 IVP

 RPG
 APG
 Uretrografi
 Uretrosistografi
 Sistografi
 Bipoler Uretosistografi
 Miksi sistouretrografi
Imaging of the Genitourinary Tract
 Imaging of the Genitourinary Tract

 Modalities
 Plain films
 “KUB”
 Plain films plus contrast
 IVP or IVU
 RUG, cystogram, pyelogram
 Cross-sectional imaging
 CT, MRI, US
 angiography
 inferior venacavography
Imaging of the Genitourinary Tract

normal study
UROGRAFI INTRAVENA
 PERSIAPAN
 Diet lunak.
 Puasa 8 jam (dari malam hari; makan dan minum).
 Cek ureum dan creatinin (≤2,5).
 Laksansia.

 DOSIS :
 Dewasa: 0,5-1cc/ kg bb
 Anak: 1-2cc/kg bb
 INDIKASI:
 Kelainan kongenital
 Infeksi
 Batu
 Trauma
 Tumor
 Hematuria (mikro, gros)
 YANG DINILAI PADA IVP ADALAH PERJALANAN
KONTRAS
Interval for taking film :
30 second – 1 minute: nephrogram phase
4 – 5 minute : visualization of the collecting
system
8 – 15 minute : ureter
25 – 40 minute : urinary bladder
60 minute : if necessary
2 hours : unvisualized kidney
Delayed urography : 1,3,6,12,24 hours until the point of
obstruction demonstrated
Post void film : ability to empty the bladder
evaluate the distal ureter that may be
hidden by opacified bladder on the
prevoiding radiograph
evaluate bladder mucosa
TUJUAN PERMENIT: EKSKRESI KONTRAS PADA
PUNCAKNYA
 If the lower ureter are not actually visualized : prone
position compression
 Contra indication compression :
1. Ureter Obstruction
2. Aorta aneurism
3. Acute abdomen
 Oblique film : Superimposed of the urinary tract
 Defect of the urinary tract
 UPRIGHT :
 Ren Mobilis
 Most inferior portion of bladder : cystocele / hernia
YANG DINILAI
 Kontur, ukuran dan letak kedua ginjal.
 Pengisian PCS: Normal : menit ke5-15; > 15 mnt
:delayed; >2 jam: NON /UNVISUALIZED KIDNEY
 PELEBARAN PCS KANAN/KIRI
 N: TAK MELEBAR  KALIKS MINOR : CUPPING
 Melebar : Blunting, Flattening, Rounding, Ballooning
 URETER KANAN/KIRI: Normal: tak melebar
 Ingat 3 tempat penyempitan ureter: PUJ, penyilangan
dg a. iliaca, UVJ.
 VU: dinding (N. reguler; tidak reguler: sistitis)
 Adakah indentasi, filling defect dan add shadow.
 POST MIKSI/ POST PENGOSONGAN KATETER:
 Residu urine: normal: minimal, jika banyak/cukup banyak:
sistitis.
 Apabila dengan kateter maka fungsi pengosongan tidak
perlu dinilai.
 Lihan bendungan: N: tidak tampak bendungan
 Total: apabila tidak ada aliran kontras pada bagian
distalnya, atau bendungan sama antara pre dan post miksi
 Parsial: apabila ada aliran kontras di distalnya atau
besarnya bendungan berkuarang dibanding pre miksi.
GRADING HIDRONEFROSIS IVP
Imaging of the Genitourinary Tract

horseshoe kidney
Imaging of the Genitourinary Tract

stone at UVJ with surrounding edema

Imaging of the Genitourinary Tract

ureteral calculus
Imaging of the Genitourinary Tract

renal cysts
 Imaging of the Genitourinary Tract

polypoid filling defect in renal pelvis: TCC

Imaging of the Genitourinary Tract

TCC
Imaging of the Genitourinary Tract

internal iliac artery aneurysm

Imaging of the Genitourinary Tract

vaginal mass, uterine impression

RPG (RETROGRADE PYELOGARFI)
 Jika IVP gagal/ nonvisualized kidney maka dilakukan
RPG.
 Tujuan: Untuk mengetahui letak obstruksi
 Dengan dipasang kateter sampai PCS melalui
sistostomi oleh dr. bedah).
 Lalu isikan kontras sambil tarik kateter pelan sampai
VU terisi.
CYSTOGRAPHY
 Purpose :
 Show bladder ruptur
 Low pressure vesicoureteral reflux
 Vesical fistula
 Method :
 Using folley catheter, contrast media instilled
into urinary bladder until the limit of the
patient comfort.
 Take the radiograph : AP, oblique, post
evacuation.
 lateral ( if necessary ).
 Oblique : to distinguish filling defect /
diverticula.
 Post evacuation : vesical diverticula, filling
defect caused by neoplasm, vesicoureteral
reflux.
 Imaging of the Genitourinary Tract

prostatic enlargement, bladder outlet obstruction

Imaging of the Genitourinary Tract

bladder diverticula, neurogenic bladder

 Retrograde Cystouretrography :
 Purpose : describing vesica urinaria, vesical neck,
urethra anterior & posterior.

 Method :
 Using 12 – 14 catheter Folley inserted into urethra until
deflated baloon just appear inside the meatus.(fossa
naviculare)
 Dynamic study : contrast injected under fluoroscopic control.
CYSTOURETHROGRAPHY
 Bipoler Cystourethrography :
 Purpose :
 describing vesica urinaria, vesical neck, urethra anterior &
posterior.
 Method :
 Using folley catheter, contrast media instilled into urinary bladder
until the limit of the patient comfort.
 Take the radiograph : AP, oblique ( if necessary )
 Using 12 – 14 catheter Folley inserted into urethra until deflated
baloon just appear inside the meatus.(fossa naviculare)
 Dynamic study : contrast injected under fluoroscopic control.
 Micturition / Voiding Cystourethrography :
 Purpose :
 Demonstrate the external urethral sphincteric mechanism.
 Evaluate the urethra
 Diagnose high pressure vesicoureteral reflux
 Method :
 The bladder should be filled until the patient is certain she / he
can void after the catheter removed.
 Male : 450 oblique position, so entire urethra can be
demonstrated, Female : AP
 Can be used double-bubble catheter : OUI & OUE
VESICO URETERAL REFLUX (VUR)
INTERNATIONAL CLASSIFICATION OF
VESICOURETERAL REFLUX
 GRADE I : Reflux only into ureter
 GRADE II : Reflux into collecting system,
without dilation
 GRADE III : Reflux into collecting system
with mild dilation
 GRADE IV : Reflux into collecting system,
with moderate dilation
 GRADE V : Reflux into collecting system,
with severe dilation
NORMAL URETHRA
 Imaging of the Genitourinary Tract

 CT Imaging can identify

 hydronephrosis due to ureteric orifice
involvement
 abnormal lymphadenopathy
 pelvic organ and side wall invasion
 distant mets
 Pitfall
 Unreliable in delineating primary tumor at bladder
neck or dome
 Imaging of the Genitourinary Tract

 Stage I
 Imaging of the Genitourinary Tract

 Solitary Renal Mass

 DDx: cyst, AML, RCC, abscess

? lymphoma
 Imaging of the Genitourinary Tract

 Renal Lymphoma
 Imaging of the Genitourinary Tract

 Renal Lymphoma
 Imaging of the Genitourinary Tract

 Stage II
 extension into
perinephric fat
 thickening of
renal fascia
 adrenal gland
involvement
 visible collateral
vessels
 Imaging of the Genitourinary Tract

 Stage IIIA
 RV invasion and extension into IVC
 Imaging of the Genitourinary Tract

 Tumor Thrombus in Renal Vein, IVC

 Imaging of the Genitourinary Tract

 Tumor Thrombus in Renal Vein and IVC

 Imaging of the Genitourinary Tract

 Stage IIIB
 regional lymph node
metastases
 if > 2cm, almost always contain
tumor
 clusters more suspicious
 CT: > 80% sens. & spec.
 Pitfall

 inflammatory nodes

 Imaging of the Genitourinary Tract

 Stage IIIB
 Imaging of the Genitourinary Tract

 Stage IV
 invasion of adjacent
organs
 difficult to determine by
CT

 Imaging of the Genitourinary Tract

 Stage IV
 distant mets
 lungs (37%)
 bones & liver (33%)
 mesentery, adrenals
abdominal wall, brain,
pancreas
 Imaging of the Genitourinary Tract

 Stage IV
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
 Imaging of the Genitourinary Tract

 Testicular Carcinoma
 most common malignancy in males aged 15 to 35
 germ cell tumors
 95% of testicular tumors
 Seminomatous
 Non-seminomatous
 non-germ cell tumors Seminoma
 Sertoli, Leydig cells

 Lymphoma
 Leukemia
 Metastases
Imaging of the Genitourinary Tract

Seminoma
Imaging of the Genitourinary Tract

Metastatic Choriocarcinoma

–rarely exists in pure form

–peak incidence in 2nd and 3rd decade
–highly malignant tumor, metastasizes early
 Imaging of the Genitourinary Tract

Mature teratoma in a 22-year-old man

Subtypes: mature, immature, malignant

benign in children, malignant in adults
 Imaging of the Genitourinary Tract

 Hydrocele
 fluid collection between layers of
tunica vaginalis
 congenital
 patent processus vaginalis
 communication between abdomen
and scrotum
 acquired
 inflammation, torsion, trauma,
 idiopathic, neoplasm,
 surgery
 Imaging of the Genitourinary Tract

 Varicocele
 dilated, tortuous pampiniform plexus, > 2 mm
 common cause of male infertility (Rx: embolization)
 primary
 absent or incompetent valves

 collateral bypass

 secondary
 pressure on spermatic vein

 hydronephrosis, masses

 accentuated by
 upright position, valsalva
 Imaging of the Genitourinary Tract

Scrotal Hernia

Hernia Contents: omental fat, small bowel, large bowel

 Imaging of the Genitourinary Tract

 DDx of Acute Scrotum

 Testicular Ischemia
 torsion

 post surgical, trauma, infarction

 Scrotal Inflammation
 epididymitis

 epididymo-orchitis

 Scrotal Trauma
 Neoplasm
 rare cause of acute scrotum
 Imaging of the Genitourinary Tract

• Testicular Torsion
• Sonography
– diffusely hypoechoic
– hydrocele
– absence of intra-testicular flow
– Nuclear Scintigraphy
– very high sensitivity, specificity
– ? availability
– Problem Situations
– intermittent torsion
– torsion of appendix testis
Imaging of the Genitourinary Tract

Epididymo-Orchitis

skin thickening, complex hydrocele,

hypoechoic testis, marked hypervascularity
 Imaging of the Genitourinary Tract

 Testicular Rupture
 rapid, non-invasive, highly sensitive
 confirmation of clinical suspicion
 imaging findings
 focal alteration in testicular echogenicity
 discrete fracture plane
 hematocele
 vascular disruption on Color Doppler Sonography
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract
Imaging of the Genitourinary Tract