Radio 250 [8]: ICC in Radiology and Nuclear Medicine

Lec 08: Genitourinary/Pelvis Radiology

October 16, 2014

Rosanna Fragante, MD

Fat
S = Suprarenal glands (aka the adrenal glands)
A = Aorta/IVC
D = Duodenum (second and third segments [some also include the
fourth segment] )
o P = Pancreas (tail is intraperitoneal)
o U = Ureters
o C = Colon (only the ascending and descending parts)
o K = Kidneys
o E = Esophagus
o R = Rectum
kidneys are located within the cone of renal fascia (Gerota fascia),
surrounded by the fat of the perirenal space
o
o
o
o

TOPIC OUTLINE
I.

Retroperitoneum

II.

KUB Imaging
A. Intravenous pyelography
B. Ultrasound
C. CT/MRI
D. CT Angiography
E. CT Stonogram
F. CT Urogram

III. Anatomical Abnormality

A. Adrenal gland
B. Nephroptosis
C. Pelvic Kidney
D. Horseshoe kidney
E. Crossed ectopy
F. Complete duplication
G. Incomplete duplication
IV. Cystic Diseases
A. Simple Renal Cyst
B. Polycystic Kidney Disease
C. Medullary Sponge Kidney
V.

URETER
3 mm thin, can collapse
1 cm diameter and 25 cm long
Three narrowings:
o
Junction of ureter and renal pelvis (ureteropelvic junction)
o
Where it crosses the brim of the pelvic inlet
o
Passage through the wall of urinary bladder (ureterovesicular
junction)

Inflammation/Infection
A. Pyelonephritis
B. Renal Abscess
C. GU Tuberculosis

VI. Urinary bladder

A. Prostatomegaly
B. Cystitis
C. UB diverticula
VII. KUB Trauma

Fig. 2. Diagram of the kidney.

A. Renal Trauma
B. Bladder trauma and extrophy

II. KUB IMAGING

VIII. Calculi

A. INTRAVENOUS PYELOGRAPHY

A. Nephrocalcinosis and Nephrolithiasis

B. Urolithiasis
C. Cystolithiasis

IX. KUB Malignancies

A. Wilms tumor

Series of films with contrast material to better visualize the urinary

system
Inject contrast with radiopaque iodine
Can be used to asses kidney function

B. Renal Cell CA
C. Transitional Cell CA
X. Renal Angiography
XI. Adrenal Glands
XII. Prostate and Scrotum
XIII. Uterus and Adnexa

I. RETROPERITONEUM

Fig. 3. IVP showing a kidney stone

B. ULTRASOUND

No radiation
Real-time
Can distinguish between solid and cystic structures
Can be used as a guide in biopsy

Fig.1. Contents of the Retroperitoeum

Contents: Fat PAD SUCKER

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Lec 08: GU/Pelvis Radiology

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Right renal artery is longer than the left RA
D. CT ANGIOGRAPHY
Can be used for preoperative evaluation before a transplant
Shows the size and morphology of kidneys, vascular anatomy
and collecting system
Shows variants and other pathologies such as stones or masses
Biggest artery id the Main, smaller considered Accessory artery
Pre-hilar branch is a coomon variant
Note: Renal arterial supply has no collateral
Fig. 4. Ultrasound of right kidney showing multiple
indentations.
C. MULTIDETECTOR CT/MRI

Detection and evaluation of:

o Obstruction and urolithiases
o Cause of hematuria
o Characterize and staging of tumors
o Cause of chronic pelvic pain
o Crypotochidism
Guidance of biopsy
Multidetector; can use different views: axial, coronal
Characterize adjacent structures
Modality of choice: CT then MRI
o
CT is readily available, less expensive

Fig. 6. CT Angiography of Kidney

E. CT STONOGRAM

Replaced X-ray for visualizing stones

Can detect even cystic or uric acid stones
Check Hounsfield unit/ CT number to determine the type of
stone: higher number means more calcified
F. CT UROGRAM
Gives contrast
Perinephric bridging septa
o Serve as conduit for spread of fluid, inflammation,
neoplasm
o Preclude adequate drainage of fluid/abscess
Tumor extending beyond Gerotas fascia means poor prognosis

Fig. 5. CT Scan showing a large stone in the left kidney.

Triphasic CT
Arterial/Nephrogram phase
o Shows corticomedullary differentiation
o Shows renal lesions
Venous phase
Late Venous Pyelogram
o Shows the collecting system
o Shows urothelial lesions, transitional cell carcinoma,
stones, blood clots
Kidney
Cortex contains glomerulus and part of tubules
Medullary pyramids contain part of tubules
Major calyces drain into the pelvis
Renal pelvis collects urine and drain into ureter
Left renal vein (6-10cm) is longer than the right RV (2-4cm)
Multiple veins most common abnormality

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Fig. 7. CT urogram showing the absence of stones.

III. ANATOMICAL ABNORMALITY
A. ADRENAL GLAND

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Thickness: 5-6 mm
Located in the superomedial aspect of the kidney, in the
perirenal space
Common variants:
o Fetal lobulations
o Dromedary hump
o Prominent Column of Bertin

o
o

Nephrolithiasis
Wilms tumor, TCCA

Fig. 10. Horseshoe kidney (left) and Pelvic kidney (right).

E. CROSSED ECTOPY
Fig. 8. Common variants of adrenal glands.
B. NEPHROPTOSIS/WANDERING KIDNEY
Descent of kidney >5cm or 2 vertebral bodies when the patient
moves from a supine to upright position

90% with fusion

Complications:
o 50% with nephrolithiasis
o Infection
o Hydronephrosis
The kidney is located opposite from where its ureter inserts into
the bladder

Fig. 11. Crossed Ectopy Variations

F. COMPLETE DUPLICATION
Ureteric bud splits or arises twice from kidney with upper and
lower lobe moiety
Upper ectopic ureter prone to obstruction with ureterocoele

Fig. 9. Ptotic right kidney

C. PELVIC KIDNEY
Most asymptomatic
Complications/prone to:
o Trauma (decreased protection)
o Nephrolithiasis
o Anomalies

ureteropelvic
junction
vesicoureteral reflux and decreased function

obstruction,

D. HORSESHOE KIDNEY
Most common fusion anomaly
Complications:
o Trauma
o Calculi
o Transitional cell CA
Prone to

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Fig. 12. Incomplete duplication on the right.

G. INCOMPLETE DUPLICATION

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Fusion of ureters, entry at one point

Fig. 14. Simple Renal Cyst in Xray, CT Scan amd UTZ.

Bosniak III
wall thickening
multiple septations
o Higher chance of malignancy (30-60%)
Fig. 13. Bilateral incomplete duplication
IV. CYSTIC DISEASES
A. SIMPLE RENAL CYST

B. AUTOSOMAL RECESSIVE/INFANTILE POLYCYSTIC

KIDNEY DISEASE
Before birth
Bilateral enlarged kidneys with small dilated ducts papillary tips
to cortex
Grapelike kidney

Bosniak I
Fluid inside is clear
50% of population greater than 50 years
Tubular diverticula which detach and filled with fluid
Thin walls
No solid component
Fig. 15. Polycystic Kidney Disease

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C. MEDULLARY SPONGE KIDNEY

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Brushlike densities stone disease in multiple ectatic tubules
and papillae
Recurrent stone formation

Fig. 18. Renal abscess (A) with thick walls and and
septations.
C. GU TUBERCULOSIS

Fig. 16. Medullary nephrocalcinosis

V. INFLAMMATION/INFECTION
A. PYELONEPHRITIS
Common cause: E. coli
Usually seen in DM, obstructive process e.g. stones, ureterovesical refux
Usually normal but contrast excretion can be delayed or
decresed
Female babies have higher chance of having this

Fig. 17. Axial CT Scan scan showing wedge shaped defects

due to edema caused by pyelonephritis
B. RENAL ABSCESS
Complication of pyelonephritis: collection of infective fluid leads
to complex mass
If pus/fluid is not evacuated, antibiotics will not work

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Hematogenous spread from lungs

Granulomas start from cortex and go to collecting system
Get papillary necrosis and sterile pyuria
Cortical scarring with dilatation and distortion of adjoining calices
coupled with strictures of the pelvicaliceal system
putty kidney

Fig. 19. KUB Film (left) and CT Scan (right) with foci of renal
tuberculosis, shown by white arrows. Multiple calcific
densities are seen. In the ureter, there are stones. CT scan
(upper right) shows presence of multiple granuloma in the
liver (possible source of genitourinary TB)
VI. URINARY BLADDER
A. PROSTATOMEGALY

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Fig. 21. IVP showing dilated ureter and calices.

Because of the obstruction, vesicoureteral reflux may ensue
an lead to hydroureter and hydronephrosis (dilation of the
ureters, renal calyces and kidneys)
C.

Fig. 20. IVP showing enlarged prostate.

An enlarged prostate may lead to chronic bladder outlet
obstruction with subsequent cystitis or inflammation of the
bladder mucosa.
Patients complain of poor stream due to retention
(DRIBBLING)
In IVP, it may appear as a wedge-shaped opacity (Christmas
tree sign) that is hyperdense after administration of contrast.
The contrast that is able to occupy the bladder is crescentshaped.
Bladder wall may exhibit irregularity due to overdistention and
inflammation

B. Chronic Bladder Outlet Obstruction Cystitis

URINARY BLADDER DIVERTICULA

Fig. 22. Urinary bladder diverticula

Another consequence of chronic bladder outlet obstruction is
the formation of diverticular due to the thinning of the bladder
wall.
VII. KUB TRAUMA

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A. RENAL TRAUMA
Injury to the kidney may lead to hemorrhages at the perirenal
region
If patient presents with flank pain, perform CT and assess the
extent of the hematoma
Reperfusion may be done but patient must be observed first.
Temporize if the BP does not go low.

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Fig. 23. CT Scan of kidney showing hemorrhage

B.

Bladder Trauma and Extrophy

Fig. 24. Widening of the symphisis pubis.

Seatbelts are now designed with a strap across the upper
body to help distribute the impact in collisions and minimize
bladder trauma
Widening of the symphysis pubis may lead to complete
bladder extrusion from the pelvic cavity in severe trauma
cases.
These are mostly due to straddle injuries and may involve the
urethra in males
VIII. CALCULI
A. NEPHROCALCINOSIS AND NEPHROLITHIASIS

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Fig. 25. Plain radiograph (right) and UTZ (left) showing

stones
Nephrolithiasis stone deposition in the kidney
Nephrocalcinosis calcium deposition in the kidney
Plain radiograph may present as a hyperdense structures or
none at all (uric acid and cysteine stones)
Ultrasound presents as an irregular hyperechoic structure
that possesses posterior sonic shadowing due to the nonpenetration of sound waves
B. UROLITHIASIS
Urolithiasis stone deposition in the ureter or renal pelvis
Where do the stones mostly deposit along the ureter?
Uretero-pelvic junction, as the ureter crosses the pelvic brim,
ureterocystic junction
May cause dilated renal pelvis and ureter proximal to the
stone if it chronically causes obstruction
Flank pain is described as a shard of glass passing against
your palate

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Fig. 26. Stone in the ureter.

C. CYSTOLITHIASIS

Fig. 28. Wilms tumor.

Most common childhood renal malignancy
Can be seen in 0-2 year old patients
Genetic abnormality
Large heterogeneous mass that may present as a cystic
lesion

B. RENAL CELL CA

Fig. 27. Stone in the urinary badder.

Cystolithiasis stones in the urinary bladder
These are seen in males mostly as lamellated, egg-like
structures
IX. KUB MALIGNANCIES
A. WILMS TUMOR

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Fig. 29. CT Scan showing renal cell carcinoma

Most common malignant renal tumor
From the renal epithelium

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C. TRANSITIONAL CELL CA

Fig. 31. Stenosed renal artery

The RAAS Pathway is stimulated and the development of
secondary hypertension is developed compensation for
poor renal blood flow causes hypertension
B. Fibromuscular Dysplasia of the Renal Arteries

Fig. 30. CT Scan (top) UTZ (bottom) showing TCCA

Multi-focal and may extend to the ureters and the urinary
bladder
Found within the collecting system
Always look for lymph node and regional invasion
Most common site is in the bladder
This happens because the carcinogens that are excreted
renally pass through this route. Risk increases if there is longstanding obstruction
RF: Smoking, factory workers, chemotherapy
As opposed to TCCA, Anaplastic CA is highly aggressive,
fast-growing and increases high incidence of invasion to
adjacent structures

Medscape: angiopathy that affects medium-sized arteries

predominantly in young women of childbearing age.
XI. ADRENAL GLANDS

X. RENAL ANGIOGRPAHY
A. RENAL ARTERY STENOSIS

Fig. 32. Haemorrhage in adrenal gland.

Adrenal cortex outer layer; produces mineralocorticoids,
glucocorticoids and androgen
Adrenal medulla inner layer; produces epinephrine and
norepinephrine
A. ADRENAL ADENOMA

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Fig. 34. CT Scan showing phaeochromocytoma.

Tumor or mass affecting the adrenal medulla that may lead to
hypertension due to the increased production of
catecholamines
Triad: Diaphoresis, Palpitations and Headache
To localize tumor, use CT because it has a sensitivity of 95%
Use non-ionic media if IV Contrast is needed to prevent
allergic reactions from occurring
C. ADRENOCORTICAL CARCINOMA

Fig. 33. Adrenal adenoma.

Cortical lesion that possesses a tear-drop appearance
Low-density, well-defined
Possesses mild enhancement
May present with Cushings syndrome, Conns disease or as
an incidental finding
Use CT with contrast or MRI
B. PHEOCHROMOCYTOMA

Fig. 35. Adrenocortical carcinoma

NCI: A rare cancer that forms in the outer layer of tissue of
the adrenal gland (a small organ on top of each kidney that
makes steroid hormones, adrenaline, and noradrenaline to
control heart rate, blood pressure, and other body functions)
D. ADRENAL MYELOLIPOMA

Fig. 36. Adrenal Myelolipoma

Histologic diagnosis for this finding can be given if fat is
visualized in an adrenal mass
Fat = -128 Hounsfeld units
XII. PROSTATE AND SCROTUM

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A. BENIGN PROSTATIC HYPERPLASIA

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Fig. 37. Inner gland enlargement of the prostate

Inner gland enlargement and may compress the urethral
orifice and cause chronic bladder outlet obstruction
B. ACUTE EPIDIDYMO-ORCHITIS

Fig. 38. Acute epididymo-orchitis

Presents with scrotal pain and tenderness
Enlargement and marked hypervascularity in the epididymis
and testis use Doppler sonography
May be caused by a bacterial or viral (Mumps) infection

Fig. 40. UTZ showing endometrium and myometrium

Normal: Pear-shaped
Transvaginal or transabdominal ultrasound
Endometrium (yellow arrow)is more echogenic than the
myometrium
A. MYOMA UTERI

Fig. 41. Myoma in the uterus

B, ENDOMETRIAL HYPERPLASIA

C. TESTICULAR TORSION

Fig. 39. Testicular torsion

Medical emergency
Presents with scrotal pain
Use CT with Doppler to visualize scrotal vessels
XIII. UTERUS AND ADNEXAE

Fig. 42. Endometrial hyperplasia

C. Normal Ovaries in Childbearing Women

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Fig. 43. Ovaries in child bearing women

Larger and has follicles
Ovaries average 4 x 3 x 2 cm in size
Maximum ovarian volume = 22 mL
D. Normal Ovaries in Post-menopausal Women

Fig. 45. Hemorrhagic cyst

Medium level echogenicity within the cyst
Does not resolve within 2 months
G. Early Pregnancy Evaluation

Fig. 43. Ovaries in child post menopausal women

Smaller and has no or very minimal follicles
E. Physiological Ovarian Cyst

Fig. 46. Intrauterine pregnancy

Fig. 44. UTZ showing ovarian cyst

Thin-walled and well-defined
Anechoic
Resolves or regresses in follow-up ultrasound
F. Hemorrhagic Cyst or Endometrioma

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Fig. 47. Ectopic pregnancy

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Fig. 48. Monochorionic diamnitoic twin pregnancy

Fig. 49. Dichorionic diamnitoic twin pregnancy

Fig. 51. Normal placenta: high lying and with normal blood flow
in Doppler sonography

Fig. 52. Placenta previa = covers the internal cervical os

I. Amniotic Fluid Evaluation
Fig. 50. 3D and 4D Reconstruction
H. Placental Evaluation

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Fig. 53. Normal amniotic index

Fig. 55. Fetal baby boy exhibits the bird sign

Fig. 54. Oligohydramnios - less than normal amount of

amniotic fluid surrounding the child

Fig. 56. Fetal baby girl - exhibits the hamburger sign

J. Fetal Sex Determination

END OF TRANSCRIPTION
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