1. Urinary Tract Imaging

2. Plain Films
Scout film, primary survey, to follow known stones, check placement of catheters/stents/drains/foreign bodies

3. Plain Film- Left Distal Ureteral Calculus

4. Contrast Films IVP (intravenous pyelography)
Contrast Films
IVP (intravenous pyelography)
Rapidly concentrated by kidneys and opacifies urinary tract
Low osmolar nonionic contrast material (LOCM)- 50% less osmolar load- fewer complications than high osmolar

5. IV Urography Renal parenchyma, collecting system, ureter
Renal parenchyma, collecting system, ureter
Evaluates- urothelial abnormality, hematuria, urolithiasis
+/- bowel prep/npo
Scout, +/- obliques
Contrast- bolus or drip
Nephrographic phase- immediate to first minutes- parenchyma
Pyelographic phase- 5 minutes- collecting system
+/- compression, oblique- calyces, prone to distend ureter, upright- renal ptosis/layering in severe hydro, post-void- evaluate BOO/diverticulae/filling defect

6. Normal Urogram

7. Urogram with Prone Film- better visualization of ureters

8. Voiding Cystourethrogram (VCUG)
Functional and anatomic evaluation of bladder
Typically for children with recurrent UTIs
Dx- reflux, urethral valves, ureterocele, dysfunctional voiding, urethral strictures, bladder/urethral diverticula
Scout
Pediatric: 5 or 8 F feeding tube, fill bladder with contrast (age +2 x 30)
Adult: standard catheter
Film during filling- bladder pathology, early reflux
Films during void- reflux, urethral abnormality
Oblique- evaluate grade 1 reflux, males
Post-void film

9. Normal Male Cystogram
                                                                        

10. VCUG

11. Retrograde Urethrogram (RUG)
Evaluate anterior and posterior urethra- strictures, trauma
8-16 F foley in fossa navicularis, fill balloon with 1-2 mL and inject 30-50% contrast while filming obliquely
Some resistance at membranous urethra and sphincter

12. Normal RUG

13. Nephrostogram Antegrade urogram- inject contrast into nephrostomy tube
Antegrade urogram- inject contrast into nephrostomy tube
Indications- post-sx to evaluate for urine leak, post-perc neph to evaluate residual stones, evaluate site of ureter obstruction, dx ureteral fistulas
Prep- sterile urine sample, +/- antibiotics

14. Ultrasound Grayscale and doppler
Ultrasound
Grayscale and doppler
Renal- parenchyma, solid vs cystic, hydro
Use with IVP to evaluate hematuria
Assess allografts, congenital abnormalities, stones
Cortex vs medulla- pyramids (medulla) less echogenic than cortex
Adrenal- CT/MRI better except in peds (no Renal pelvisc fat)
Nodules, cysts, hemorrhage, location, tumors
Cortex hypoechoic, medulla echogenic
Bladder- examine wall, lesions
Normal wall<6 mm
Echogenicity in bladder fluid = debri, FB, infection
Ureteral jets- should appear in 15 minutes unless obstruction exists
Prostate-

15. Ultrasound (cont.) Scrotal- Use high frequency probe (up to 10 MHz)
Scrotal-
Use high frequency probe (up to 10 MHz)
Evaluate- mass, pain, torsion, orchitis, epididymitis, hydrocele, hernia, varicoceles
Testicle- granular, 4 x 3 cm, small anterior fluid collection- tunica, epididymis- hyperechoic
Veins- >2mm= varicocele- evaluate in erect position with valsalva
Urethral-
Male- evaluate stricture- scar length and depth, longitudinal along phallus or intraluminal
Female- diverticulum

16. L: liver R: kidney S: renal sinus

19. CT Standard CT Technique for Renal Imaging
Standard CT Technique for Renal Imaging
5mm-10mm collimation usually adequate to demonstrate kidneys
IV contrast allows differentiation of pathologic processes from normal parenchymaCorticomedullary differentiation max at 30 sec
Nephrographic phase best seen at sec
Non-contrast Helical CT for uro/nephrolithiasis

21. Congenital Abnormalities
Duplicated collecting system/partial duplication bifid renal pelvis
Horseshoe Kidney: Connecting isthmus across midline, usu between lower poles
Crossed Ectopia: The ureter of the ectopic kidney inserts into the bladder orthotopically (I.e. on opposite side)
Pelvic or Intrathoracic Kidney
Renal hypoplasia
Renal agenesis

22. Crossed Ectopia Lower kidney is usually the ectopic one
In 90% there is fusion of both kidneys (crossed- fused ectopia)
Incidence 1:1000 births
Slightly increased incidence of calculi, however, incidence of other assoc anomalies is low

24. Nephrolithiasis
Epidemiology Up to 10% by age 70, usually in 3rd to 4th decade
4:1 M to F ratio
More prevalent in the South
Risk Factors: Hypercalcemic states, Crohn’s, stents, RTA, infection, gout, hypercalciuria, hyperuricosuria, cystinuria
SymptomsAsymptomatic, flank pain, hematuria

25. CT Imaging of Stones
Essentially all renal and ureteral calculi have high attenuation on non-contrast CT (all but matrix stones have atten of > 100HU)
CT has sensitivity of 97% and specificity of 96%
Can also see hydronephrosis, hydroureter, renal enlargement, or perirenal stranding
Must differentiate from phlebolith which is a calcified blood clot in a pelvic vein.(appearance: round/ovoid, smooth, central lucency, in true pelvis)

27. CT Imaging of Pyelonephritis
Focal or diffuse renal enlargement
Parenchyma may be low in attenuation on non- contrast (C-) images
Usually wedge-shaped regions of decreased enhancement on C+ images
Perinephric stranding or fluid collections, often w/ thickening of Gerota’s fascia

29. Renal Cystic Disease Very common􀃆50% of pts over age of 50
Assoc w/ many syndromes, etiology unknown, probably arise from obstructed tubules or ducts
Most commonly asymptomatic
Rarely, may have hematuria, HTN, cyst infection, or mass effect

30. CT Characteristics of Simple Cysts
Smooth, imperceptible cyst wall
Sharp demarcation from surrounding renal parenchyma
Water attenuation (<15 HU), homogenous throughout lesion
Non-enhancing
Simple cysts are w/o septations or calcification
May have slight elevation of adjacent renal parenchyma 􀃆Beak sign

32. Renal Cell Ca
Most common primary renal malignancy (85% of primary renal tumors)
Assoc w/ smoking, family hx, age, Von Hippel- Lindau, Acquired Cystic Disease/chronic dialysis, phenacetin abuse
Presentation: Hematuria, flank pain, wt loss, palp mass, fever, anemia, paraneoplastic syndromes
liver enzymes w/o mets􀃆Stauffer syndrome

33. CT characteristics
Variable from complex cyst to large, heterogeneous renal mass
Generally enhancing
May have calcifications
May have hemorrhage and central necrosis
Usually no fat

35. Horseshoe kidneys
Horseshoe kidneys are the most common type of renal fusion anomaly). They render the kidneys susceptible to trauma and are an independent risk factor for the development of renal calculi and transitional cell carcinoma of the renal pelvis. 
Horseshoe kidneys are found in approximately 1 in adults and are more frequently encountered in males (M:F 2:1)1-3. The vast majority of cases are sporadic, except for those associated with genetic syndromes
Radiographic features
Ultrasound
Unless aware of the typical appearances of a horseshoe kidney, the abnormally rotated and inferiorly located kidney results in poor visualisation of the inferior pole and underestimation of the length.  2.
CT and MRI
Both CT and MRI demonstrate renal tissue of normal imaging appearance, but with abnormal configuration. Enhancement is normal, and excretory phase imaging may be used to assess the collecting system.

37. Wilms tumor
Wilms tumor arises from mesodermal precursors of the renal parenchyma (metanephros
Wilms tumor (nephroblastoma) accounts for 87% of pediatric renal masses and occurs in approximately 1:10,000 persons . Its peak incidence is at 3–4 years of age, and 80% of patients present before 5 years of age 

38. Figure 2.  Sagittal static US image obtained through the inferior right kidney shows the large, predominantly hyperechoic mass, which is located in the posteroinferior part of the kidney and contains areas of heterogeneous echotexture.
©2004 by Radiological Society of North America

39. Axial contrast material-enhanced CT image obtained through the abdomen shows a large, lobulated, heterogeneously attenuating mass of the posterolateral right kidney with involvement of the subcapsular and perinephric spaces. The areas of lower attenuation suggest the presence of hemorrhage and necrosis.
distortion of the renal collecting system from mass effect without definite invasion. There is normal enhancement of the inferior vena cava (IVC).

40. Hydronephrosis — literally "water inside the kidney" — refers todistension and dilation of the renal pelvis and calyces, usually caused byobstruction of the free flow of urine from the kidney. Untreated, it leads to progressive atrophy of the kidney.In cases of hydroureteronephrosis, there is distention of both the ureter and the renal pelvis and calice