal papilla ulcer  necrosis, cavitation  pyonephrosiscalcification, renal self- resection
imaging
KUB: (－) /calcification
Urography: edge irregular (insect bite), cavitation, pelvic/ureter deform
CT: sensitive with cal. but pelvic/ureter deform
MRI insensitive
diag. – consider clinical data

88. Inflammatory change-renal tuberculosis
imaging
KUB （－） / calcification
Self-resection

89. Inflammatory change-renal tuberculosis
imaging
Urography: edge irregular (insect bite), cavitation, pelvic/ureter deform
ulcer of renal papillae
cavitation

90. Inflammatory change-renal tuberculosis
imaging
CT sensitive with cal. but with pelvic/ureter deform
plain CTscan
enhancement

91. Inflammatory change-renal tuberculosis
imaging
CT sensitive with cal. also with pelvic/ureter deform -MSCT
enhancement
delayed
plain CTscan

92. Inflammatory change-renal tuberculosis
imaging
CT sensitive with cal. also with pelvic/ureter deform -MSCT
enhancement
plain CTscan

93. Inflammatory change-renal tuberculosis
imaging
CT sensitive with cal. also with pelvic/ureter deform -MSCT

94. Inflammatory change-renal tuberculosis
imaging
CT sensitive with cal. also with pelvic/ureter deform -MSCT

95. Hydronephrosis-summary

96. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

97. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

98. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/ureter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

99. Hydronephrosis
urography (retrograde )
Ureteral carcinoma

100. Hydronephrosis
urography: (IVP, retro, percutaneous ) some causes can be diagnosed

101. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

102. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

103. Hydronephrosis-summary
sonography: high sensitivity and cause-diagnositic

104. Hydronephrosis-summary
sonography: high sensitivity and cause-diagnositic

105. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

106. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly replaced by uro- hydrography

107. Hydronephrosis-summary
CT: cause-diagnostic, sensitivity relatively high
delay scan
plain scan
enhanced

108. Hydronephrosis-summary
CT: cause-diagnostic, sensitivity relatively high
ureteral carcinoma

109. Hydronephrosis-summary
CT: cause-diagnostic, sensitivity relatively high
retroperitoneal fibrosis

110. Hydronephrosis-summary
CT: cause-diagnostic, sensitivity relatively high
retroperitoneal fibrosis

111. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

112. Hydronephrosis - summary
Obstruction of the urinary tract malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis…
imaging-various dilatation of pelvis/uriter
plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract
urography: some causes can be diagnosed
sonography: high sensitivity and cause-diagnositic
CT: cause-diagnostic, sensitivity relatively high
MRI: seldom used, urography partly rapalced by uro- hydrography

113. Hydronephrosis-summary
MRI: seldom used, urography partly rapalced by uro-hydrography
retroperitoneal fibrosis

114. Prostate: imaging diagnosis

115. Prostate-imaging anatomy
Characteristics:
soft-tissue,
poor natural X-ray contrast
central zone-rich in muscle fiber
periphery zone-rich in loose CT & glands

116. Prostate-imaging anatomy
MRI-USG-CT，not shown with plain film

117. Prostate-imaging anatomy
MRI-USG-CT，not shown with plain film
T1WI
T2WI

118. Prostate-imaging anatomy
MRI-USG-CT，not shown with plain film

119. Prostate-imaging anatomy
MRI-USG-CT，not shown with plain film

120. prostate BHP benign hypertrophy of prostate
sup. border 10mm over the pubis / diameter > 5cm
no abnormal signal/echo/density inside

121. prostate
BHP
MPR
with enhancement
plain CT scan

122. prostate
BHP
T2WI
T1WI

123. prostate prostate carcinoma
low signal lesion in periphery zone in T2WI
staging

124. prostate
prostate carcinoma
stage C
stage B

125. prostate
prostate carcinoma
with enhancement
plain CT scan

126. prostate
prostate carcinoma
plain CT scan
MPR
with enhancement

127. Questions after lecture
How to chose imaging exam for the patient with gross hematuria (how to determine the method and purpose of next exam according to the result of pre-exam)?
What is the pathologic underlying of the various manifestations of renal carcinoma with different imaging method?
What imaging method is the first chosen for the prostate exam?