1. URORADIOLOGY
Ayşegül SARSILMAZ M.D.
Radiology

2. Radiological Modalities
Ultrasound
Intravenous Pyelography
Computed Tomography
Magnetic Resonance Imaging
Radionuclide Scanning

3. Ultrasound
CT (-)  Anatomical info.
MRI
Radionuclide  Functional info.
IVP  Anatomical + Fnx.

4. ULTRASOUND First line investigation !!!
Provides anatomical information without ionizing radiation
No need for intravenous contrast !!!

5. INDICATIONS (USG)
İnvestigate patients with symptoms thought to arise from UT
Size of the kidneys
Presence of hydronephrosis
Renal tumors, cysts, abcesses
Assess bladder and prostate

6. Normal Findings Kidneys; smooth in outline
Central echogenic region (renal sinus)
Renal cortex (hypoechoic)
Pyramids (triangular hypoechoic areas)
Size : mm
Urinary Bladder : examined in distended state, imperceptible walls, anechoic lumen

10. Intravenous Pyelography
Largely replaced by US
ml of contrast is injected intravenously
Carried via blood to the kidneys, passes through the glomerular filtrate  collecting systems
Main indications:
Detailed demonstration of PCS and ureters
Acute ureteric colic
Investigation of renal calculi
Investigation of hematuria

11. Identify all calcifications !!!
First step: Plain film
Look at renal contour
Identify all calcifications !!!
Urinary calculi (kidney,ureter,bladder)
Nephrocalcinosis
Prostatic calcification

16. Kidneys: position , length , contours
Calices: should be symmetrical, cup-shaped.
If dilated  club-shaped (due to obstruction or destruction of papilla)
Renal pelvis and ureters: normal pelvis is funnel-shaped, ureters are seen in only part of their length due to peristaltism.
Bladder: centrally located, smooth outline, should be empty after micturition

18. Computed Tomography Indications:
To characterize renal masses and stage tumors
To diagnose or exclude renal trauma
To demonstrate stones
To assess acute ureteric colic
To delineate renal vascular anatomy

19. Normal Findings Renal sinus ; low attenuation in the center
There should not be any calcification
Ureters are seen as dots in cross section lying on the psoas muscles
Bladder has a smooth outline, thin wall, anechoic urine.
Axial images may be reformatted in the coronal and sagittal planes

21. MRI Used in selected circumstances
(renal artery stenosis, IVCal extension of renal tumors)

23. Voiding Cystourethrogram
Bladder is filled with contrast medium through a catheter and films are taken during voiding
Observed fluoroscopically to identify reflux of contrast medium from bladder to upper UT.
Risk of urinary tract infection, chronic pyelonephritis and renal scarring is increased in VUR.

24. Grading of VUR Grade 1 reflux of urine only into the ureter
Grade 2 reflux into the pelvis and calices, no dilatation
Grade 3 mild to moderate dilatation of the ureters and renal pelvis
Grade 4 moderate dilatation and tortuosity of the ureters,pelvis,calices
Grade 5 gross dilatation and tortuosity of the ureters,pelvis and calices

27. UPPER URINARY TRACT DISORDERS
Urinary Calculi
Urinary Tract Obstruction
Renal Parenchymal Masses
Urothelial Tumors
Acute Pyelonephritis, Perinephric abscess
Chronic Pyelonephritis
Congenital Anomalies

28. LOWER URINARY TRACT DISORDERS
Bladder Tumors
Bladder Diverticula
Prostatic Enlargement

29. Urinary Calculi
Most calculi are calcified and can be seen as radiodense on plain x-ray.
Only pure uric acid and xanthine stones are radiolucent on plain radiography, and they can be identified at CT or US.
US ; hyperechoic with posterior acoustic shadowing
CT ; hyperdense

32. UPPER URINARY TRACT DISORDERS
Urinary Calculi
Urinary Tract Obstruction
Renal Parenchymal Masses
Urothelial Tumors
Acute Pyelonephritis, Perinephric abscess
Chronic Pyelonephritis
Congenital Anomalies

33. Urinary Tract Obstruction
The main feature is dilatation of the pelvicaliceal system and ureters
Main causes :
Calculi
Blood clot
Sloughed papilla
Tumors
US, IVP and CT

34. US : dilatation of PCS is seen as multiloculate fluid collection in the central echo complex (caused by pooling of urine within the distended pelvis and calices). Proximal ureteric dilatation can also be demonstrated but overlying bowel gas obscures dilatation of the mid and distal ureter.

36. IVP Plain films may be helpful to demonstrate the calculus
Delayed films are essential
Filling of the pelvicaliceal system with contrast medium is greatly delayed.

37. CT
In acute obstruction, non-contrast CT demonstrates the calculi.

38. UPPER URINARY TRACT DISORDERS
Urinary Calculi
Urinary Tract Obstruction
Renal Parenchymal Masses
Urothelial Tumors
Acute Pyelonephritis, Perinephric abscess
Chronic Pyelonephritis
Congenital Anomalies

39. Renal Parencymal Masses
Causes: cyst, benign tumor (angiomyolipoma), renal cell carcinoma, metastases, abscess US
usually renal masses are first detected by US.
Cystic versus Solid
Simple cyst: common in elderly, solitary or multiple, unilocular or septated. Acoustic enhancement.

41. Angiomyolipoma: small echogenic masses.

42. Renal Cell Carcinoma
RCCs account for 86% of all primary renal parenchymal tumors.
On US; solid tumors
May be iso, hypo or hyperechoic.
When a tumor is demonstrated, extension into the renal vein and inferior vena cava should be assessed.

43. CT Useful for diagnosis and staging of renal tumors
Shows local direct spread, enlargement of lymph nodes, liver or other organ metastases, renal vein and IVC involvement.

45. UPPER URINARY TRACT DISORDERS
Urinary Calculi
Urinary Tract Obstruction
Renal Parenchymal Masses
Urothelial Tumors
Acute Pyelonephritis, Perinephric abscess
Chronic Pyelonephritis
Congenital Anomalies

46. Urothelial tumors are seen as filling defects in the renal pelvis and ureters
Filling defects in the collecting system: calculi, blood clot, tumor
They may obstruct the ureter and cause hyrdonephrosis.

48. Congenital Anomalies Bifid Collecting System Ectopic Kidney
Horseshoe kidney
Renal Agenesis

49. Bifid Collecting System
Most frequent congenital variation
Unilateral or bilateral
Bifid pelvis ureteric duplication

51. Ectopic Kidney During fetal development kidneys ascend in the abdomen
Ectopic kidney results when this ascent is halted
In some cases kidneys lie on the same side and are fused (crossed fused ectopia)

52. Horseshoe Kidney
The kidneys may fail to seperate, giving rise to a horseshoe kidney
Lower poles are fused by parenchyma or fibrous tissue

54. LOWER URINARY TRACT DISORDERS
Bladder Tumors
Bladder Diverticula
Prostatic Enlargement

55. Bladder Tumor Most frequent site for neoplasms of the urinary tract
On US; bladder tumors are seen as soft tissue masses protruding into the bladder.
IVP; filling defect in the bladder
On CT and MRI; soft tissue mass projecting from the bladder wall

58. LOWER URINARY TRACT DISORDERS
Bladder Tumors
Bladder Diverticula
Prostatic Enlargement

59. Bladder Diverticula
May be congenital or secondary to chronic obstruction
Demonstrated by US, CT or MRI.

62. LOWER URINARY TRACT DISORDERS
Bladder Tumors
Bladder Diverticula
Prostatic Enlargement

63. Prostate Imaging
Prostatic enlargement : benign prostatic hypertrophy, prostatic carcinoma
Prostatic ultrasound; transducer introduced into the rectum
TRUS guided biopsy
MRI ; tumor is seen mostly in the peripheral zone as hypointense on T2

67. Scrotal Swelling US, Color Doppler US, MRI
Testicular tumor, orchitis-epididymo-orchitis, testicular torsion, hydrocele
Doppler ; used in acute scrotum; to differentiate between epididiymo-orchitis and testicular torsion
Epididiymo-orchitis ; medical treatment
Torsion ; surgery