Imaging of urinary tract

Preijo Sidipratomo
What is the urinary tract?
• The urinary tract is your body’s
drainage system for removing
wastes and extra fluids. The urinary
tract includes two kidneys, two
ureters, a bladder, and a urethra.

• The kidneys filter wastes and fluids

to produce urine. The urine travels
from the kidneys down two narrow
tubes called the ureters. The urine
is then stored in a hollow, muscular,
balloon-shaped organ called the
bladder. When the bladder
empties, urine flows out of the
body through a tube called the
urethra at the bottom of the
bladder.
What does “imaging” mean?
• Imaging is a general term for techniques used to create pictures.
• In medicine, imaging produces pictures of bones, organs, and vessels
inside the body. Imaging helps health care professionals see the cause
of medical problems.
The radiological examinations of the urinary
tract are
• 1. x-rays
• Intravenous urography (IVU).
• 2.Ultrasound.
• 3. Computed tomography(CT) .
• 4.Radionuclide examinations.(radio nuclid scan)
• 5. Magneticresonance imaging (MRI).
• 6. Arteriography .
• 7. Studies requiring catheterization or direct puncture of the collecting
systems.
• The last three examination are limited to selected cases
Imaging technique Ultrasound
• To investigate patients with symptoms thought to arise from the
urinary tract.
• To demonstrate the size of the kidneys and exclude hydronephrosis in
patients with renal failure.
• To diagnose hydronephrosis, renal tumours, abscesses and cysts
including polycystic disease.
• To assess and follow-up renal size and scarring in children with
urinary tract infections.
• To assess the bladder and prostate
• Normal renal ultrasound
• At ultrasound, the
kidneys should be
smooth in outline. The
parenchyma surrounds a
central echo-dense
region, known as the
central echo complex
(the renal sinus),
consisting of the
pelvicaliceal system,
together with the
surrounding fat and
renal blood vessels
• Normal ureters are not
usually visualized due to
overlying bowel gas.
• The urinary bladder
should be examined in
the distended state: the
walls should be sharply
defined and barely
perceptible .The bladder
may also be assessed
following micturition, to
measure the post
micturition residual
volume of urine.
Urography
• Urography is the term used to describe the imaging of the renal tract
using intravenous iodinated contrast medium.
• There are 2 types :
• 1.The traditional intravenous urogram ( IVU )
• 2. CT urography .
• CT has the advantage of being highly sensitive for the detection of stones,
including those that may be radiolucent on plain film, allows the
characterization of renal lesions and the detection of ureteric lesions, and
demonstrates the surrounding retroperitoneal and abdominal tissues. In
addition , CT overcomes the overlap of superimposed tissues, which can
cause difficulty when interpreting traditional IVU.

• The principles of both techniques are similar. Firstly, ‘non-contrast’

imaging of the renal tract is required, in order to identify all renal tract
calcifications. In some case, where the clinical question relates to renal
calculi, the non contrast CT may be sufficient (known as the ‘CT KUB’).
The main indications for urography are:
IVU study
• -Plain film in intravenous urogram: it used to Identify all calcifications.
Decide if they are in the kidneys by relating them to the renal outlines
, calcification seen in the line of the ureters or bladder must be
reviewed with post contrast scans, to determine whether the
calcification lies in the renal tract. Note that calcification can be
obscured by contrast medium and stones are missed if no plain film is
taken
.Check that the kidneys are in
their normal positions . The left
kidney is usually higher than the
right.
pelvis and ureters
Bladder

• The bladder is a centrally located structure that should have a smooth

outline. It often shows normal smooth indentations from above
owing to the uterus or the sigmoid colon, and from below by muscles
of the pelvic floor .
• After micturition the bladder should
• be empty, apart from a little contrast
• trapped in the folded mucosa
Computed tomography urography
• CT is initially performed without intravnous contrast medium (non-
contrast CT or ‘CT KUB’) to identify calcification
Computed tomography urography
indication and include:
• (i) The early renal cortical enhancement phase.
• (ii) The homogeneous nephrogramphase; and
• (iii)The delayed urographic phase, obtained
• several minutes later to demonstrate contrast within the collecting
systems.
Magnetic resonance imaging
• Magnetic resonance imaging gives similar anatomical information to CT,
with the advantage of being able to obtain scans directly in multiple
planes. It is generally used in selected circumstances , including :
• -To demonstrate renal artery stenosis .
• - Inferior vena caval extension of renal tumours.
• - To clarify problems not solved by ultrasound or CT.
• -To assess the extent of bladder or prostate cancer prior to consideration
for surgery.
• Calcification is not visible on MRI, which is one of the main disadvantages
of the technique for renal tract imaging
Normal magnetic resonance imaging
• As with CT and
ultrasound, the renal
contours should be
smooth.
Corticomedullary
differentiation is best
seen on T1-weighted
images and
immediately following
intravenous contrast
enhancement with
gadolinium .
• The renal
collecting
systems,
ureters and
bladder are
best seen on
T2-weighted
images, as the
fluid returns a
high signal
intensity
Special techniques
• Retrograde and antegrade pyelography
• The techniques of retrograde and antegrade pyelography (the term
pyelography means demonstrating the pelvicaliceal system and ureters)
involve direct injection of contrast material into the pelvicaliceal system or
ureters through catheters placed via cystoscopy (retrograde pyelography)
or percutaneously into the kidney via the loin (antegrade pyelography).

• The indications are limited to those situationswhere the information

cannot be achieved by less invasive means, e.g. IVU, CT or MRI to confirm a
possible transitional cell carcinoma in the renal pelvis or ureter.
Voiding cystourethrogram (micturating
cystogram) and videourodynamics
• In voiding
cystourethrography, the
bladder is filled with
iodinated contrast medium
through a catheter and films
are taken during voiding. The
entire process is observed
fluoroscopically to identify
vesicoureteric reflux.
• The bladder and urethra can
• be assessed during voiding
• to demonstrate strictures or
• urethral valves .
Urethrography
• The urethra is visualized during
voiding cystourethrography.For
full visualization of the male
urethra, however, an ascending
urethrogram with contrast
medium injection via the external
urethral meatus is necessary .
• The usual indications for the
examination are:
• - The identificationof urethral
strictures
• - To demonstrate extravasation
from
• the urethra or bladder neck
• following trauma
Radionuclide scans
• A radionuclide scan, also called a nuclear scan or radioisotope scan,
detects small amounts of radiation after radioactive material is
injected into the blood. This scan provides information about how
your kidneys function and helps health care professionals diagnose
many conditions, including cancers, injuries, and infections.

• Renal scan, also called kidney scan. Your health care professional
might use a renal scan to check your kidneys and the urinary system.
This type of exam includes injecting a small amount of radioactive
material into the blood and using a special camera and computer.
• There are different types of renal scans, and they can be used to check the
kidneys along with other imaging methods such as ultrasound, CT scans,
and MRIs. Sometimes they can provide unique information that is hard to
get from other imaging procedures. A health care professional determines
which method will provide the best information about your kidneys and
urinary system.

• PET scan .
• A positron emission tomography (PET) scan is a type of imaging that uses a
small amount of radioactive material, a special camera, and a computer to
help health care professionals see how the organs and tissues are working.
PET scans are sometimes performed on combined PET/CT scanners
• Ca.
ginjal
metat
asis
Renal arteriography
• Renal arteriography is
performed via a
catheter introduced
into the femoral artery
by the Seldinger
technique . Selective
injection are made into
one or both renal
arteries . It is mainly
used:
• - To confirm the CT or
MRI findings of vascular
anatomy prior to renal
surgery.
• -To confirm renal
artery stenosis prior to
percutaneous balloon
angioplasty
• Left renal
artery
stenosis
literatures
• https://www.muhadharaty.com/lecture/
• https://www.niddk.nih.gov/health-information/diagnostic-
tests/urinary-tract-imaging