Urinary system: imaging diagnosis 唐光健
Questions to think of Which diagnostic imaging modality is the most suitable for the urinary system and why? What urinary diseases are suitable for imaging examination? What imaging method should be chosen with different sort of disease considered clinically? What information we expect to get from the imaging?
Urinary System Characteristics: poor natural contrast Luminal Structure calyces, pelvic, ureter, bladder -UROGRAPHY Parenchyma Kidney-cortex, medulla -TOMOGRAPHIC IMAGING
Imaging modalities: plane film（KUB）-limited effective Urography Intravenous pyelography IVP Retrograde pyelography Cystography Urethrography -show morphous of the lumen indirectly -overall view of the urinary tract -affected by the renal function & lumen construction Ultrasonography USG -real time, convenient, low cost, available -good characteristic of stone, fluid CT Computed Tomography -high resolution of high density & low density -contrast enhancement MRI Magnetic Resonant Imaging -good contrast of soft tissues
Normal Manifestations KUB: contour of kidney -edge, density, size, position…
Normal Manifestations IVP –compress the ureter, picture 15’-30’ after contrast administration renal papilla Vtx body formix major calyx-neck minor calyx fundament renal pelvic ureter bladder
Normal Manifestations IVP –compress the ureter, picture 15’-30’ after contrast administration renal papilla Vtx body formix major calyx-neck minor calyx fundament renal pelvic ureter
Normal Manifestations IVP-normal variant branching ampullary
Normal Manifestations retrograde pyelogram back flow-collecting duct BF, renal sinus BF, perivein BF, lymph duct BF
Normal Manifestations B-mode sonography- renal sinus, renal parenchyma, renal profile…
Normal Manifestations CT– without/with contrast ~cortical phase, parenchymal phase, excrete phase ~profile, density, enhancement… Parenchymal phase cortical phase plane scan
Normal Manifestations CT– without/with contrast ~cortical phase, parenchymal phase, excrete phase ~profile, density, enhancement… Parenchymal phase excretive phase cortical phase
Normal Manifestations Angiography– ~no routine method, with interventional therapy ~arterial ph. parenchymal ph. Veinal ph.
Normal Manifestations MRI- T1WI higher SI with cortex T2WI homogeneous high SI (signal intensity) T2WI T1WI
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carcinoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal solid malignant renal carcinoma - neoplasm, vascularity, necrosis
Renal solid malignant pathologic features correlate to imaging neoplasm-mass effect neoplastic vascularity necrosis & bleeding in side the mass
Renal solid malignant renal carcinoma - neoplasm, vascularity, common with necrosis plain film: profile change-helpless with diag. urography: elongated & deformed pelvic- poor specification BUS: substantial, hypo/inhomogeneous echoic angiography: vessel shift, tumor flashing, neo-vessel. Staging CT high specific & sensitive. Staging MRI Seldom used
Renal solid malignant renal carcinoma plain film: profile change-helpless with diag.
Renal solid malignant renal carcinoma urography: elongated & deformated pelvic-poor specification
Renal solid malignant renal carcinoma BUS: substantial, hypo/inhomog eneous echoic
Renal solid malignant renal carcinoma CT high specific & sensitive. Staging plain scan delay scan With enhancemnet
Renal solid malignant renal carcinoma CT high specific & sensitive. Staging delay scan plain scan with enhancement
Renal solid malignant renal carcinoma angiography: vessel shift, tumor flashing, neo-vessel. Staging parenchymal phase post ia adrenalin arterial phase
Renal solid malignant renal carcinoma CT high specific & sensitive. Staging renal vein, IVC invaded by RCC
Renal solid malignant renal carcinoma CT high specific & sensitive. Staging renal vein, IVC invaded by RCC
Renal solid malignant renal carcinoma angiography: vessel shift, tumor flashing, neo-vessel. Staging Arterial phase Parenchymal phase
Renal s solid malignant renal carcinoma angiography: vessel shift, tumor flashing, neo-vessel. Staging post embolizing of RA IVC angiography
Renal solid malignant renal carcinoma MRI seldom use
Renal solid benign Renal hamartoma (angiomyolipoma) - ratio of tree elements various, bleeding often
Renal solid malignant Angiomyolipoma pathologic features correlate to imaging neoplasm-mass effect adipose tissue, smooth muscle, vessels hypo-developed neoplastic vessels-bleeding
Renal solid benign renal angiomyolipoma plain film: profile change-helpless with diag. urography: elongated & deformed pelvic-poor specification sonography: hyperechoic substantial mass mostly CT: high specific with fat density, high sensitive, bleeding might be seen MRI inhomogeneous signal, signal of fat & old bleeding
Renal solid benign renal angiomyolipoma sonography: hyperechoic substantial mass mostly
Renal solid benign renal angiomyolipoma CT high specific with fat density, high sensitive, bleeding might be seen CT plain scan with enhancement
Renal solid benign renal angiomyolipoma CT high specific with fat density, high sensitive, bleeding might be seen with enhancement CT plain scan
Renal solid benign renal angiomyolipoma CT high specific with fat density, high sensitive, bleeding might be seen with enhancement Coronal MPR
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
cystic, inside kidney-renal cyst pathologic features correlate to imaging with thin, even wall, flat epithelium clear fluid inside & no blood flow
cystic, inside kidney-renal cyst plain film: profile changing urography: pelvix & calix deforming, no specific BUS： anechoic lesion, high specific CT： clear appearance, high sen. & spe. for calcification of the wall or septation MRI：cystic, signal of fluids, different diagnosis needed if signal be non-specific
cystic, inside kidney-renal cyst Urography deforming of pelvic & calculi, low specific
cystic, inside kidney-renal cyst C BUS, high specific anechoic lesion, echo enhancement post.
cystic, inside kidney-renal cyst C CT： clear appearance, high sen. & spe. for calcification of the wall or septation Waterlike, no enhancement, “no wall”
cystic, inside kidney-renal cyst C CT： clear appearance, high sen. & spe. for calcification of the wall or septation
cystic, inside kidney-renal cyst C CT： clear appearance, high sen. & spe. for calcification, differentiation with high density cyst Enhancement scan Plain scan
cystic, inside kidney-renal cyst C MRI, atypical signal-differentiate cystic, sig. of fluid
cystic, inside kidney-renal cyst Multicystic kidney
cystic, inside kidney-multycystic kidney plain film: enlargement & shift of renal shadow urography: elongation/deformation of the pelvic BUS: renal enlargement of both sides with multi-cyst ~ diagnosed CT: manifest clear, with multi-cystic liver often
cystic, inside kidney-multycystic kidney plain film: enlargement & shift of renal shadow urography: elongation/deformation of the pelvic BUS: renal enlargement of both sides with multi-cyst ~ diagnosed CT: manifest clear, with multi-cystic liver often
cystic, inside kidney-multycystic kidney urography: elongation/ deformation of the pelvic
cystic, inside kidney-multycystic kidney BUS: renal enlargement of both sides with multi-cyst ~ diagnosed
cystic, inside kidney-multycystic kidney CT: manifest clear, with multi-cystic liver often
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
cystic, outside-sub capsule hematoma Imaging character: out of kidney, no blood perfusion, fluid inside, partial solid if clot inside KUB: useless BUS: crescent anechoic area outside kidney adjacent kidney deform echoic if clot in hematoma
cystic, outside-sub capsule hematoma CT: crescent, low density, high density if clot within hematoma, no enhancement, kidney deform
cystic, outside-sub capsule hematoma Angiography: renal vessel compressed & shifted find source of bleeding
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
pathologies of Urinary tract wall carcinoma of renal pelvis
pathologies of Urinary tract wall carcinoma of renal pelvis - neoplasm, often small, seldom necrosis plain film: helpless urography: filling defect, high sensitive sonography: hypoechoic substantial mass in pelvic/ureter CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging MRI equivalent SI in T1 & T2WI
pathologies of Urinary tract wall carcinoma of renal pelvis - neoplasm, often small, seldom necrosis plain film: helpless urography: filling defect, high sensitive sonography: hypoechoic substantial mass in pelvic/ureter CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging MRI equivalent SI in T1 & T2WI
pathologies of Urinary tract wall carcinoma of renal pelvis urography: filling defect, high sensitive
pathologies of Urinary tract wall carcinoma of renal pelvis CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging with enhancement plain scan delay scan
pathologies of Urinary tract wall carcinoma of renal pelvis CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging
pathologies of Urinary tract wall carcinoma of renal pelvis MRI equivalent SI in T1 & T2WI T2WI T1WI STAGE
pathologies of Urinary tract wall carcinoma of renal pelvis urography: filling defect, high sensitive
pathologies of Urinary tract wall carcinoma of ureter CT: slight/medial enhancement, filling defect in hydronephrostic pelvic/ureter in excrete phase Staging delay scan with enhancement plain scan
pathologies of Urinary tract wall carcinoma of ureter MRI equivalent SI in T1 & T2WI, hydrography
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carinoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
pathologies of Urinary tract lumen- lithiasis 90% X-ray positive, diagnose considering clinical data KUB: renal calculi-pelvic/calix (staghorn stone) ureter calculi-? CT: high sensitive, exact positioning USG: high specific but low sensitive with ureter calculi
pathologies of Urinary tract lumen- lithiasis KUB: renal calculi-pelvic/calix (staghorn stone) ureter calculi-?
pathologies of Urinary tract lumen- lithiasis Sonography: renal calculi-pelvic/calix (staghorn stone) ureter calculi-?
pathologies of Urinary tract lumen- lithiasis CT: high sensitive, exact positioning Enhancement scan slab MIP plane scan
pathologies of Urinary tract lumen- lithiasis KUB: Urography: renal calculi-pelvic/calix ureter calculi-?
pathologies of Urinary tract lumen- lithiasis CT: high sensitive, exact positioning Enhancement scan MIP plane scan
pathologies of Urinary tract lumen- lithiasis MRI: no routine, low SI both T1WI & T2WI
pathologies of Urinary tract lumen- lithiasis CT: high sensitive, exact positioning
pathologies of Urinary tract lumen- lithiasis USG: high specific but low sensitive with ureter calculi
pathologies of Urinary tract lumen- lithiasis CT: high sensitive, exact positioning plane scan Enhancement scan
pathologies of Urinary tract lumen- lithiasis Soft tissue around cal., hydronephrosis proximately
pathologies of Urinary tract lumen- lithiasis Soft tissue around cal., hydronephrosis proximately
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carinoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Renal pathologies pathologies of Parenchymal Solid -benign: angiomyolipoma -malignant: carninoma Cystic inside kidney: renal cyst outside kidney: sub capsule hematoma pathologies of Urinary tract of the wall –transitional cell carcinoma of the lumen –calculus Inflammatory change-tuberculosis Hydronephrosis –differentiate diagnosis
Inflammatory change-renal tuberculosis nephropyelitis renal papilla ulcer necrosis, cavitation pyonephrosiscalcification, renal self- resection imaging KUB: (－) /calcification Urography: edge irregular (insect bite), cavitation, pelvic/ureter deform CT: sensitive with cal. but pelvic/ureter deform MRI insensitive diag. – consider clinical data
Inflammatory change-renal tuberculosis imaging KUB （－） / calcification Self-resection
Inflammatory change-renal tuberculosis imaging Urography: edge irregular (insect bite), cavitation, pelvic/ureter deform ulcer of renal papillae cavitation
Inflammatory change-renal tuberculosis imaging CT sensitive with cal. but with pelvic/ureter deform plain CTscan enhancement
Inflammatory change-renal tuberculosis imaging CT sensitive with cal. also with pelvic/ureter deform -MSCT enhancement delayed plain CTscan
Inflammatory change-renal tuberculosis imaging CT sensitive with cal. also with pelvic/ureter deform -MSCT enhancement plain CTscan
Inflammatory change-renal tuberculosis imaging CT sensitive with cal. also with pelvic/ureter deform -MSCT
Inflammatory change-renal tuberculosis imaging CT sensitive with cal. also with pelvic/ureter deform -MSCT
Hydronephrosis-summary
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/ureter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis urography (retrograde ) Ureteral carcinoma
Hydronephrosis urography: (IVP, retro, percutaneous ) some causes can be diagnosed
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis-summary sonography: high sensitivity and cause-diagnositic
Hydronephrosis-summary sonography: high sensitivity and cause-diagnositic
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly replaced by uro- hydrography
Hydronephrosis-summary CT: cause-diagnostic, sensitivity relatively high delay scan plain scan enhanced
Hydronephrosis-summary CT: cause-diagnostic, sensitivity relatively high ureteral carcinoma
Hydronephrosis-summary CT: cause-diagnostic, sensitivity relatively high retroperitoneal fibrosis
Hydronephrosis-summary CT: cause-diagnostic, sensitivity relatively high retroperitoneal fibrosis
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis - summary Obstruction of the urinary tract- malformation, calculi, tuberculosis, inflammation, compression from outside-retroperitoneal fibrosis… imaging-various dilatation of pelvis/uriter plain film: renal shadow enlarged, no cause be diagnosis except calculi of urinary tract urography: some causes can be diagnosed sonography: high sensitivity and cause-diagnositic CT: cause-diagnostic, sensitivity relatively high MRI: seldom used, urography partly rapalced by uro- hydrography
Hydronephrosis-summary MRI: seldom used, urography partly rapalced by uro-hydrography retroperitoneal fibrosis
Prostate: imaging diagnosis
Prostate-imaging anatomy Characteristics: soft-tissue, poor natural X-ray contrast central zone-rich in muscle fiber periphery zone-rich in loose CT & glands
Prostate-imaging anatomy MRI-USG-CT，not shown with plain film
Prostate-imaging anatomy MRI-USG-CT，not shown with plain film T1WI T2WI
Prostate-imaging anatomy MRI-USG-CT，not shown with plain film
Prostate-imaging anatomy MRI-USG-CT，not shown with plain film
prostate BHP benign hypertrophy of prostate sup. border 10mm over the pubis / diameter > 5cm no abnormal signal/echo/density inside
prostate BHP MPR with enhancement plain CT scan
prostate BHP T2WI T1WI
prostate prostate carcinoma low signal lesion in periphery zone in T2WI staging
prostate prostate carcinoma stage C stage B
prostate prostate carcinoma with enhancement plain CT scan
prostate prostate carcinoma plain CT scan MPR with enhancement
Questions after lecture How to chose imaging exam for the patient with gross hematuria (how to determine the method and purpose of next exam according to the result of pre-exam)? What is the pathologic underlying of the various manifestations of renal carcinoma with different imaging method? What imaging method is the first chosen for the prostate exam?