TOPIC OUTLINEI. RetroperitoneumII. KUB Imaging

A. Intravenous pyelographyB. UltrasoundC. CT/MRID. CT AngiographyE. CT StonogramF. CT Urogram

III. Anatomical Abnormality

A. Adrenal glandB. NephroptosisC. Pelvic KidneyD. Horseshoe kidneyE. Crossed ectopyF. Complete duplicationG. Incomplete duplication

IV. Cystic Diseases

A. Simple Renal CystB. Polycystic Kidney DiseaseC. Medullary Sponge Kidney

V. Inflammation/InfectionA. PyelonephritisB. Renal AbscessC. GU Tuberculosis

VI. Urinary bladder

A. ProstatomegalyB. CystitisC. UB diverticula

VII. KUB Trauma

A. Renal TraumaB. Bladder trauma and extrophy

VIII. Calculi

A. Nephrocalcinosis and NephrolithiasisB. UrolithiasisC. Cystolithiasis

IX. KUB Malignancies

A. Wilm’s tumorB. Renal Cell CAC. Transitional Cell CA

X. Renal AngiographyXI. Adrenal GlandsXII. Prostate and ScrotumXIII. Uterus and Adnexa

I. RETROPERITONEUM

Fig.1. Contents of the Retroperitoeum

Contents: “Fat PAD SUCKER”o Fato S = Suprarenal glands (aka the adrenal glands)o A = Aorta/IVC

o D = Duodenum (second and third segments [some also include the fourth segment] )

o P = Pancreas (tail is intraperitoneal)o U = Ureterso C = Colon (only the ascending and descending parts)o K = Kidneyso E = Esophaguso R = Rectum

kidneys are located within the cone of renal fascia (Gerota fascia), surrounded by the fat of the perirenal space

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)

Fig. 2. Diagram of the kidney.

II. KUB IMAGING

A. INTRAVENOUS PYELOGRAPHY

Series of films with contrast material to better visualize the urinary system

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

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

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Fig. 4. Ultrasound of right kidney showing multiple indentations.

C. MULTIDETECTOR CT/MRI

Detection and evaluation of:o Obstruction and urolithiaseso Cause of hematuriao Characterize and staging of tumorso Cause of chronic pelvic paino Crypotochidism

Guidance of biopsy Multidetector; can use different views: axial, coronal Characterize adjacent structures Modality of choice: CT then MRIo CT is readily available, less expensive

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

Triphasic CT Arterial/Nephrogram phaseo Shows corticomedullary differentiationo Shows renal lesions

Venous phase Late Venous Pyelogramo Shows the collecting systemo Shows urothelial lesions, transitional cell carcinoma, stones, blood

clotsKidney 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 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. 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 septao Serve as conduit for spread of fluid, inflammation, neoplasmo Preclude adequate drainage of fluid/abscess

Tumor extending beyond Gerota’s fascia means poor prognosis

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

III. ANATOMICAL ABNORMALITY

A. ADRENAL GLAND

Thickness: 5-6 mm Located in the superomedial aspect of the kidney, in the perirenal

space Common variants:o Fetal lobulationso Dromedary humpo Prominent Column of Bertin

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

Fig. 9. Ptotic right kidney

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C. PELVIC KIDNEY

Most asymptomatic Complications/prone to:o Trauma (decreased protection)o Nephrolithiasiso Anomalies – ureteropelvic junction obstruction, vesicoureteral

reflux and decreased function

D. HORSESHOE KIDNEY

Most common fusion anomaly Complications:o Traumao Calculio Transitional cell CA

Prone too Nephrolithiasiso Wilm’s tumor, TCCA

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

E. CROSSED ECTOPY

90% with fusion Complications:o 50% with nephrolithiasiso Infectiono 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. 12. Incomplete duplication on the right.

G. INCOMPLETE DUPLICATION

Fusion of ureters, entry at one point

Fig. 13. Bilateral incomplete duplication

IV. CYSTIC DISEASES

A. SIMPLE RENAL CYST

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

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Bosniak III wall thickening multiple septationso Higher chance of malignancy (30-60%)

B. AUTOSOMAL RECESSIVE/INFANTILE POLYCYSTIC KIDNEY DISEASE

Before birth Bilateral enlarged kidneys with small dilated ducts papillary tips to

cortex Grapelike kidney

Fig. 15. Polycystic Kidney Disease

C. MEDULLARY SPONGE KIDNEY

Brushlike densities – stone disease in multiple ectatic tubules and papillae

Recurrent stone formation

Fig. 16. Medullary nephrocalcinosis

V. INFLAMMATION/INFECTION

A. PYELONEPHRITIS

Common cause: E. coli

Usually seen in DM, obstructive process e.g. stones, uretero-vesical 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

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

C. GU TUBERCULOSIS

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

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A. PROSTATOMEGALY

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 crescent-shaped.

Bladder wall may exhibit irregularity due to overdistention and inflammation

B. Chronic Bladder Outlet Obstruction Cystitis

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. 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

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.

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

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 non-penetration 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. 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. WILM’S TUMOR

Fig. 28. Wilm’s 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. 29. CT Scan showing renal cell carcinoma Most common malignant renal tumor From the renal epithelium

C. TRANSITIONAL CELL CA

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 long-standing obstruction

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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

X. RENAL ANGIOGRPAHY

A. RENAL ARTERY STENOSIS

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

Medscape: angiopathy that affects medium-sized arteries predominantly in young women of childbearing age.

XI. ADRENAL GLANDS

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

Fig. 33. Adrenal adenoma. Cortical lesion that possesses a tear-drop appearance Low-density, well-defined Possesses mild enhancement May present with Cushing’s syndrome, Conn’s disease or as an

incidental finding Use CT with contrast or MRI

B. PHEOCHROMOCYTOMA

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. 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)

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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

A. BENIGN PROSTATIC HYPERPLASIA

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

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. 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

Fig. 42. Endometrial hyperplasia

C. Normal Ovaries in Childbearing Women

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

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D. Normal Ovaries in Post-menopausal Women

Fig. 43. Ovaries in child post menopausal women Smaller and has no or very minimal follicles

E. Physiological Ovarian Cyst

Fig. 44. UTZ showing ovarian cyst Thin-walled and well-defined Anechoic Resolves or regresses in follow-up ultrasound

F. Hemorrhagic Cyst or Endometrioma

Fig. 45. Hemorrhagic cyst Medium level echogenicity within the cyst Does not resolve within 2 months

G. Early Pregnancy Evaluation

Fig. 46. Intrauterine pregnancy

Fig. 47. Ectopic pregnancy

Fig. 48. Monochorionic diamnitoic twin pregnancy

Fig. 49. Dichorionic diamnitoic twin pregnancy

Fig. 50. 3D and 4D Reconstruction

H. Placental Evaluation

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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. 53. Normal amniotic index

Fig. 54. Oligohydramnios - less than normal amount of amniotic fluid surrounding the child

J. Fetal Sex Determination

Fig. 55. Fetal baby boy – exhibits the bird sign

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

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