GU IMAGING
2012
The kidneys and adrenal glands are retroperitoneal structures. The
kidneys have direct blood flow from the aorta and to the IVC.
TAKE HOME POINTS
1- OBSTRUCTION VS NON OBSTRUCTION
2 - SOLID VS CYSTIC
3- PREGNANT OR NOT
4- INTRAUTERINE OR ECTOPIC
ANATOMY
•
•
•
•
•
•
KUB-plain x-ray
IVP
CT
NUCLEAR MEDICINE
ULTRASOUND and MRI
ANGIOGRAPHY
Ultrasound and CT are used as first line tools in GU disease imaging.
LT. KIDNEY
RT. KIDNEY
PSOAS MUSCLE
PSOAS MUSCLE
R
The kidneys are not always seen on an abdomen x-ray but can sometimes be outlined
by retroperitoneal fat. The psoas muscle may be seen for a similar reason.
THE BLADDER IS VISUALIZED BECAUSE IT
IS OUTLINED BY FAT—A LOWER DENSITY.
INTRAVENOUS PYELOGRAM – IVP
INTRAVENOUS IODINE CONTRAST
WITHOUT CONTRAST-plain or
scout film
ARTERIOGRAM
INTRAARTERIAL IODINE CONTRAST
6
R
KUB
IVP
KIDNEY- URETERS- BLADDER
INTRAVENOUS PYELOGRAM
R
The administration of iodinated IV contrast can image the GU tract with radiographs---IVP. This
exam is not done as frequently now as in past and more imaging is by ultrasound and CT.
PELVIS
MALE
FEMALE
CONTRAST IN DISTAL
URETER
BLADDER
PROSTATE
UTERUS
The prostate gland impresses
the bladder normally in males
but enlarges with prostatic
hypertrophy.
BLADDER
Note superior impression on
bladder due to uterus.
IVP
Female abdomen
SI JOINT
BODY OF
UTERUS
Note superior
impression on bladder
due to uterus.
BLADDER
CT SCANS
without and with contrast administration
The IV contrast which is being filtered and increasing density of the renal tissue. Compare
with liver density.
A 65-year old man needs an emergency CT scan with IV
contrast. Which of the following is a risk factor for
development of contrast induced acute tubular necrosis?
0%
0%
0%
0%
0%
1.
2.
3.
4.
5.
Hypertension
Pheochromocytoma.
Urinary tract infection
Diabetes
Immune-compromised state
10
NUCLEAR MEDICINE RENOGRAM
This study
measures
radioactivity as it
moves through
the kidneys over
time. Regions of
interest are drawn
on the computer
and counts are
calculated for 30
minutes. This
generates
functional imaging
with data
indicating peak
time, rate of
excretion and
percent function
The IV administration of the radiopharmaceutical allows for sequential imaging to assess renal function. This is a
pharmaceutical agent which is secreted by the kidneys and has a radioactive tag allowing imaging and
quantification.
ULTRASOUND
MORRISON’S
POUCH
( A POTENTIAL SPACE)
Longitudinal
Scan Of The Right
Kidney
Image of Rt. kidney, liver and Morrison's pouch. The echogenic signal in the center of the kidney is renal sinus fat.
THE VALUE OF ULTRASOUND IN
INITIAL EVALUATION OF RENAL
FAILURE IS:
0%
0%
0%
0%
0%
1.
2.
3.
4.
5.
Low cost
Portability
Lack of radiation
Evaluating blood flow
Excluding obstruction
10
ABDOMINAL ARTERIOGRAM
CATHETER
RENAL ARTERIOGRAM
Here arterial contrast is injected into the aorta and immediate imaging shows the arterial lumen
outlined by the iodine.
MR ARTERIOGRAM
Gadolinium Injection
Standard
Renal Arteriogram
Catheter Injection Of
Iodinated Contrast
Venous injection of gadolinium contrast at MR can outline the arterial tree without the risk of
catheterization. The detail is not as good as arterial imaging but is a lower risk procedure.
HYSTEROSALPINGOGRAM
Contrast has been
injected through a
cannula placed
into the cervical
os. Iodinated
contrast flows
retrograde with
injection filling the
uterine cavity with
reflux into the
fallopian tubes.
This is used to assess
infertility due to tubal
obstruction.
UTERINE CAVITY
FIMBRIAE
FREE CONTRAST IN
PERITONEAL CAVITY
CANNULA
FALLOPIAN
TUBE
PELVIS
Trans-abdominal Scanning
BLADDER
UTERUS
The uterus is imaged abdominally using the bladder as an acoustic window
to displace bowel and allow visualization.
ULTRASOUND - SAGITTAL
Trans vaginal Scanning
Better detail of the endometrium is shown using the transvaginal ultrasound probe. A higher
megahertz transducer with better resolution but less depth penetration is used.
TESTICULAR ULTRASOUND
Used to assess for
masses and blood flow.
Flow can be assessed
by Doppler
Small parts scanning, testicular, thyroid and carotid uses high megahertz transducers for better resolution.
PATHOLOGY
•
•
•
•
•
Congenital
Trauma
Infection
Vascular
Malignant
CONGENITAL
ABNORMALITY
Horseshoe Kidney
KIDNEY
Ascent stopped by
Inferior Mesenteric Artery
CROSSED FUSED KIDNEY
Pelvic Kidney
Embryologically the kidneys can be fused on one side or be ectopic -- ie. Pelvic location
ADULT POLYCYSTIC DISEASE
Hepatic and Renal
Multiple cysts are present in kidneys leading to renal failure in adulthood. Hepatic
and Pancreatic cysts can coexist. Increased risk of cerebral aneurysm
Bicornuate uterus is a
abnormality of Mullerian duct
development and can hinder
pregnancy.
BENIGN RENAL CYST
Fluid filled benign renal cyst shows
fluid density at CT and lack of
echoes at Ultrasound.
WHICH OF THE FOLLOWING IS TRUE
REGARDING RENAL INJURY IN
TRAUMA?
0%
0%
0%
0%
0%
In penetrating trauma absence of hematuria rules out renal
injury.
In blunt trauma, microscopic hematuria alone is rarely
associated with renal injury.
Most renal injuries require operative repair.
Renal injuries are extremely uncommon in children with blunt
trauma
Plain radiography is the imaging test of choice for diagnosis.
10
TRAUMA
Fractured Kidney
Horse stepped on patient
VESICO URETERAL REFLUX
catheter
Reflux from filling bladder with contrast. This can
lead to pyelonephritis and scarring .
Moderate and severe examples
WHICH OF THE FOLLOWING IS
TRUE REGARDING DIAGNOSIS OF
KIDNEY STONES?
0%
0%
0%
0%
0%
1-Normal urinalysis essentially rules out the diagnosis.
2-KUB radiograph has ˃90% specificity.
3-Most kidney stones are radiolucent.
4-Ultrasonography has ˃90% sensitivity.
5-CT scan has roughly 90% sensitivity and specificity.
10
RENAL
CALCULI
CT
KUB
RENAL ULTRASOUND
Sagittal Scan of Rt. Kidney Stone
Echogenic stone shows shadowing
ULTRASOUND
Kidney
Hydronephrosis
Dilated collecting system is
shown as enlarged fluid filled
system on ultrasound.
Resolution
STONE
IN THE
URETER
Hydronephrosis
Stone
Note left sided dilated collecting system
Stone
CT WITH CONTRAST SHOWS
DILATED
COLLECTED SYSTEM
STONE IN BLADDER
A 50-year-old mad develops acute onset of severe right
flank pain. A CT scan demonstrates a passed kidney stone
in the bladder. The patient has never had a kidney stone
before. He asks you what his risk of getting another stone
is. You tell him that the lifetime risk of recurrence is
approximately:
0%
0%
0%
0%
0%
1.
2.
3.
4.
5.
<1%
10%
25%
50%
75%
10
RENAL ARTERY STENOSIS
Renal angioplasty can restore normal perfusion. This can treat
hypertension caused by Renin-Angiotensin effect of hypo perfused kidney.
RENAL ARTERY
STENOSIS
CATHETER
Delayed function on
affected side
DECREASE IN BLOOD
PRESSURE
RENIN/ANGIOTENSEN CASCADE
ANGIOTENSION I---II
VIA
ANGIOTENSIN CONVERTING ENZYME (ACE)
ANGIOTENSIN II CONSTRICTS EFFERENT
ARTERIOLE
MAINTAINING FILTRATION AT GLOMERULUS
GLOMERULUS
Afferent arteriole
Efferent arteriole
CAPTOPRIL (ACE INHIBITOR)—SITE OF ACTION
RENAL ARTERY STENOSIS
Renal angioplasty can restore normal perfusion. This can treat
hypertension caused by Renin-Angiotensin effect of hypo perfused kidney.
BALLOON
RENAL ARTERY
STENOSIS
CATHETER
Dilatation to treat focal
renal artery stenosis with
catheter and stent
placement to maintain
vessel size.
RENAL ARTERY
STENT
Stents are easily seen on
plain radiographs.
RENAL
MALIGNANCY
Ultrasound and CT
Solid lesion on ultrasound and soft
tissue mass on CT is most suspicious
for Renal cell carcinoma.
TRANSITIONAL CELL
CARCINOMA
Transitional cell carcinoma is a urothelial lesion
shown as filling defect in calyces, ureter or
bladder.
UROTHELIAL LESION
ON
BLADDER WALL
Pediatric malignancy
Wilm’s tumor and Neuroblastoma
Intra renal
Lowe L H et al. Radiographics 2000;20:1585-1603
Supra adrenal
Neuroblastoma compared to Wilms
tumor...
0%
0%
0%
0%
0%
1. Metastasizes to lungs more
2. Area more bilateral
3. Less likely Calcify
4. Can cause hypertension
5. Can be in atypical locations more often
10
SOLID HYPOECHOIC
TESTICULAR LESION
Solid lesions in testes are suspicious for
malignancy and usually need biopsy.
TESTICULAR TORSION
Twisting of testes (torsion) can obstruct blood flow and infarct the
testes. Note normal Doppler flow in the left and absent flow on the
right.
PROSTATE
Benign Prostatic
Hyperplasia
This can obstruct the ureters entering the
bladder leading to hydronephrosis and renal
failure.
NOTE OBSTRUCTION
ENLARGED PROSTATE
Note bladder base impression
Biopsy Is Required to separate
Malignancy vs BPH
ENLARGED PROSTATE
Note bladder base impression
METASTATIC BONE
DISEASE
METASTATIC PROSTATE CANCER
Prostate malignancy often metastasizes to the skeleton and is usually
sclerotic (dense) vs lytic (destructive). The nuclear bone scan shows
increased activity at site.
UTERUS
Hypoechoic lesion in
uterus is a typical
appearance of a uterine
leiomyoma ( fibroid). A
benign tumor.
UTERINE LEIOMYOMA
calcified
Large uterine fibroids can calcify and be seen on radiographs.
BENIGN OVARIAN CYST
Ovarian cysts occur normally with ovulation and can be several cms in size.
CYSTIC OVARIAN CARCINOMA
Doctors are whippersnappers in ironed white coats Who spy
up your rectums and look down your throats. And press you
and poke you with sterilized tools And stab at solutions that
pacify fools. I used to revere them and do what they said
Till I learned what they learned on was already dead.
--Gilda Radner
OVARIAN MALIGNANCY IS PRONE TO
PERITONEAL SPREAD WITH CYSTIC
MASSES THROUGHOUT ABDOMEN.
DERMOID
Ovarian dermoid tumors can have fat,
soft tissue and bony elements.
PELVIC INFLAMMATORY DISEASE
PID can clinically be confused with:
0%
0%
0%
0%
1.
2.
3.
4.
Cholecystitis
DVT
Ectopic pregnancy
Small bowel obstruction
10
NORMAL
OBSTETRIC ULTRASOUND
Intrauterine Pregnancy
(IUP)
Doppler Cardiac Signal
Obstetrical Scan
Measurement of crown / rump length of fetus is to estimate gestational age
and assess for intrauterine growth retardation -- IUGR
A 27 year old female patient with RLQ pain,
pelvic pain and hypotension would be
suspicious for:
1.
0% 2.
0% 3.
0% 4.
0%
Appendicitis
Ectopic pregnancy
Ovarian torsion
PID
10
BLADDER
UTERUS
NORMAL
INTRAUTERINE
PREGNANCY
PREGNANCY
BLADDER
UTERUS
ECTOPIC
PREGNANCY
Ectopic pregnancy remains the
leading cause of death with a 9%–
14% mortality rate.
ARE THE AUDIENCE QUESTIONS AN
IMPROVEMENT OVER THE BASIC LECTURE
FORMAT?
0%
0%
0%
0%
0%
1-Strongly agree
2-Moderately agree
3-Neutral
4-Moderately Disagree
5-Strongly disagree
10
Countdown