Anatomy

The kidneys, renal pedicle, and adrenal glands are located in the perirenal space, which is
bound by the
anterior and posterior renal fascia (Gerota's fascia; for anatomy, see the section titled
Retroperitoneum).
Renal Pedicle (Fig. 4-1)
• Renal artery
• Renal vein
• Collecting system and ureter
• Lymphatics
Collecting System
• Minor calyces: most kidneys have 10 to 14 minor calyces
• Major calyces
• Renal pelvis: may be completely within the renal sinus or partially “extrarenal”
Orientation and Size of Kidneys
• Kidneys are 3 to 4 lumbar vertebral bodies in length, 12 to 14 cm long, and 5 to 7 cm wide.
• Intravenous pyelograms (IVPs) overestimate the true renal length because of magnification
and renal engorgement from osmotic diuresis. Ultrasound (US) often underestimates the true
renal length because of technical difficulties in imaging the entire kidney.
• Left and right kidney size should not vary more than 1 cm.
• Right kidney is 1 to 2 cm lower than the left kidney and slightly more lateral.
• Renal axis parallels axis of psoas muscles.

Bolus IVP
Today, IVPs are rarely used but are covered for historical purposes. The bolus administration
ensures maximum
concentration of contrast media in the kidney.
Indication: healthy ambulatory patients (screening type urography [e.g., for urinary tract
infection]), trauma.
Technique
1. Kidney, ureter, bladder (KUB)
2. Inject 100 mL of 30% contrast
3. 1-min and 5-min film of both kidneys
4. 10-min KUB and both obliques
5. Coned bladder view
6. Postvoid KUB

Drip-infusion nephrotomogram
With drip infusion, the nephrogram persists longer, allowing more time for
nephrotomography and special views, if necessary. Today, this is much less commonly
performed than the bolus technique or computed tomography (CT). If calcifications are seen
on the renal outlines, scout oblique films can be obtained to determine the exact location
relative to the kidneys.
Technique
1. KUB and preliminary tomogram of kidneys (starting at 8 cm from back)
2. Drip infusion of 300 mL of Urovist 14% (or Conray-30) or 150 mL of Isovue 300 (or
Omnipaque 300)
3. Obtain tomograms after 150 mL has been given.
Usually 7 to 9 cuts are obtained.
4. Postinfusion KUB and both oblique views
5. Coned bladder view
6. Postvoid KUB

Retrograde pyelogram
A catheter is placed in the distal ureter via cystoscopy and contrast is administered via the
catheter by hand injection to opacify the collecting system (no parenchymal opacification).
This technique is primarily used for PUL access and difficult nephrostomy placements.
Pretreatment protocol for IV iodinated contrast in patients with previous allergic
reaction
• Prednisone, 50 mg PO or IV, 13 hours, 7 hours, and 1 hour before contrast injection
• Diphenhydramine, 50 mg PO or IV, 30 to 60 minutes before contrast media injection
CT protocols of the kidney/ureters

Stone Protocol
• Noncontrast CT of the abdomen and pelvis using 5-mm collimation
Percutaneous nephrostomy (PCN)
Refers to percutaneous drainage of renal collecting system by catheter placement.
Complications: 2%-4% (extravasation of contrast, bleeding)
Indications
• Hydronephrosis (acute, subacute obstruction)
• Pyonephrosis
Technique (Fig. 4-2)
1. Preprocedure workup:
• Check bleeding status.
• Antibiotic coverage: ampicillin, 1 g; gentamicin, 80 mg in patients with normal renal
function and no contraindications
• Review all films and determine on plain film where kidneys are located, especially in
relation to colon, spleen, and pleural reflections.
• US or IV contrast opacification of kidneys may be helpful in difficult approaches or
nondilated collecting systems. IV contrast is less useful with severe obstruction because
opacification may not occur or may be impractically delayed.
2. Local anesthesia, aiming for upper pole calyx
with 20-gauge Chiba biopsy needle. Aspirate
urine to check for position and for partial
decompression of collecting system before contrast
opacification.
3. Using a second needle/sheath system, aim for middle pole calyx. Skin insertion point is
inferior and slightly lateral to calyx. When positive urine returns, advance 0.038-inch
guidewire as far as possible. If wire coils in calyceal system, a Kumpe catheter may be useful
for manipulation.
4. Dilate skin up to 12 Fr.
5. Pass 10-Fr PCN tube over guidewire. Remove stiffener and guidewire. Coil pigtail. Inject
contrast to check position of catheter. Cut thread.
6. In the setting of infection, complete evaluation of the ureter via an antegrade injection is
best
deferred to a second visit.

Baru

I NVESTIGATIONS

a. Plain film

The standard plain radiographic imaging of the urinary tract is the KUB (kidneys, ureters
and bladder), which consists of a full length abdominal film and an upper abdominal (cross-
kidney) film ( Fig. 29.6). The films are taken with the patient supine using a low voltage
technique (60-65 kV) to maximise soft-tissue contrast. The full length filth is taken in
inspiration using a 35 x 43 cm cassette positioned with the lower border at the symphysis
pubis to ensure the urethra (particularly the prostatic urethra) is included on the film. The
cross-kidney filth is taken in expiration using a 24 x 30 cmcassette with the lower border 2.5
cm below the iliac crests.
The outline of several anatomical structures can be seen on the KUB, including renal,
psoas and bladder outlines, much of the axial skeleton, the bowel gas pattern and the lung
bases, all of which should he routinely inspected. A range of pathology may he observed in
these and other structures but the KUB is a relatively unreliable diagnostic tool and, despite
the occasional incidental finding in other systems, its principal use is in the assessment of
urinary tract calculi. It is, however, extremely unreliable in the diagnosis of ureteric calculi,
with an accuracy of only around 50%.
There are numerous causes of calcification visible on the plain radiograph, with considerable
overlap in their appearances, and a specific diagnosis is often not possible. The more
common causes arc listed in Box 29.1. The KUB is most usefully employed as part
of an intravenous urogram (IVU) or to follow up a previously proven calculus.

Intravenous urography
The intravenous urogram (IVU) is the classic routine investigation of' uroradiology. With the
advent of ultrasound its role is now much diminished and its future is the subject of
considerable debate as other modalities, particularly spiral computed tomography (CT),
become more widely available. At this date, however, it is still widely used and requires
consideration. Currently the main indications are the investigation of persistent or frank
haematuria, renal and ureteric calculi (particularly prior to endourological procedures),
ureteric fistulas and strictures and complex urinary tract i nfection (including tuberculosis).
The IVU concit of the series of plain films taken after administration of an intravenous
injection of a water-soluble iodinecontaining contrast medium. There is considerable
variation in the exact details of how an IVU is performed in different departments,
although there should be general agreement on the underlying principles.
Traditionally the patient was prepared with a period of 4 h starvation and fluid deprivation
and the bowel purged with a strong laxative. Bowel preparation is now generally regarded as
unhelpful and it was unpleasant for the patient: it has now largely been dispensed with.
Occasionally the patient will feel nauseated after the IVU injection and rarely there will be a
severe reaction with the need for cardiovascular and occasionally cardiopulmonary support.
With this in mind, it seems reasonable to persist with avoidance of food for 2-4 h prior to the
procedure. There has been a considerable body of work on the potential adverse effects of
intravenous contrast on renal function and its relationship to the patient's fluid status.
Traditionally fluid was restricted prior to the IVU in order to i mprove opacification oh the
collecting system. However, it has long been accepted that dehydration is associated with an
increased risk of nephrotoxicity, which may be permanent in patients with diabetes mellitus,
myeloma, hyperuricaemia, sickle-cell disease and pre-existing renal disease. The risk of
irreversible damage to renal function in a previously healthy kidney due to the contrast
injection i s very low. This appears to he further reduced with avoidance of dehydration.
Modern non-ionic contrast agents do not provoke an osmotic diuresis and the degree of
opacification is unlikely to be significantly altered by dehydration. Fluid restriction should
therefore he avoided and if there is a risk that the patient is dehydrated before the IVU this
should be corrected first.
The classical series of plain films (immediate, 5 and 15 min, full l ength release and
postmicturition) is described, with mention of some of many potential modifications. A
preliminary postmicturition plain film (KUB) is performed. This should he examined to
check exposure factors, centring and obvious pathology, particularly urinary tract
calcification. Intravenous contrast is given relatively rapidly by hand. The standard dose is 50
ml of 350-370 strength water-soluble contrast. Some understanding of the underlying
structure of water-soluble contrast agents is desirable and a knowledge of potential adverse
reactions and their treatment is i mperative. These issues are discussed under water-soluble
contrast ( p. 926). At this point it is worth emphasising some safety features.
Although modern contrast medium is exceptionally safe, there is a small risk of serious
reactions. The most dangerous of these are the anaphylaeloid-type hypersensitivity reactions.
To minimise the risks of these a routine inquiry about previous contrast exposure and allergy
is recommended before administering the contrast medium.
The injection should be through some form of indwelling cannula or needle that can he taped
into place for the duration of the investigation. This allows emergency treatment to he
administered if required, or a further injection of contrast if opacification is seen to be
inadequate. There should also be a doctor (usually the radiologist) available in the X-ray
department throughout the investigation.
Most adverse events are likely to take place within the first few minutes after the injection.
Emergency drugs, oxygen and resuscitation equipment should also be readily available.
Treatment of contrast reactions is discussed on page 928, as is the specific problem of
metformin interaction.
A cross-kidney film is taken immediately after contrast injection and at 5 min after the
injection (Fig. 29.7). Abdominal compression is applied as soon as the 5 min film has been
taken (a variety of devices are available for this) to inhibit ureteric drainage and promote
distension of the pelvicalyceal systems, optimising their visualisation. A further cross-kidney
film is taken at 12-15 min to demonstrate this.
Compression is routinely omitted in children and should be avoided in a number of situations.
It is contraindicated if there is an aortic aneurysm. If the patient's abdomen is tender it should
also be avoided. This contraindication includes recent abdominal surgery and the acute
painful abdomen, the latter including renal colic. In the case of renal colic, even if the patient
can tolerate compression it is best avoided because it is unlikely to contribute to the
investigation and potentially may exacerbate the tendency of the acute obstruction to provoke
extravasation of urine at the fornices. If this does occur, however, it is not a cause for undue
alarm as it is not uncommonly encountered spontaneously in renal colic and does not
appear to be associated with adverse sequelae.
If the 15 min film is satisfactory the compression is removed and a full length film is taken
immediately to offer the best opportunity of demonstrating the ureters. The patient is then
asked to empty the bladder and a further full length film is taken to demonstrate drainage of
the upper tract and the postmicturition bladder volume.
This classical series can he modified to deal with particular circumstances, to attempt to
increase the sensitivity of the procedure or to reduce the radiation dose to the patient. Some
of the most frequently employed modifications are detailed in Table 29.1. Three
circumstances in particular are worthy of further comment. are worthy of further comment.
When there is significant acute obstruction, usually due tocalculi, there is delay in
opacification of the collecting system. The delay may be considerable, up to 24 h or more. It
is then necessary to perform the minimum number of additional films. The time interval
between films traditionally is approximately doubled, with films taken at 0.5, 1, 2, 4, 16 and
24 h, as necessary; however, in order to minimise the radiation exposure, if there is no
opacification of an acutely obstructed kidney at 30 min it is usually unhelpful to perform the
next film before around 4 h after contrast injection. A further manoeuvre to minimise
radiation dose in patients with a strong clinical suspicion of ureteric colic is to omit all films
after contrast until a full length 15 min film is performed.
Patients with proven or suspected ureteric calculus may require one or more follow-up IVUs.
These should have the minimum number of films required to answer the specific question, for
example a full length plain and 15 min postcontrast film may be sufficient. It is very rarely
necessary to perform an IVU on a pregnant patient. If it is required, the radiation exposure
should be minimised. The collecting systems in pregnancy are capacious and the ureters
exhibit poor peristalsis. Consequently a single full length preliminary film and a delayed
solitary full length film around 30-45 min may well be enough.
The stereotypical appearances of the normal IVU are as follows. It takes approximately 12-20
s for contrast to reach the renal arteries following its intravenous injection. At this stage its
concentration is maximal in the vascular compartment; however, this falls rapidly as the
contrast medium begins to escape into the extracellu- Jar compartment and also undergoes
rapid glomerular filtration and enters the renal tubules. In the first minute of the IVU healthy
kidneys (assuming a normal cardiovascular system) show diffuse enhancement. This is
referred to as the nephrogram. During the nephrogram phase the renal size (normally at least
three vertebrae i n length but no more than four) and outlines arc best seen. In roughly the
first half minute, contrast in the vascular compartment dominates and therefore the cortex is
more enhanced than the medulla: this differentiation is sometimes visible on the immediate
film of the IVU series (but regularly visible on CT performed at this stage). In the second half
minute, contrast in the tubules increases and enhancement of the kidneys is more diffuse.
Contrast begins to appear in the calyces from around 1 min. From this time, in good quality
films, contrast may also be visible in the collecting ducts as fine linear opacities running
along the medullary pyramids towards the calyces. This may be referred to as pyelotubular
stasis or, when less defined, as the medullary or pyramidal blush, and is a normal
phenomenon.
Contrast in the normal calyces will begin to drain immediately i nto the pelvis and ureter and
this phase may be referred to as the pyelogram. The successful application of compression
impedes ureteric drainage and distends the pelvicalyceal system, producing optimal
visualisation of the pelvicalyceal system around 12-15 min.
After compression is released there is a transient increase in flow down the ureters and the
release film offers the best chance of demonstrating the ureters. The normal ureters exhibit
continual peristalsis and on a single film it is uncommon to demonstrate the entire length of
both (or even either) ureters. They will often demonstrate smoothly narrowed areas
(especially at the pelviureteric junctions and as they cross the iliac vessels in the pelvis) and
more relaxed capacious areas. This is normal and how vigorously further efforts are made to
demonstrate the entire length of the ureter depends on the clinical situation. In most situations
partial visualisation of a non-obstructed but otherwise normal ureter is acceptable. If there is
persistent hacmaturia or abnormal cytology further efforts to demonstrate the ureter are
required and may include prone films, repeat IVU after a short interval and/or retrograde
pyclography.

USG
Ultrasound of the urinary tract can be considered under three headings: ultrasound of kidneys
and bladder, ultrasound of the male genitalia and ultrasound of the prostate.
Kidneys and bladder
Routine ultrasound of the urinary tract consists of examination of the kidneys and the full
urinary bladder and is probably now the most frequently performed radiological investigation
of the urinary tract. The commonest indications are urinary tract infection and prostatism.
Other indications include haematuria, obstruction, masses, calculi, congenital abnormalities.
renal failure and assessment of transplants. It is frequently used to guide diagnostic or
therapeutic procedures. Assessment of the postmicturition bladder volume is often also
performed as part of the same examination, especially for prostatism. Most modern probes
emit a broad band of ultrasound that can be biased towards high (for thin patients) or low
frequency, usually within the 2-6 MHz range for abdominal and pelvic work. The position of
the normal kidneys is extremely variable and the optimal window for visualisation has to be
determined for each patient. Conventionally each kidney is examined subcostally from the
loin with the patient in the lateral position, the side of interest uppermost. Often, however,
complementary views can be obtained with the patient supine with a more lateral or
intercostal approach.
On ultrasound the normal renal cortex appears slightly hypoechoic compared to the liver and
spleen. It lies as a peripheral rim with normal invaginations (columns of Bertin) projecting
inwards between the medullary pyramids (Fig. 29.8). The pyramids are markedly hypoechoic
compared to the cortex in the first 6 months of life, becoming less hypoechoic with ageing
and in some disease states. Corticomedullary differentiation is therefore most obvious in
young adults and children, and the hypoechoic pyramids are occasionally mistaken for the
dilated calyces of a hydronephrosis.
Arcuate arteries can be identified in 25% of the adult population as focal hyperechoic areas at
the corticomedullary junction. The centrally placed renal sinus contains the calyces,
infundihula, part or all of the renal pelvis, blood vessels, lymphatics, fibrous tissue and fat. It
is the most hyperechoic part of the kidney, owing to the presence of fat. The normal renal
pelvis may be seen within the sinus fat as an echo-free structure, especially with a full
bladder in the female. Often it will decrease in size when the patient empties her bladder.
This, and the absence of dilated calyces separating the sinus fat, allows differentiation from
hydronephrosis. Most normal adult kidneys have a maximum length of 10-12.5 cm, although
substantial numbers of normal kidneys may be seen within the 9-13.5 cm range. Kidneys are
roughly related to the patient's size and show some decrease in length with age (especially
above 80 years). A difference of 2.0 cm or more between the two kidneys raises the
possibility of unilateral disease. Measurements of renal length on ultrasound are of the order
of 0.5 cm less than on IVU, which suffers from radiographic magnification. Although areas
of scarring and diffuse cortical loss are appreciated subjectively, it is difficult to measure
cortical thickness objectively with any degree of accuracy. In young healthy adults cortical
thickness is of the order of 2.5-3 cm at the poles and 1.5-2.0 cm elsewhere. This may
decrease substantially with age and he associated with an increase i n the central sinus fat, a
phenomenon also visible on IVU.
Doppler assessment of the renal artery flow in order to identify significant renal artery
stenosis may be requested as part of the investigation of hypertension (discussed further
under renal arterial disease) and early in the assessment of renal transplant viability. The
pelviureteric and vesicoureteric junctions may be seen on ultrasound, especially when
diseased, but otherwise the normal ureter is not routinely demonstrated.
Routine examination of the bladder requires it to be moderately full. The normal bladder has
a triangular shape in the sagittal plane, and that of a square with the corners rounded off in
the transverse plane. The normal wall thickness is 2-3 mm when the bladder is moderately
full (Fig. 29.9). In the investigation of bladder outflow obstruction an assessment of
postmicturition residue is often requested. This is fraught with inaccuracies, related as it is to
the bladder volume initially (both over- and underdistension may preclude normal emptying)
and variability in the shape of the bladder.
It is, however, a broadly useful tool and simple to employ. The bladder is assumed to be
roughly elliptical and the maximum transverse, sagittal and craniocaudal dimensions are
measured. There is usually a volume function on the ultrasound machine that will generate a
volume from these figures, or they can he multiplied together and by the constant for an
ellipse, which is 0.533 (or roughly a half). The prostate is routinely identified at the bladder
base, especially when enlarged. The seminal vesicles are also often seen posterior to the
bladder.

Direct contrast investigations

In this group of investigations water-soluble contrast is injected via some form of catheter
directly into part of the urinary tract. The following are considered under this heading:
retrograde pyelography, cystography, loopography, stentography and urethrography. A
further group of procedures, including antegrade pyelography, also involve direct injection of
contrast into the collecting system but because they involve a percutaneous approach they are
considered under the heading of non-vascular interventional procedures.
All of these procedures may potentially introduce infection into the urinary tract and care
should he take to use a sterile technique, and broad-spectrum antibiotics should be
administered prior to the procedure.
Retrograde pyelography This investigation aims to optimally opacify the pelvicalyceal
system and ureter. It usually follows an IVU and is indicated when there is persistent
uncertainty about the diagnosis, particularly if there is haernaturia and/or suspicious cytology.
It is indicated to confirm or refute the presence of one or more filling defects within the
collecting system, or to improve demonstration of the collecting system, either when there
has been inadequate demonstration of part or all of the system or when the IVU is normal but
the abnormal laboratory findings persist. It is occasionally used to demonstrate the lower end
of an obstructed ureter.
The urologist positions catheters within one or both ureters cystoscopically and the patient is
transferred to the X-ray department. Under screening control 5-20 ml of a 150 strength
watersoluble iodine-containing contrast agent is injected via each catheter in turn. It is
important to avoid injecting air bubbles, which can be mistaken for filling defects. The
pelvicalyceal system and ureter should be adequately opacified but not overdistended. Spot
films should be taken prior to injection of contrast and then of the opacified pelvicalyceal
system and ureter (Fig. 29.12). The ureteric catheter can be withdrawn to allow contrast
injection at a site of concern after adequate images have been obtained higher up.

Overvigorous injection of contrast may lead to reflux of contrast into the collecting ducts
(pyelotubular reflux) and forniceal rupture with contrast extravasation into the renal sinus
(pyelosinus extravasation) or more extensively into the regional lymphatics or veins
(pyelolymphatic and pyelovenous extravasation) (Fig. 29.13).

Cystography Cystography can be classified into three groups: mieturiting cystourethrography

(MCUG), dynamic cystography and simple cystography. The MCUG is primarily performed
for the assessment of vesicoureteric reflux and is therefore essentially an investigation of
childhood. It is discussed in the paediatric investigations section below. Dynamic
cystography is part of the urodynamics investigation of the lower urinary tract, and again is
discussed below in the appropriate section.
Simple cystography is a relatively frequently performed and straightforward investigation in
the adult. It is used to assess the integrity of the bladder following trauma or surgery or to
investigate suspected fistulas involving the bladder (usually into the gastrointestinal tract,
occasionally elsewhere such as the vagina). In the context of trauma the patient should be
referred with a catheter already in place (either suprapubic or urethral if the referring surgeon
can safely position one). A spot film should be obtained before contrast is administered.
Approximately 250 ml of 150 strength contrast is infused into the bladder via a giving set.
This should be done under frequent intermittent screening control so that extravasation can he
identified as soon as it occurs. When the bladder has been filled or when extravasation is
identified a spot film is obtained in the supine position. Ideally 45° oblique and lateral spot
films should be obtained but the patient will often have significant pelvic trauma and this
may not he possible. If a C-arm is available this may be useful but external splinting of the
pelvis may degrade the images. In modern trauma management many patients will undergo
CT scanning of the abdomen and pelvis after intravenous contrast. Under these circumstances
repeating the images of the bladder 20 min after contrast is administered is at least as accurate
as direct contrast cystography and obviates the need to transfer the patient to a different table
for a further investigation.
When a patient has undergone radical prostatectomy or cystcctomy, with preservation of the
sphincter and reconstruction of the bladder using small bowel, a cystogram is often
performed around 10 days postoperatively to demonstrate the integrity of the surgical
anastamoses prior to removal of the urethral catheter. Only 100-150 nil of contrast is required
and the patient will often cornplain of fullness at a significantly smaller volume, at which
stage the infusion should stop. The patient is likely to be ambulant and adopt easily the
positions required for the full series of images ( Fig. 29.16). When a patient has a suspected
vesical fistula, 250 ml of contrast can he used to maximise the chance of demonstrating the
fistula. Again the patient usually has no trouble adopting the required positions.

Urethrography This can be performed via an ascending or descending approach. With

advances in urethroscopy these procedures are required much less than formerly. Descending
urethrography is usually part of the micturating cystogram and is rarely indicated in adults.
When it is performed in adults the bladder should be adequately filled (with at least 200 ml of
150 strength contrast). The screening table should be positioned erect. Imaging is performed
directly anteroposterior in females (Fig. 29.17) and in a 45° oblique projection in males (Fig.
29.18).
Males are generally used to micturating while standing, often in unusual situations, and can
manage with a bottle while screening is performed and spot films taken of the urethra and
bladder base. Females are provided with a special drainage receptacle that is held between the
thighs.
Ascending urethrography is essentially confined to the male. It is used in the investigation of
trauma, stricture and fistulas. The patient is positioned in a 45° oblique position with the
dependent hip partly flexed to provide stability and ensure the urethra is not projected over
hone. A I2-16 gauge Foley catheter is positioned with its balloon a Couple of centimetres into
the distal urethra. The balloon is gently partially inflated to provide a seal without undue
trauma. Between 5 and 10 nil 150 strength contrast is injected gently into the urethra under
direct screening and spot filets arc taken (Fig. 29.19). The urethra is usually easily opacifed
hack to the urogenital diaphragm. In a minority of patients contrast will reflux into the
posterior urethra and bladder. Usually, however, with ascending urethrography the prostatic
urethra is not demonstrated.Overenlhusiastic instillation of contrast into the urethra can he
painful and produce extravasation of contrast into the corpora cavernosa (Fig. 29.20).
Female urethrography is rarely required, virtually all urethral pathology being better
demonstrated on urethroscopy or trailsvaginal sonography.
Antegrade pyelography This is a relatively simple procedure. It is used to evaluate the cause
and level of ureteric obstruction in the minority of patients in whom non-invasive imaging
has not provided the information. It may also be the first step in performing a nephrostomy or
the Whitaker procedure (discussed in the section on urodynarnics). The patient is positioned
approximately 45° semiprone and the pelvicalyceal system cannulated with a fine (22 gauge)
needle. The general rule in gaining access to the pelvicalyceal system in all these procedures
is that a puncture directly into the renal pelvis risks lacerating it. Ideally the puncture should
be directed through the renal parenchyma into a suitable calyx and then into the pelvis.
Confirmation of cannulation of the collecting system is obtained by aspirating urine. If this
appears infected, the system should be drained and infection treated before proceeding with
an antegrade pyclogram: 150 strength contrast is infused into the system to opacity it (Fig.
29.21). If the procedure is being performed for diagnostic purposes, a series of spot films of
the ureter down to the level of the obstruction is taken. The flow of contrast down the ureter
can he assisted by elevating the head of the screening table.
CT Scan
CT has a wide variety of indications, including the characterisation of renal masses.
staging of urinary tract tumours and the assess meat of inflammatory and traumatic
processes, calculi and the causes of obstruction. It is also used to direct biopsies and
the positioning of percutaneous drains. It may also be used to assess renal artery
stenosis. Protocols vary between institutions but should conform to the same
principles. They are tailored towards the clinical problem and common protocols are
described below.
The gastrointestinal tract should be opacified before imaging for renal masses: 40 ml
of 150 strength (or 20 ml of 300 strength) water-soluble iodine-base contrast diluted
to I litre with fruit quash taken orally half an hour prior to the scan is a suitable
protocol.
An initial plain scan from the dome of the diaphragm to the iliac crests is performed, a
suitable protocol being collimation of 8 mm, pitch of 1.5 and slice thickness of 7-8
mm. This is repeated after an intravenous injection of contrast. The tinting is
important, aiming towards imaging the kidneys while contrast is in the renal veins and
inferior vena cava. This is usually optimal around 20-30 s from the start of the
injection. With fast modern scanners 50 ml of 300 strength contrast is usually
adequate. For lower tract tumours both the plain and postcontrast scans should be
from the dome of the diaphragm to the symphysis pubis. A further I litre of dilute
oral contrast taken 4 h before the scan is useful to image the large bowel and rectum.
Alternatively, the same strength contrast can be administered immediately before the
scan as an enema. All patients being investigated for malignancies should have a chest
radiograph and some departments will also perform routine CT of the chest.
CT is commonly performed as a relative emergency for suspected acute urinary tract
problems. When CT is performed for urinary tract calculi, both intravenous and oral
contrast are avoided. Relatively narrow collimation (5-7 mm) with a pitch of 1.5-2.0
is recommended, bearing in mind that excessively narrow collimation increases the
radiation close to the patient. Using the wider collimation and higher pitch does not
appear to significantly reduce the accuracy of the scan. The mAs should also he kept
to a minimum.
In the context of trauma, a protocol similar to the post nephrogram phase described
above for the investigation of renal masses is suitable. Repeat scanning after 6-8 min
may demon strate urinary extravasation especially if there is suspected ureteropelvic
disruption. In the assessment of renal or perinephric abscess, 8 mm slices are obtained
prior to intravenous contrast and then again during the nephrogram phase.
Opacification of the gas trointestinal tract with dilute oral contrast is useful in these
cases. Spiral CT with a contrast infusion and relatively narrow collimation and image
reconstruction (for example 3 mm and 1.5 mm respectively; pitch of 1-1.6) is suitable
for demonstration of the renal arteries and major branches in the assessment of renal
artery stenosis or in the preoperative work-up of patients for partial nephrectomy.
The normal renal parenchyma is of intermediate density, measuring between 30 and
60 HU (Fig. 29.30). The renal sinus and perinephric fat are low density, around -10 to
-50. Following intra-venous contrast the cortex enhances more rapidly than the
medulla, appearing more dense from around 20 s to 60 s when there is maximum
corticomedullary differentiation. Around 60-180 s the renal parenchyma becomes
homogeneously high density, around 80-120 HU. After this, contrast appears in the
collecting system. The ureter can he identified as it runs retroperitoneally along the
medial aspect of the psoas muscle, especially when dilated or contract-filled (Fig.
29.31).
After entering the pelvis the ureter runs posterolaterally to the level of the ischial
spine, where it turns anteromedially and can be dentified running in front of the
seminal vesicles or vaginal fornices to reach the bladder base. The bladder is seen as a
thin-walled structure between the urine and the fat. The seminal vesicles appear as
tubular structures related to the superior aspect of the prostate, posterior to the lower
bladder and anterior to the rectum. There is a fat plane between the seminal vesicle
and the bladder (Fig. 29.32).
The prostate is usually of homogeneous soft-tissue density but often shows multiple
foci of calcification, increasingly from early adulthood onwards (Fig. 29.33).
On CT, normal lymph nodes are seen as soft-tissue density similar to unenhanced
renal parenchyma, homogeneous apart from the possibility of a small area of fat at the
hilum. Normal nodes are up to 10 mm in maximum transverse diameter in the para-
aortic and iliac chains and 6 mm in the rctrocrural region.
 Baru
IVP
Radiographic anatomy
An IVP is analogous to two kids blowing through a straw
i nto a balloon. They first take a deep breath. As they blow, their
faces become blushed and the balloon enlarges (Fig.4-1 A).
The IVP is a series of abdominal films taken sequentially
over time. The first image is a plain radiograph of the abdomen
(Scout film). On this image, one should see the kidney
and bladder contours. The kidneys on the scout are
analogous the kids' faces and the bladder is analogous to the
balloon. The two kidneys are normally 3 to 4 lumbar vertebrae
in length. The right kidney is lower then the left one because
it is pushed down by the liver.
The other films are taken after IV contrast injection. As the
kidneys filter blood and excrete urine, the urinary system becomes
outlined by the white contrast material. This is analogous to the air flow going through the straw. One should see the
whitened kidneys (nephrograms), which are analogous to the
blushed faces of the boys in our story. The collecting systems,
composed of the calyces, the infundibulae, the renal pelvices, are
analogous to the kids' cheeks. In addition, one can visualize the
ureteropelvic junctions (UPJ), the ureters, and the ureterovesicular
junctions (UVJ), which represent the straws (Fig.4-2). The
whitened bladder is analogous to the inflated balloon.
Approach
A. Scout film
Approach the scout film as an abdominal radiograph (see Abdominal Radiograph chapter).
Pay particular attention to the urinary system.
Look for:
1. Kidney and bladder contours (size and shape)
2. Kidney stones (white calcification over a kidney shadow)
3. Ureteric stone ( white calcification along the course of the ureters)
B. Contrast injected films
Contrast films are usually taken at 1, 5 and 15 minutes after
injection. Compare one side to the other. Look at:
1. Nephrograms
- Absent: The kidney on contrast injection film does not whiten compared to the scout film.
- Delayed: The kidney is not whiter on the 5 minute film than on the scout.
- Hyperdense: Too white
2. Collecting system and ureter
- Dilatation (hydronephrosis and hydroureter)
- Non-calcified stone or tumor (black filling defect)
- Laceration (leaking of contrast; Fig.4-3).
3. Bladder contour
Remember to always compare the contrast injected films with the scout film, by looking at
them back and forth (Fig.4-4). The contrast injected films are used to determine if a
calcification seen on the scout film is inside or outside of a ureter (Fig.4-5).
III. Specific problems
A. Hydronephrosis and hydroureter
Imagine that one of the kids obstructs his straw with a pebble, or by pinching it. He needs a
deeper breath to overcome the obstruction. When blowing, his face becomes red and the air
flow in his straw is slow. Both the straw before the obstruction and the kid's cheeks dilate
because of back pressure (Fig.4-1 B).
This situation is analogous to an obstructing ureteric stone (pebble) or a tumor encasing the
ureter (pinching).
On the IVP, look for the following signs of obstruction (Fig.4-6A, 4-6B, 4-6C, 4-6D).
I . Delayed nephrogram and delayed contrast excretion: The affected kidney and collecting
system take longer to brighten (deeper breath, slow air flow).
2. Hyperdense nephrogram: The affected kidney becomes too white (red face).
3. Hydronephrosis (Fig.4-7) and hydroureter. Dilation of the collecting system (blown up
cheeks) and dilatation of the ureter (dilated straw) before the obstruction.
Initial films may not show the site of obstruction since it takes longer to outline a blocked
system with contrast.
Therefore, to locate the site of obstruction, one must ask for delayed films. To do this, double
the time of the last film. For example, if the last film was taken at 30 minutes after injection,
ask for a 1 hour film.
Remember that hydronephrosis and hydroureter may be caused by something other than an
obstruction (e.g. Reflux nephropathy). When there is no delayed nephrogram and no delayed
contrast excretion, there is no obstruction.
B. No nephrogram
Imagine that the blushing face of one kid is not visible. It either means that he is not blowing
or that he is not there. similarly, when there is no nephrogram on one side, either the kidney
is non-functioning (Fig. 4-IC) or it is absent (Fig. 4-1 D)
 Baru

Radiology of the Urinary Tract: Introduction

Radiology imaging has advanced dramatically since the first edition of this text.
Technological advances and other innovations have greatly modified imaging of the urinary
tract, with the dominant change being an increasing emphasis on cross-sectional modalities,
especially CT. The result has been improved accuracy and earlier diagnoses of urinary tract
disorders.

This chapter introduces the basic concepts in imaging of the urinary tract. The available
imaging modalities and principles of their interpretation are discussed, especially in terms of
its anatomy and its variants. The importance of choosing the most appropriate study for a
given clinical scenario cannot be overemphasized and the next section of the chapter reviews
technique selection. Clinical exercises and case examples are used to demonstrate important
imaging concepts and diseases of the urinary tract. Finally, a bibliography of suggested
readings is provided at the end of the chapter.
Techniques and Normal Anatomy

This section introduces the common radiologic techniques used in evaluation of the urinary
tract. Emphasis is on a detailed description of each technique as it applies to the urinary tract.
Also, a discussion of normal anatomy and some important fundamental concepts of
interpretation is included. A basic knowledge of the gross anatomy is assumed with emphasis
placed on the radiographic anatomic considerations.

Abdominal Radiography

Conventional radiographs (plain films) can occasionally provide important clues to diseases
of the urinary tract. Radiographs of the abdomen when used to evaluate the urinary tract are
often referred to as KUBs (kidney, ureter, and bladder). KUBs may serve a role as
preliminary films (scouts) prior to an examination such as an intravenous urography, or they
may be used as a general evaluation of the abdomen or the urinary tract. As stated,
abnormalities of the urinary tract may be suggested on conventional radiographs and, among
other things, the bones and soft tissues should be evaluated and abnormal densities, especially
calcifications, should be sought. "Gas, mass, bones, stones" can be used as a reminder of
main areas to examine on the KUB (Fig. 9–1). Soft tissue masses can occasionally be
detected and suggest renal or pelvic lesions. Sclerotic bony lesions can suggest metastatic
prostate cancer and lytic bony lesions can be seen with disseminated renal cell carcinoma.
Additionally, the bony changes of renal osteodystrophy (diffuse bony sclerosis) may be
identified on plain radiographs. Vertebral anomalies are associated with congenital
malformations of the urinary tract.

In the setting of trauma, fractures of the lumbar transverse processes suggest possible renal
injuries and pelvic fractures raise concern for coexistent bladder or urethral trauma. Air and
calcifications should be specifically sought over the urinary tract. Emphysematous
pyelonephritis, a urologic emergency with high mortality, is the result of a renal infection by
gas-producing organisms and may be diagnosed on plain films by mottled or linear
collections of air within the renal parenchyma. If emphysematous pyelonephritis is suspected,
emergency computed tomography (CT) should be performed to delineate the extent of
involvement and immediate urologic consultation obtained.

Finally, radiographs are useful for detecting and evaluating urinary tract calculi. It has been
reported that 90% of calculi are radiopaque and can be identified on conventional
radiographs. However, recent studies suggest that no more than 40% to 60% of urinary tract
stones are detected and accurately diagnosed on plain radiographs. The sensitivity for
detection of stones is limited when the calculi are small, of lower density composition, or
when overlapping stool, bony structures, or air is obscuring the stones. Additionally, the
specificity of conventional radiography is somewhat limited because a multitude of other
calcifications occur in the abdomen, including arterial vascular calcifications, pancreatic
calcifications, gallstones, leiomyomas, and many more. (More than 200 causes of
calcification in the abdomen have been described.) Phleboliths, which are calcified venous
thromboses, are especially problematic because they frequently overlap the urinary tract and
are difficult to differentiate from distal ureteral stones. Lucent centers are a hallmark of
phleboliths, whereas renal calculi are often most dense centrally. Additionally, oblique films
and tomograms may be useful to differentiate true renal calculi from densities within the
tissues anterior or posterior to the kidney.

Intravenous Urography
Intravenous urography (IVU), also known as intravenous pyelography (or more commonly,
the IVP), has dominated imaging of the urinary tract for more than 50 years. Although recent
advances in other techniques have substantially reduced its role, IVU remains an important
study for some urinary tract disease processes. More importantly, however, decades of use of
the IVU have established the fundamentals of imaging evaluation of the urinary tract. An
understanding of these principles forms a foundation for radiologic interpretation of the
urinary tract with the IVU or other more "advanced" imaging modalities. Thus, the IVU
technique is explained with interspersed discussion of anatomy, normal variants, and, most
importantly, some fundamentals of interpretation.

Although an urgent examination should not be delayed to prepare a patient for an IVU,
overlying stool can obscure important detail on an intravenous urogram and therefore a mild
bowel preparation of clear liquids and laxatives before an elective study is recommended.
The study should always begin with a scout KUB. This has several purposes including
detection of calcifications (which may be obscured after contrast material is injected),
assurance of proper technique (patient positioning, exposure parameters) prior to contrast
administration, and exclusion of contraindications to the study (retained barium, etc.). The
scout film should encompass the area from the adrenals to the symphysis pubis, and
sometimes more than one film may be required.

Intravenously injected iodinated contrast is excreted primarily by glomerular filtration in the

kidney, opacifying the urinary tract as it progresses from the kidney through the ureter and to
the bladder. Capturing this sequential "opacification" on radiographs is the fundamental basis
of the IVU. There are many variations in the filming sequence for the urogram that are
acceptable as long as it optimizes visualization of specific anatomy of the urinary tract during
maximum contrast opacification.

Optimal visualization of the kidney is accomplished very early in the examination. Within 1
to 3 minutes after injection, the contrast bolus is filtered by the glomeruli and fills the
nephron, resulting in intense opacification of the renal parenchyma; this phase of contrast
opacification is called the nephrogram. Evaluation of the kidneys during the nephrographic
phase is often enhanced with tomograms (nephrotomograms) (Fig. 9–2). The kidneys should
be evaluated for their position, orientation, size, contour, and radiographic density. The
kidneys are typically located at the level of the upper lumbar spine with the right kidney
slightly lower than the left. They generally lie with their axes along the psoas muscles with
the upper pole slightly more medial than the lower. Alterations in position and orientation of
the kidneys may be related to congenital anomalies such as pelvic kidneys or may be
secondary to mass effect from an adjacent lesion.
The size of the kidneys is somewhat variable depending on age and sex of the patient, but on
the intravenous urogram the kidneys normally range from 11 to 14 cm. The right kidney is
typically slightly smaller than the left. Measurement of renal size is also dependent on the
examination. For example, on the IVU the kidneys appear artificially larger due to
magnification. To account for this as well as other parameters such as overall body size, a
generalization is that the kidneys should measure between three and four lumbar vertebra
lengths. Additionally, the kidneys should be symmetric in size with a discrepancy greater
than 2 cm requiring an explanation. There are a number of causes of abnormal renal size,
ranging from incidental anomalies such as congenital renal hypoplasia to significant
conditions such as renal artery stenosis (small kidney) or infiltrating renal neoplasm (large
kidney).

The kidneys should have a reniform shape and a smooth contour. Embryologically, the
kidney is composed of lobes that smoothly fuse to create the kidney; however, not
uncommonly, small residual clefts remain where the lobes fail to completely fuse, a condition
referred to as persistent fetal lobation. This must be distinguished from true renal scarring,
which most often results from chronic vesicoureteral reflux/chronic bacterial pyelonephritis
or from renal infarcts. The clefts of fetal lobation occur between lobules, i.e., the cortex
between calyces, whereas scarring typically occurs in the cortex over the calyx. Additionally,
the calyces are generally distorted and rounded with chronic reflux disease. Bulges to the
renal contour are of more concern because they raise suspicion for a mass. A key concept in
evaluation of a possible mass is parenchymal thickness as measured from calyces to edge of
the kidney. A fairly common normal variant is the dromedary hump, which is a bulge created
along the lateral mid aspect of the left kidney related to splenic impression on the kidney.
This bulge is differentiated from a mass by a typical calyx that extends out toward the bulge,
keeping the parenchymal thickness similar to the rest of the kidney. A true mass results in
increased parenchymal thickness or even mass effect on the adjacent calyces, which are
displaced away from the bulge. The radiographic density of the kidneys following contrast
injection is related to arterial supply, renal function and excretion, and venous outflow.
Alterations in any of these parameters may result in abnormalities of one or both of the
nephrograms. For example, ureteral obstruction results in a delayed and increasingly dense
nephrogram.
Soon after the nephrographic phase, contrast begins filling the intrarenal collecting system
including the calyces and renal pelvis. This portion of the study is termed the pyelographic
phase (Fig. 9–3). Several films are used to evaluate the collecting system (intrarenal
collecting system and ureter) beginning at our institution with a KUB obtained 5 minutes
after contrast injection. Evaluation of the intrarenal collecting system is improved by placing
a compression device over the lower abdomen, thereby compressing the ureters on the
sacrum, resulting in increased distention and improved visualization of the proximal ureters
and renal collecting system. Compression is contraindicated in several settings, including
ureteral obstruction, abdominal aortic aneurysm, and recent abdominal surgery. Typically,
compression is applied after the 5-minute KUB has been obtained and evaluated by the
radiologist. A film of the kidneys is performed after 10 minutes, allowing for the compression
of the ureter to result in proximal distention. The intrarenal collecting system consists of
calyces, infundibula, and the renal pelvis. Normally, each kidney consists of 7 to 14 evenly
distributed calyces. The individual renal calyx, from the Latin for "chalice," is a delicate
appearing cup-shaped structure. Not uncommonly, partial fusion of the calyces occurs,
especially in the renal poles, creating the compound calyx. Other calyceal variants occur,
including variants of number (polycalycosis, unicalyx kidney) and size (megacalycosis,
microcalyx) and must be differentiated from true pathology. The calyces may not be
visualized if compressed or may be deviated by masses. The normal delicate, cup-like
appearance can be distorted or irregular in conditions such as papillary necrosis, tuberculosis,
or transitional cell carcinoma. Subtle rounding or ballooning of the calyces is one of the
earliest signs of urinary tract obstruction. Diverticula may arise from the calyces, creating a
haven for stone formation, recurrent infection, or even transitional cell malignancy. The renal
pelvis is also quite variable in appearance. A common variation is the so-called "extrarenal"
pelvis, where the pelvis lies outside the renal sinus. In this setting the pelvis tends to be more
prominent and rounded, mimicking hydronephrosis. This can be differentiated from true
obstruction by normal appearing calyces. The renal pelvis should be evaluated for filling
defects and mass effect.

Release of compression results in a bolus of contrast material entering the ureters, which is
evaluated with a KUB, and often with oblique films, obtained immediately after release of the
device at 15 minutes (Fig. 9–4). Occasionally, fluoroscopy may be utilized to visualize
suspicious areas of the ureter not seen on the conventional films. The ureter extends from the
ureteral pelvic junction to the ureteral vesicle junction. Proximally, the ureter passes over the
psoas muscle and should generally lay just lateral to the lumbar spine. The midportions of the
ureters course over the lateral sacrum with the distal portion gently curving laterally in the
pelvis before entering the bladder. The ureter is an actively peristalsing structure that is not
normally seen in total on the IVU. In fact, complete visualization of the ureter may suggest
distal obstruction. The ureter should be inspected for filling defects, which can be caused by
stones or tumor, and should be symmetric in size. Evaluation of the ureteral course is
important. Typically, the ureter should be no more lateral than the tips of the lumbar
transverse processes and no more medial than the lumbar pedicles. Deviations of the normal
ureter generally suggest extrinsic diseases, such as mass lesions. However, in patients with
large psoas muscles the ureters may be displaced laterally as an incidental result.

Finally, the bladder is opacified last on the study beginning around 5 minutes after injection.
Early filling films, later distended films, and postvoiding images complete the evaluation of
the bladder (Fig. 9–5). The bladder is an oval to rounded structure that normally lies just
above the pubic symphysis on the IVU. Not uncommonly, especially on early filling films,
some extrinsic compression of the bladder can be seen due to the sigmoid colon. In women,
the dome of the bladder may normally be indented by the uterus. These normal findings must
be differentiated from abnormal extrinsic mass effects. Bladder wall thickness can sometimes
be visualized and assessed, especially if thickened. Additionally, the bladder mucosa should
be scrutinized for irregularity or filling defects that may suggest a mass.
Films in addition to the typical IVU sequence may be used, taking advantage of the greater
density of contrast material than that of urine, and include prone and upright films as well as
delayed films as needed. Regardless of the filming routine, the best IVU is the one monitored
by the radiologist and tailored for the patient based on the study indication.

Retrograde Pyelography/Cystography/ Urethrography

Direct injection of water-soluble iodinated contrast material is a useful method of examining

various regions of the urinary tract. The advantage of this method of evaluation is the direct
control over the contrast injection rather than reliance on secondary excretion from the
kidney. Retrograde pyelography, often carried out in conjunction with cystoscopy, is
performed by placing a small catheter into the distal ureter. Contrast material is then injected
through this catheter into one or both ureters. Fluoroscopy and conventional radiographs
should then be obtained. This study usually results in excellent evaluation of the ureter and
intrarenal collecting system. The ureter is typically seen in its entirety, which rarely occurs
with other imaging studies. Interpretation is similar to that of the IVU with the caveat that the
contrast within the collecting system is under greater pressure than physiologic conditions
and mild ballooning of the calyces as well as occasional extravasation can occur normally.

Imaging of the bladder is performed with a cystogram, for which a catheter is placed into the
bladder and contrast material is then injected. The contrast material is optimally injected
under fluoroscopic observation but occasionally is performed with only static conventional
radiographs, such as in the trauma setting. Anatomic considerations and evaluation are
similar to the IVU with a few caveats. One advantage to cystography is that vesicoureteral
reflux can be evaluated during the conventional cystogram unlike during IVU. Recently, CT
cystography, in which after contrast instillation CT imaging is utilized instead of
conventional films, has been used, especially in the setting of trauma to evaluate for bladder
injury.

The urethra may be evaluated with contrast material via two methods. In one, the urethra is
evaluated during voiding, often following a cystogram (voiding cystourethrogram or VCUG).
Alternatively, a retrograde study may be performed (retrograde urethrogram). The urethra in
the male consists of four portions, including the prostatic, membranous, bulbous, and penile
portions. During voiding, the urethra is fairly uniformly distended and tubular in appearance
(Fig. 9–6). On a retrograde study, the more posterior urethra (prostatic and membranous) is
often contracted and seen as a thin wisp of contrast. The female urethra appears as a short,
slightly funnel-shaped tubular structure during voiding (Fig. 9–7) (Note that a special catheter
is required for evaluation of the female urethra in a retrograde fashion.) The urethra in males
is generally evaluated for injuries but may also be examined for filling defects, masses,
strictures, and fistula. The female urethra is most commonly examined for diverticula.

Ultrasonography

Ultrasonography is a useful technique for evaluation of the urinary tract, made especially
attractive by its ease of use and lack of complications (no contrast material or ionizing
radiation). The kidneys are generally well seen in all but the largest of patients (Fig. 9–8).
The renal medulla is hypoechoic (darker) relative to renal cortex and can be identified in
most normal adults as cone-shaped central structures. (Occasionally, this corticomedullary
distinction is not visible.) The renal cortex is isoechoic or slightly hypoechoic compared with
the echogenicity of the adjacent liver. Renal echogenicity exceeding that of the liver is
abnormal and requires explanation. Most commonly hyperechoic kidneys are seen in the
setting of medical renal disease, such as end-stage hypertensive glomerulosclerosis.

In addition to echogenicity, the kidneys should be assessed for size, location, and symmetry.
Scarring and masses can be evaluated. Unlike the IVU, where masses are often nonspecific,
ultrasonography allows a more detailed evaluation including the ability to confidently
diagnose the most common renal mass—the simple cyst. Solid masses, however, remain
nonspecific and generally require further evaluation. Like the IVU, there are normal variants
that can mimic mass lesions including dromedary humps and persistent collections of normal
renal tissue within the substance of the renal parenchyma referred to as persistent columns of
Bertin. Additionally, the parenchyma near the renal hila may appear prominent as well,
occasionally mimicking a mass. Each of these lesions may be distinguished by their
echogenicity being equal to surrounding tissue, lack of mass effect, and characteristic
location. Occasionally, additional imaging may be required in equivocal cases.

The renal sinus is the area engulfed by the kidney medially, harboring the renal pelvis,
arteries, veins, nerves, and lymphatics that enter and exit the kidney, all contained within a
variable amount of fat. Fat is typically brightly echogenic on ultrasound, and fat within the
renal sinus dominates the ultrasonographic appearance, creating what is known as the central
echo complex. The size of the central echo complex is variable, often more prominent in the
elderly and minimal in the child. Absence of the central echo complex may suggest a mass
such as a transitional cell carcinoma replacing the normal fat. Alternatively, the complex may
be very prominent in the benign condition of renal sinus lipomatosis. Calcifications are
characteristic on ultrasound, being brightly echogenic and resulting in shadowing posteriorly
as the sound waves are attenuated. Renal stones or calcifications may be detected within the
renal parenchyma or in the intrarenal collecting system. The echogenicity of the normal renal
sinus, however, creates difficulty because sometimes it obscures or mimicks small stones.
Ultrasonography is also excellent for detecting hydronephrosis with the distended collecting
system being easily recognized within the central echo complex. The ureters are not normally
seen on ultrasound due to obscuring overlying tissue and their small size. Evidence of their
patency may be verified by Doppler detection of urine rapidly entering the bladder from the
distal ureters, i.e., distal ureteral jets (Fig. 9–9). The bladder is seen as a rounded or oval
anechoic (fluid) structure in the pelvis. The bladder may demonstrate mass lesions, such as
transitional cell carcinoma, or stones. The urethra is not typically seen on an ultrasound
image although urethral diverticula may occasionally be demonstrated.

Computed Tomography

CT is now the dominant radiologic imaging modality for evaluation of the urinary tract. The
advent of multidetector spiral CT has further propelled CT to the forefront of urologic
imaging. Several factors make CT effective in assessing the urinary tract. The high contrast
resolution and spatial resolution afforded by CT allow detection and evaluation of subtle
differences in very small structures. Mathematical calculations of the attenuation of the CT x-
ray beam allow quantitative evaluation of the relative density of structures (i.e., their
Hounsfield units), and it is through these "CT numbers" that much unique diagnostic
information of the urinary tract is gained. Examinations can be performed amazingly fast
because thin-slice CT scans of the entire urinary tract are now obtainable in just a few
seconds. Finally, the wide availability and relative safety of CT furthers its appeal.

CT scans of the urinary tract may be performed with and/or without intravenous iodinated
contrast material depending on the indications. Noncontrast studies may be performed to
evaluate stone disease and other calcifications. Additionally, noncontrast views of the
kidneys serve as a baseline to evaluate for lesion enhancement after contrast administration, a
critical factor in mass evaluation. On noncontrast examinations the kidneys are homogeneous
and have a density similar to most soft tissue (Fig. 9–10). In all but the thinnest adults, fat is
seen surrounding the kidneys and extending into the renal sinus. Contrast-enhanced studies of
the kidneys are best performed with a mechanical power injector.
With rapid scanning and contrast bolus timing, several sequential phases of opacification
within the kidney can be delineated by CT including corticomedullary, nephrographic, and
excretory phases. The corticomedullary phase can be seen if scanning is performed during the
first 20 to 90 seconds after contrast administration and represents the early preferential blood
flow to the renal cortex (Fig. 9–11); however, small masses could be missed during this
phase, being obscured within the unenhanced renal medulla. Subsequently, contrast begins to
pass into the distal collecting tubules within the renal medulla, resulting in a more
homogeneous opacification of the renal parenchyma, termed the CT nephrographic phase.
This generally occurs around 2 to 4 minutes after contrast medium injection. Finally, the
excretory phase is seen when contrast opacifies the collecting system (Fig. 9–12). Each
different phase of opacification may better demonstrate different disease processes and thus
various scanning protocols are used to evaluate the kidneys depending on the indication.
One of the major recent advances in imaging has been the ability to noninvasively evaluate
the vascular system, and thin-section early CT images accurately demonstrate the main
arterial and venous structures of the kidney (Fig. 9–13). Just as with IVU or any modality, the
kidneys should be evaluated for position, orientation, size, and radiographic density. Unlike
IVU, however, CT provides much greater specificity regarding renal disease, including mass
lesions. The ubiquitous simple cyst is generally easily diagnosed and differentiated from the
more concerning solid mass. Fat within a solid mass generally allows the diagnosis of the
benign angiomyolipoma. The solid, non-fat-containing mass in the adult should be
considered a renal cell carcinoma until proven otherwise. CT is sensitive in detecting renal
masses and, although not always supplying a specific diagnosis, typically provides important
information allowing for appropriate patient management.