Radiological Anatomy

of the Upper Urinary

Tract
-BY DR NARENDRA
POST GRADUATE
 Kidneys are retroperitoneal paired organs.
 Each kidney lies , on the posterior abdominal
wall, lateral to the vertebral column.

 In the supine position, the kidneys extend

from approximately T12 to L3.

 The right kidney is slightly lower than

the left kidney because of the large size
of the right lobe of the liver.

 With contraction of the

diaphragm during respiration,
both kidneys move downward
in a vertical direction
(high of one vertebra, 1 inch,
• The kidney is a reddish brown, bean-shaped organ.
• Although they are similar in size and shape, the left

kidney is slightly longer and more slender than the

right kidney, and nearer to the midline.
• Each kidneys has:

Convex upper & lower ends.

Convex lateral border. Hilum
Convex medial border at
both ends, but its middle
shows a vertical slit called the hilum.
Internally the hilum extends into a large cavity called the
renal sinus.
• The hilum transmits, from anterior to
posterior, the renal vein, renal artery &
the ureter (VAU).
• Lymph vessels & sympathetic fibers also
pass through the hilum.
• The renal sinus contains the upper
expanded part of the ureter called the renal
pelvis.
• Perinephric fat is continues into the hilum
and the sinus and surrounds all these
structures.
COVERINGS
1. Fibrous capsule:
 closely adherent to its surface
2. Perirenal fat:
 covers the fibrous capsule.
3. Renal fascia:
 Condensation of areolar connective tissue that

lies outside the Perirenal fat and encloses the

kidney and the suprarenal gland.
4. Pararenal fat:
 Lies external to the renal fascia, is part of
the retroperitoneal fat.
•The fascia anterior to the kidneys is called the
Gerota’s fascia while the posterior fascia is called
the fascia of Zuckerkandl

• The space enclosed between the anterior and

posterior fascia is called the perinephric space.
Laterally, the anterior and posterior perirenal fascia fuse with
the lateroconal fascia at the fascial trifurcation.

While the posterior pararenal space is continuous laterally with

the lateral extraperitoneal space (the properitoneal line) lying
between the parietal peritoneum and transversalis fascia, this
space is closed medially.

Medially, the posterior perinephric fascia fuses with the

transversalis fascia over the paraspinal muscles, that is the
psoas muscle and the quadratus lumborum.

The posterior perinephric space hence lies directly over the

psoas muscle being separated only by the transversalis fascia.

Any inflammation process of the kidneys can spread rapidly into

the psoas muscles and from there into the iliacus muscle,
iliopsoas, and the pelvis.
Posterior Relations:
Blood Supply
 The renal artery arises from the aorta at the
level of the second lumbar vertebra
 Each renal artery divides into five
segmental arteries that enter the hilum of
the kidney, four infront and one behind the
renal pelvis
 Lobar artery arise from each segmental
artery, one for each renal pyramid
Segmental branches & vascular segments of
kidneys
•Each kidney has 5 segmental branches and is divided into 5
vascular segments:
1. Apical.
2. Caudal.
3. Anterior Superior.
4. Anterior Inferior.
5. Posterior.
 Each lobar artery gives two or three interlobar
arteries.

 The interlobar arteries run toward the cortex on

each side of the renal pyramid.

 Interlobar arteries give the arcuate arteries at

the junction of the cortex and medulla.

 The arcuate arteries give several interlobular

arteries.

 Afferent glomerular arterioles arise as branches

of interlobular arteries.
Veins, Lymph, Nerve
Supply
 Renal vein emerges from the hilum in front
of the renal artery and drains into the IVC.
 Left renal vein is longer than the right
renal vein.
 Lateral aortic lymph nodes lie around the
origin of the renal artery.
 Renal sympathetic plexus: afferent fibers
that travel through the renal plexus enter
the spinal cord in the 10th, 11th, and 12th
thoracic nerves.
 Ureter
The two ureters are muscular tubes that
extend from the kidneys to the posterior
surface of the urinary bladder
The urine is propelled along the ureter by
peristaltic contractions
Each ureter measures about 25 cm long
Each ureter has three constrictions along its
course,
 1- Where the renal pelvis joins the ureter,
 2- As it crosses the pelvic brim,
 3- Where it pierces the bladder wall ( intra-
mural part)
 It enters the pelvis by crossing the
bifurcation of the common iliac artery in
front of the sacroiliac joint
 It runs downward & forward on the lateral
wall of the pelvis to enter the lateral angle
of the bladder
Variants of the Calyceal
Anatomy
 Compound calyx: multiple single calyces fail
to divide and form a single large calyx known as
the compound calyx. Several renal papillae
which represent the apices of the renal
pyramids drain into a single calyx.
Compound calyces are usually seen at the polar
region, i.e. at the upper or lower poles and are
prone to reflux nephropathy.
 Complex renal calyces and
megacalycosis: In megacalycosis, there is a
greater number of calyces than normal (>15).

There is dilatation of some or all renal calyces

with normal renal pelvis and ureter. Renal
calyces may have a blunted morphology. This
condition should not be confused with
papillary necrosis in which the number of
calyces is not increased and necrosis tends to
be dissimilar from calyx to calyx.
 Calyceal diverticulum: It represents a focal
extrinsic dilatation of a renal calyx. A calyceal
diverticulum connects to the calyceal fornix
and projects into the cortex rather than the
medulla.
Normal Variations
1.Ptosis or an ectopic location.
-most common site for the ectopic kidney is
the pelvis.
2.Renal duplication is common and spans a
range from complete to minimal.
sonography may only show an elongated
kidney perhaps with separation of the renal
sinus into two parts. A double pelvis may
be visualized when the collecting system is
distended.
Dromedary hump -bulge along the lateral border
of the left kidney due to molding by the adjacent
spleen.
HYPERTROPHIED COLUMN OF BERTIN

-normal variant.

-represents unresorbed polar parenchyma

from one or both of the two subkidneys that
fuse to form the normal kidney.
Sonographic criteria
 Isoechogenicity
 continuity with rest of the renal cortex,
 lack of mass effect, indentation of renal sinus
laterally, generally less than 3 cm in size with
a normal vascular pattern on Doppler.
A wedgeshaped echogenic defect or an
echogenic line, the intervesicular fissure or
parenchymal junctional defect, may
sometimes be seen running obliquely from
the sinus to the capsule in upper anterior or
lower posterior part of the kidney.
 GRAYSCALE ULTRASOUND
 Reliable technique for the evaluation of upper urinary tract.
 Noninvasive, easily available, accurate, safe, and does not
require exposure to ionizing radiation.
 Can be performed bedside for sick patients and
interventions can be performed under ultrasound guidance.

Indications for sonography in upper urinary tract:

Diagnosing dilatation of the collecting system and to search
for renal obstruction.

Evaluation of cystic renal lesions. Their architecture including

internal septations, wall thickening, calcifications, presence
or absence of solid components (in order to assign a
Bosniak grade) can all be evaluated on ultrasound.
 Assessment of congenital anomalies and renal
infections as ultrasound is a safe method for evaluating
the urinary tract particularly in pediatric patients as
high resolution sonography is easily feasible and
radiation can be avoided.
 Postnatal ultrasound for the evaluation of urinary tract
in documented prenatal fetal hydronephrosis.
 Characterization of renal masses.
 Detection of nephrolithiasis and resultant back pressure
changes, if any.
 Painless hematuria in low- and medium-risk patients.
 Guidance for therapeutic and interventional procedures
 Cortical and Parenchymal
Thickness
 The cortical thickness is the distance between
the renal capsule and
outer margin of the
renal pyramids.
 Parenchymal thickness

is the distance between

renal capsule and
margin of the
sinus echoes.
DOPPLER EVALUATION

INDICATIONS
 Renovascular hypertension •
 Characterization of mass lesions •
 Differentiation between obstructive and

nonobstructive hydronephrosis •
 Evaluation of transplant kidney •
 Renal vein thrombosis •
 Miscellaneous, e.g. trauma, arteriovenous

malformation (AVM), etc.

 Rapid systolic upstroke, which is occasionally
followed by a secondary slower rise to peak
systole.

 There is a gradual diastolic decay but with

persistentforward flow in diastole.

 Spectral indices are measured in the renal

artery

 The values in the main artery are higher than

in the more distal smaller arteries and they
are lowest in the interlobular arteries at
proximal, middle, and at the hilum.
 ULTRASOUND
ELASTOGRAPHY
 Diagnose kidney diseases and provides a
more accurate estimate of the functional
impairment than blood tests or kidney
dimensions.

Shear wave elastography (SWE)

 emerging technique
 Noninvasive measurement of tissue stiffness.
 uses focused acoustic energy pulses to

produce shear waves which travel

perpendicular to the tissue
 Stiffer the tissue, more is the shear wave
velocity.

 Higher values of shear wave velocity thus

correlate with higher degrees of renal
fibrosis.
 COMPUTED TOMOGRAPHY OF
THE UPPER URINARY TRACT
Noncontrast
 primary imaging modality to detect urinary tract

calculi.
 baseline density measurements of renal masses

and diagnosis of areas of hemorrhage/renal

hematoma.
 Areas of renal parenchymal calcification, fat

attenuation, and calcification in a renal mass can

all be detected on the noncontrast scan.
 Helpful to differentiate a renal solid mass from
hyperdense cyst.
 Normal CT Nephrogram
Corticomedullary Phase
 25–80 seconds following contrast administration.
 In this phase, the renal cortex is distinctly

differentiated from the unenhanced medulla.

 Evaluation of tumor hypervascularity and

differentiation of normal variants and

pseudotumors from renal masses.
 Best phase for the diagnosis of tumor extension

in the renal vein as maximum opacification of the

renal vein and arteries occur during this time .
 Nephrographic Phase
 begins 90–120 seconds after contrast Injection.

 There is a homogeneous enhancement of both

the cortex and medulla.
 Homogeneous enhancement of the renal
parenchyma with loss of the corticomedullary
differentiation.
 Optimum phase for not only detection but also
characterization of renal masses.
 This phase is useful particularly for the lesions
20 HU is considered suggestive of malignancy
and this lesion enhancement is usually best
visualized on the NP.

 Renal infarction, traumatic parenchymal

lesions, and acute pyelonephritis is also best
visualized .
 Excretory phase (EP)
 Begins with the excretion of the contrast
material into the collecting system and is
seen best 3–5 minutes after contrast
administration.
 Good delineation and visualization of the
pelvicalyceal system.
 Evaluation of urothelial lesions including
urothelial neoplasms, calyceal deformities,
papillary necrosis, and strictures and
inflammatory changes of the collecting
system and ureters.
CT ANGIOGRAM OF RENAL
ARTERIES
 Evaluation of renal artery stenosis (RAS).

 Preoperative assessment of the number

and course of renal arteries in renal donors.

 Assessment of renal vessels crossing the

PUJ prior to repair of obstruction.

 Evaluation of renal artery involvement in

abdominal aortic aneurysms.

 Detection of renal artery aneurysms.

 A bolus injection of 150 mL of contrast
material (300 mg Iodine/mL) with a flow rate
of 4 mL/sec produces good opacification of
the renal arteries.
 Maximum intensity projection (MIP) and

volume rendering (VRT) display modes are

most commonly used.
 MIP images provide useful information about

atherosclerotic burden, vascular stenosis, and

vascular stents, and are used in conjunction
with VRT.
 Sensitivity of computed tomography
angiogram (CTA) for determination and
location of main renal artery approaches
100%.

 Arterial branches can be identified accurately

till the segmental level.

 Limitation for detection occurs with vessels

smaller than 2 mm in size.
 MAGNETIC RESONANCE IMAGING
OF THE UPPER URINARY TRACT
 For determining the cephalic extent of an
intracaval tumor in a case of RCC when the
superior extent cannot be determined by CT.
 Characterization of small renal masses that are
indeterminate on CT or US.
 Differentiation between hemorrhagic renal cysts
and renal masses by use of subtraction imaging.
In this, a nonenhanced T1 weighted image is
subtracted from a contrast-enhanced T1 weighted
sequence which cancels the native T1 sequence
and leaves behind only the enhancing portion.
Thus, subtraction images are useful in identifying
true enhancement in complex renal cysts.
 Evaluation of renal donors.

 Evaluation of transplanted kidneys.

 In screening patients with inherited

conditions such as Von Hippel–Lindau
disease which is characterized by renal
cysts, angiomas, and RCC
 SEQUENCES
 Usually both T1- and T2-weighted images are
acquired in the axial, coronal, and sagittal
planes. Due to shorter acquisition times, T2
fast spin echo (FSE) imaging has almost
replaced the conventional spin echo (CSE) T2-
imaging.
 Imaging of the kidneys can be done in the

corticomedullary, nephrographic, and EPs

following contrast administration, similar to
that on MDCT
 Differentiation between solid masses and
complicated cystic lesions can be achieved on
comparison between pre- and postcontrast
images obtained in corticomedullary and NPs.

 Delayed postcontrast images depict tumor

extension in the perinephric fat and venous
structures.
Normal Appearance of the
Upper Urinary Tract on MR
 Visualization of the corticomedullary
differentiation on both T1- and T2- weighted
images. This differentiation is best visualized
on T1 weighted MR images where the cortex
has a higher signal intensity than the adjacent
medulla .
 The cortex has less water than the medulla

and has a longer T1-time and hence is

brighter than medulla on a T1-weighted
image.
 On T2-weighted images, the cortex appears

hypointense to the medulla.

 Renal sinus fat shows a high signal on both T1
and T2 weighted images.
 The renal capsule is seen as a hypointense
line while the perirenal and pararenal fat
shows a bright signal on all pulse sequences.
 The pelvicalyceal system is not seen in a
nondistended state.
 When distended with urine, the collecting
system shows a low signal on T1- and bright
on T2-weighted images.
 The renal arteries, veins, aorta, and IVC are
seen as flow voids.
THANK YOU