URORADIOLOGY

JEROME B. MONDALA MD, FPCR

 URORADIOLOGY

XRAY
- KUB
 URORADIOLOGY
• KUB XRAY

• KUB XRAY
 URORADIOLOGY

• KUB XRAY
 URORADIOLOGY
• Intravenous urography (IVU), also referred as intravenous pyelography (IVP) or excretory
urography (EU), is a radiographic study of the renal parenchyma, pelvicalyceal system, ureters
and the urinary bladder. This exam has been largely replaced by CT urography.
• Indications
• check for normal function of kidneys
• check for anatomical variants or congenital anomalies (e.g. horse-shoe kidney)
• check the course of the ureters.
• detect and localise a ureteric obstruction (urolithiasis)
• assess for synchronous upper tract disease in those with bladder transitional cell carcinoma(TCC)
URORADIOLOGY
 URORADIOLOGY
RENAL ULTRASOUND
In adults, the normal kidney is 10-14 cm long in males and 9-13 cm long in females, 3-5 cm wide, and weighs
150-260 g. The left kidney is usually slightly larger than the right.
Normal kidney appearance in adult:
• cortex is less echogenic than the liver
• medulla is more echogenic than the cortex
• cortex thickness equals/is more than 6 mm
• pyramids (if seen) are slightly less echogenic than the cortex
• central renal sinus, consisting of the calyces, renal pelvis and fat, is more echogenic than the cortex
• renal pelvis may appear as a central slit of anechoic fluid at the hilum
• normal ureters are generally not well seen on ultrasound
 URORADIOLOGY

• ULTRASOUND
NEPHROLITHIASIS
 URORADIOLOGY
• HYDRONEPHROSIS
• grade 1 (mild)
• dilatation of the renal pelvis without dilatation of the calyces (can also occur in the extrarenal pelvis)
• no parenchymal atrophy

• grade 2 (mild)
• dilatation of the renal pelvis (mild) and calyces (pelvicalyceal pattern is retained)
• no parenchymal atrophy

• grade 3 (moderate)
• moderate dilatation of the renal pelvis and calyces
• blunting of fornices and flattening of papillae
• mild cortical thinning may be seen

• grade 4 (severe)
• gross dilatation of the renal pelvis and calyces, which appear ballooned
• loss of borders between the renal pelvis and calyces
• renal atrophy seen as cortical thinning
URORADIOLOGY
 URORADIOLOGY

• URETERAL STONES
 URORADIOLOGY

• Cystolithiasis
 URORADIOLOGY

ULTRASOUND
RENAL CYST
 URORADIOLOGY

• ULTRASOUND
• RENAL MASS
 URORADIOLOGY

• ULTRASOUND
• RENAL MASS
 URORADIOLOGY
• CT SCAN – CT STONOGRAM
• Computed tomography of kidneys, ureters and bladder (CT KUB) is a quick non-invasive technique for
diagnosis of urolithiasis. It is usually considered the initial imaging modality for suspected urolithiasis in an
emergency setting.

Procedure
• Actual procedure will vary depending on institutional protocol/guidelines but below is a typical description:
• non contrast CT scanning is ideally performed on a multi-detector computed tomography (MDCT) scanner.
• supine or prone patient positioning
• prone has the advantage of assessing stones near the VUJ which may have just passed
• some institutions may perform a limited pelvic scan in prone if the supine scan shows a calculus near the VUJ

• data interpretation with the use of axial, sagittal and coronal reformatted images for proper evaluation.
URORADIOLOGY
 URORADIOLOGY

• Renal Cyst
 URORADIOLOGY
• Classification

• Bosniak 1

• simple cyst
• imperceptible wall, rounded
• work-up: none
• percentage malignant: ~0%

• Bosniak 2

• minimally complex
• a few thin <1 mm septa or thin calcifications (thickness not measurable);
• non-enhancing high-attenuation (due to proteinaceous or haemorrhagic contents) renal lesions <3 cm
• these lesions are generally well marginated
• work-up: none
• percentage malignant: ~0%
 URORADIOLOGY
• Bosniak 2F
• minimally complex
• increased number of septa, minimally thickened with nodular or thick calcifications
• there may be perceived (but not measurable) enhancement of hairline-thin smooth septa
• minimal thickening of the wall with perceivable enhancement
• hyperdense cyst >3 cm diameter, mostly intrarenal (less than 25% of wall visible); no enhancement
• requiring follow-up: needs ultrasound/CT/MRI follow up - no strict rules on the time frame but
reasonable at 6 months
• percentage malignant: ~5%
 URORADIOLOGY

• Bosniak 3
• indeterminate
• thick, nodular multiple septa or wall with measurable enhancement
• treatment/work-up: partial nephrectomy or radiofrequency ablation in elderly or poor surgical
candidates
• percentage malignant: ~55%

• Bosniak 4
• clearly malignant
• solid mass with a large cystic or a necrotic component
• treatment: partial or total nephrectomy
• percentage malignant: ~100%
 URORADIOLOGY
• WILMS TUMOR
• Wilms tumors are the most common pediatric renal mass, accounting for over 85% of cases and
accounts for 6% of all childhood cancers. It typically occurs in early childhood (1-11 years) with
peak incidence between 3 and 4 years of age. Approximately 80% of these tumours are found
before the age of 5 years. When part of a syndrome they occur even earlier, typically between 2
and 24 months of age.
• There is no recognised gender predilection, however, presentation is a little later in females. The
vast majority are unilateral with less than 5 % occurring bilaterally.
 URORADIOLOGY

Radiographic features
• Wilms tumors are usually large heterogeneous solid masses which displace adjacent structures.
Occasionally they may be mostly cystic.
• Metastases are most commonly to lung (85%), liver and local lymph nodes. Similar to renal cell
carcinoma tumour thrombus into the renal vein, IVC and right atrium are also characteristic of
advanced disease.
URORADIOLOGY
URORADIOLOGY
 URORADIOLOGY
• CT urography (CTU or CT-IVU) has now largely replaced traditional IVU in imaging the
genitourinary tract. It gives both anatomical and functional information, albeit with a relatively
higher dose of radiation.
• The aim is to illustrate the collecting systems, ureters and bladder with intravenous contrast,
albeit in a single acquisition as opposed to the multiple and more dynamic traditional IVU.
Visualization of other structures in the abdomen is also better with CTU than with traditional
IVU.
• Upper tract tumors, strictures and to a degree the function of the kidney can be assessed.
URORADIOLOGY
 URORADIOLOGY

• URETERAL MASS
 URORADIOLOGY

• URINARY BLADDER DIVERTICULUM

 URORADIOLOGY
• URINARY BLADDER MASS
• Transitional cell carcinoma (TCC) is the most common primary neoplasm of the urinary
bladder, and bladder TCC is the most common tumour of the entire urinary system.
• TCCs in other locations:
• transitional cell carcinoma of the renal pelvis
• transitional cell carcinoma of the ureter

• other histologies:
• squamous cell carcinoma of the bladder
• adenocarcinoma of the bladder
URORADIOLOGY
 URORADIOLOGY
• PROSTATE GLAND
• The prostate gland is part of the male reproductive system and is the largest male accessory
gland. It typically weighs between 20-40 grams with an average size of 3 x 4 x 2 cm. The
prostate is comprised of 70% glandular tissue and 30% fibromuscular or stromal tissue and
provides ~30% of the volume of seminal fluid.
• MRI is the preferred imaging modality.
• The prostate is comprised of three distinct zones with different embryologic origins:
peripheral zone
central zone
transition zone
 URORADIOLOGY

• Benign prostatic hyperplasia is due to a combination of stromal and glandular hyperplasia,

predominantly of the transition zone (as opposed to prostate cancer which typically originates in
the peripheral zone).
THANK YOU