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The Urinary Tract Imaging

Film approach and self learning cases

How to approach
plain KUB / scout film

4 steps for evaluation


plain KUB film

1.
2.
3.
4.

-
-
-
-

1. Soft tissue shadows


Outline these structures
-

Kidneys (look at
position, size, shape,
renal outline)
Psoas muscle

Bladder & uterus

Liver & spleen

T12
L1

L2
L3

Kidneys (look at
position, size, shape,
renal outline)
Psoas muscle

Bladder & uterus

Liver & spleen

L4
L5

2. Look for abnormal


calcifications

Where are the calcifications?

Where are the calcifications?

3. Look for free


air or free fluid

Abnormal air at LUQ

Dx. Emphysematous
pyelonephritis

4. Bony structures

Spine, sacrum, pelvis


hips and SI joints
Look for
- Fracture
- Bony abnormality
- Osteolytic or blastic
lesion

Intravenous pyelography (IVP)


interpretation

IVP

Scout film

3 minutes

Renal nephrogram
-Look at kidneys position,
size, shape, cortical
thickness, renal outline
- Look for filling defect

Normal nephrogram

Delayed dense nephrogram left kidney

Scout

5 mins

10 mins

Delayed dense nephrogram left kidney


Normal kidney
enhancement

Point of
obstruction

Scout

Normal kidney
excretion

5 mins

Still enhanced and


Delayed
contrast more dense =
enhancement
delayed dense nephrogram

No kidney excretion

10 mins

Absent nephrogram left kidney

scout

5 mins

delay

Absent nephrogram left kidney

Not enhanced

scout

Normal kidney already excreted


Normal enhancement
And excretion
Not enhanced
Not enhanced

5 mins

delay

IVP

10 minutes

30 minutes

- Evaluate excretory function


- Evaluate the pelvocalyceal system and ureters (look
for filling defect, hydronephrosis, hydroureter, stenosis)

Delayed excretion left kidney

Scout

5 mins

10 mins

Delayed excretion left kidney


Still enhanced
Normal kidney
enhancement

Point of
obstruction

Scout

Normal kidney
excretion

5 mins

Delayed
enhancement

And contrast
more dense

No kidney excretion at 5 & 10


mins = delayed excretion

10 mins

Hydronephrosis / Hydroureter

Double collecting system

Filling defect
Filling defect in left distal ureter

Normal pelvocalyceal
system

Filling defect in left renal pelvis

IVP
Full bladder
- Look at bladder
- Size
- Shape
- Position
- Architecture
- Density
- Look for filling defect or
outpouching lesion

Filling defect

Normal urinary bladder

Filling defect from CA bladder

Filling defect
from BPH

Irregular bladder outline

IVP
Post voiding
- Evaluate residual urine

- Look for small stone or


tumors

Congenital abnormalities

Renal agenesis

Supernumerary kidney

Malrotation

Pelvic ectopia

Cross fused ectopia


Left kidney

Right kidney

Right ureter
Left ureter

Horseshoe kidney

Double collecting system

Ureterocele

Polycystic kidney

Multicystic dysplastic kidney

Urinary tract obstruction

Plain KUB
For stone detection

Plain KUB
For stone detection

There is calcification
overlying the right renal
shadow, suggestive of
right renal stone

Ultrasound
Confirm obstruction

Hydronephrosis

Hyperechoic lesion with posterior


acoustic shadow at UPJ

Diagnosis: right UPJ stone causing obstruction with right hydronephrosis

IVP
Evaluate
1. Renal function
2. Anatomical change
3. Cause
Delayed dense
nephrogram
Normal excretion
Delayed excretory
function

5 minutes

IVP
Evaluate
1. Renal function
2. Anatomical change
3. Cause
Hydronephrosis

Hydroureter
Point of obstruction at
mid ureter

IVP
Evaluate
1. Renal function
2. Anatomical change
3. Cause

Diagnosis: Right ureteric stone causing obstruction with right


hydronephrosis and hydroureter

Mechanical obstruction

Stone

Diagnosis: Right ureteric stone causing obstruction with right


hydronephrosis and hydroureter

Common location for obstruction from ureteric stone

Ureteropelvic
junction (UPJ)

Medial isthmus

Uretervesical
junction (UVJ)

Tumor
Multiple filling defects in left
pelvis and ureter

Transitional cell carcinoma


was confirmed in this case

Extrinsic compression

Malignant peritoneal lymph node


causing luminal narrowing of the distal right ureter

Blood clot

Filling defect in right renal pelvis

Stricture

Posterior urethral valve stricture

Bladder outflow tract obstruction

Posterior urethral valve obstruction

Filling defect in urinary bladder from


benign prostate hypertrophy causing
bilateral UVJ osbtruction with hydroureter

Non-mechanical obstruction

Vesicoureteric reflux

VCUG show bilateral grade III reflux

Spastic neurogenic bladder

1. Bladder trabeculation
2. Pine tree appearance

3. Small bladder capacity

Flaccid neurogenic bladder

1. Smooth badder wall

2. Large urine capacity

Renal mass

Simple cyst
Calyceal displacement

Radiolucent round lesion


Dromedary hump

Smooth, well-defined
anechoic lesion

Distal acoustic
enhancement

Round low density lesion


No contrast enhancement

Complicated cyst

Internal septation
High denisty fluid

Thick wall and


nodule

Solid mass
Renal AML
Wilms tumor

Lymphoma

Metastasis

Renal cell carcinoma

Suspected renal mass


US

hydronephrosis
Cystic renal lesion
Simple cyst

Complicated
cyst

Follow up US
Do nothing CT scan
Biopsy

Solid renal mass

CT scan or MRI
-characterization
-location
-staging
-evaluate contralat.kidney

Urinary tract infection

Acute pyelonephritis

Enlarged size with hypoechogenicity

Nephrographic defect

Striated nephrogram

Emphysematous pyelonephritis

Air
Free air outlining both kidneys

Air

Renal abscess

Abscess
Perinephric abscess

Pyonephrosis

Hyperechoic content in
renal pelvis

Tuberculosis
moth-eaten
calyx

Amputation of bilateral
upper pole calices

Infundibular stenosis

Tuberculosis

Reduced bladder capacity


with diverticulum
Autoamputation with
calcified right kidney

Segmental dilatation with


stricture of left ureter

Trauma of the KUB system

Renal trauma
Stable
patient

Suspected renal injury

Unstable
patient

US

Hematoma

CT scan
Angiogram

No hematoma

IVP

Single shot IVP


at OR

Renal trauma

Ureteric trauma

hydronephrosis
hydroureter
Point of obstruction

Surgical clip from


Post TAH, BSO

Bladder trauma

Bladder contusion

Extraperitoneal rupture

Intraperitoneal rupture

Urethral trauma

Urethrogram shows contrast extravasation from urethra

Diagram of urethral injuries

Self learning cases

Case 1

A 53-year-old female
was sent for IVP study

Scout film

5 minutes

10 minutes

30 minutes

Full bladder

Post void

Where is the abnormality?


A.Right kidney
B.Left kidney
C.Right ureter
D.Left ureter
E.Urinary bladder

Answer

Low position of the right kidney with abnormal axis


and lower pole fusion of the right and left kidneys

CT scan

Horseshoe kidney

Case 2

Spot diagnosis

Answer

Double collecting system


left kidney

Case 3

A 3-months-old boy
was sent for IVP study

where is the
abnormality?

IVP 10 min

Describe the
abnormal finding

Full bladder

Answer

Smooth filling defect in the urinary


bladder with left hydroureter

Ectopic ureterocele

Case 4

A 56-year-old male
was sent for ultrasound evaluation

liver

liver

US

liver

Rt kidney

Rt kidney

Lt kidney

What are the findings?

US

liver cysts
Bilateral
renal cysts

Multiple cysts in
liver and kidney

CT scan

What is the diagnosis?

Polycystic kidney disease


(ADPKD)

Case 5

Describe the
findings

1. Describe the
findings
2. Give the
diagnosis

Post void

Answer

Findings

stone
obstruction
at UPJ

hydronephrosis

Stone at left UPJ


with obstruction

Case 6

A 46-year-old male

Where is the
abnormality

1. Describe the
abnormality
2. Give the
diagnosis

IVP
10 min

Answer

Calcification in
renal pelvis

Filling defect in IVP


Hydronephrosis

Stone at left renal pelvis


with obstruction

Case 7

Describe the
abnormality

Scout

Which kidney is abnormal?


Please outline both kidneys

Answer

Calcification in scout film

Small size
right kidney

Enlarged
left kidney

Right calyceal stone with small kidney


size and hyperplasia left kidney

Case 8

A 42-year-old male
Hx: left flank pain

Scout

Outline both kidneys..

1. Describe the
abnormality
2. Give the
diagnosis

Answer

- Delayed dense
nephrogram
- No contrast
excretion

Acute obstructive uropathy


IVP: dense nephrogram without
excretion left kidney

Case 9

37-year-old female

Delayed IVP 1 hour

Which kidney
is abnormal?
Described the
abnormalities ..

Answer

Non function kidney

Right staghorn stone

Right staghorn stone with


non function right kidney

Case 10

A 73-year-old male
Hx: Microscopic hematuria

1. Where is the
abnormality?
2. What is the
diagnosis?

Right renal stone

IVP 5 minutes

Describe the
findings..

IVP 5 minutes

Focal caliectasis
at upper pole

Answer

Calyceal stone with focal


calyectasis

Case 11

A 66-year-old female

Where is the
abnormality?
Describe the
abnormality?

Round calcification
at LUQ

Ultrasound shows a round hypoechoic lesion


with rim calcification in the left kidney

Calcified renal mass or cyst

Case 12

Outline the
lesion..

Outline the lesion..

IVP
Describe the
findings

A well defined soft tissue density overlying lower


pole of left kidney

Large cyst at lower pole of


left kidney

Case 13

A 46-year-old female
Presented with palpable mass at
right-sided abdomen

Describe the
abnormality..
Can you outline both
renal and psoas
shadows?

Psoas shadows

Enlarged right kidney with soft tissue


density overlying at lower pole

Plain KUB shows enlargement of the right


kidney with suspect soft tissue mass at
lower pole

What is your further


investigation?

Suspected renal mass


US

hydronephrosis
Cystic renal lesion
Simple cyst

Complicated
cyst

Follow up US
Do nothing CT scan
Biopsy

Solid renal mass

CT scan or MRI
-characterization
-location
-staging
-evaluate contralat.kidney

ANS: Ultrasound or CT scan

US of the right kidney shows a hyperechoic


mass at lower pole

Contrast CT scan shows


an enhancing mass with
fat component at lower
pole of the right kidney

Angiomyolipoma at lower pole


of the right kidney

Case 14

Hx. hematuria

IVP 5 minutes & 15 minutes

1. Describe the abnormality


2. Give the diagnosis

Answer

Irregular filling
defect at left-sided
bladder
Foleys catheter

CA bladder

Case 15

1. What study is this?


2. Give the diagnosis.

Answer

Study: VCUG
Dx: Grade II VUR

Case 16

Hx. trauma

1. Describe the findings.


2. Give the diagnosis.

Answer

Intraperitoneal
extravasation
Outline of bowel loops

Bladder dome

Intraperitoneal bladder rupture

Case 17

Hx. trauma

1. Describe the findings.


2. Give the diagnosis.

Answer

Extravasation into
perivesciular space
and
extraperitoneum

Extraperitoneal bladder
rupture

Case 18

Hx. Blunt trauma with gross


hematuria

What investigation should be performed?

Renal trauma
Stable
patient

Suspected renal injury

Unstable
patient

US

Hematoma

CT scan
Angiogram

No hematoma

IVP

Single shot IVP


at OR

ANS. Ultrasound or CT scan


(This patient had CT scan of the
KUB system)

Diagnosis..

kidney

Perinephric hematoma

Laceration of left kidney with


perinephric hematoma