3. Urinary system
The kidneys are retroperitoneal organs to do ---
electrolyte homeostasis and waste excretion
Ureters course inferiorly into the pelvis and enter the
urinary bladder
In urinary bladder the urine is temporarily stored until it is
cleared through the urethra.
4. The adrenal, or suprarenal glands are
related to the kidneys because of close
proximity to renal system
But they produce steroids (cortex) and
catecholamines (medulla) so not directly
related to renal function
6. Male genitalia and urethera
Prostate has roughly the shape of an inverted rounded
cone/ pyramid
Seminal vesicles are paired lobulated sacs about 5cm
long in young, run infero medially to join with vas
deference to form ejeculatory duct which pierce
prostate to enter the prostatic urethra
Male urethera runs from bladder neck to external
meatus
8. Male urethera
It has three section: 1.prostatic- widest part has
mound/verumontem along posterior wall
2. membranous-shortest part
least distensible
3.penile sudivides into bulbar
and distal pendulous part
9. Scrotum : It is a pouch of skin divided in to two compartment by midline fibrous
septum.
each compartment contains testes,epididmys and spermatic cord
Scrotum on U/S
10. Embryology of renal system
pronephros, mesonephros, and metanephros come in succession
The pronephros develops in the third week of life, and
regresses after inducing the maturation of the
mesonephros during the fourth to eighth weeks
The mesonephros, serves as excretory function during
these weeks, quickly regresses.
Its remnant is the Wolfiann duct, which, in males,
develops into the efferent ductules of the testes, the
epididymis, and the vas deferens;
in females, the epio ophoron and the paro ophoron.
11. Metanephros
The metanephros forms from two separate cell lines, the
ureteric bud and the metanephric blastema.
The ureteric bud develops into the collecting system,
including the ureter, renal pelvis, major and minor calyces,
and the collecting tubules of the renal medulla
The metanephric blastema develops into the excretory
portion of the kidney—the renal cortex, including the
Bowman’s capsule (glomerulus, nephron), proximal and
distal convoluted tubules, loop of Henle, and the renal
parenchymal (supporting) tissues.
13. Approach to a case of renal
problem
Ultrasound KUB region
Depending on finding x-ray KUB or NCCT
IVP to assess renal function or level of obstruction
For renal mass - CECT abdomen
14. Intravenous pyelography
Classic routine investigation
With the advent of ultrasound its role is now much
diminished
Main indication: persistent or frank haematuria
renal and ureteric calculi
ureteric fistula
stricture
complex urinary tract infection
15. Intravenous pyelography
It consists of a series of plain films taken after administration of
intravenous injection of water soluble iodine / contrast medium
Traditionally patient is prepared with a period of 4-6 hrs starvation
and fluid deprivation and bowel preparation with a strong laxative
Classical series of plain films 5 and 15mts, full length release and full
bladder and post micturition.
It can be modified to deal particular circumstances
16. How to calculate dose of contrast
Standard dose in adult is 50ml of 350-370
strength of water soluble contrast
**How much contrast needed for 60kg man ?
300mg Iodine/ml
Total 300x60= 18000mg
18000/300= 60ml
Pediatric dose----1 ml per kg body wt
Toxic levels are only just above the currently accepted
doses of 2-4.4 ml contrast medium per kg bodyweight
17. IVP in Paediatrics
IV urography in neonates and infants the dose of contrast
must be related to weight of patient and not its age
No dehydration ---CLEAR LIQUIDS should be consumed on the day of
exam. Please note that Breast Milk is not considered a clear liquid and cannot be
consumed for four (4) hours prior to the exam.
NO SOLIDS should be consumed for four hours prior to the exam
If child has a noted allergy to radiographic contrast,
additional preparations
The injection should be slow, taking about three minutes
18. Congenital lesion
Related to metanephros:
PUJ obstruction
Ureterocoel
Duplicated collecting system
Related to maturation:
Renal agenesis
Multicystic/ Dysplastic
Medullary spong kidney
Related to migration:
Renal ectopia
Horse shoe kidney
19. Pelvi-uretro junction
obstructionIt is caused by an
overabundance of collagen
tissue in the ureter, leading
to thickening and stricture
resulting in obstruction of
the urinary tract.
Early diagnosis is important
to prevent hydronephrosis
in severe, cases, can proceed
to loss of renal cortex then
poor renal function
. Related to metanephros:
PUJ obstruction
Ureterocoel
Duplicated collecting system
20. Ureterocoel
A ureterocele is a
congenital saccular dilatation
of the terminal portion of
the ureter.
Classic appearance known as
the "cobra head deformity“
resembles a snake's head
bulging into the bladder,
Best seen on IVP
. Related to metanephros:
PUJ obstruction
Ureterocoel
Duplicated collecting system
22. Renal agenesis
When the ureteric bud fails
to reach the metanephric
blastema, there is no
induction of nephron
development, and the result
is renal agenesis
Ultrasound, CT, and
radionuclide scan provide
definitive diagnosis
The contralateral kidney
usually becomes
hypertrophic and enlarged
to compensate
Related to maturation:
Renal agenesis
Multicystic/ Dysplastic
Medullary spong kidney
23. Multicystic/Dysplastic
kidney
Multicystic dysplastic kidney
(MCDK) occurs as a result of
inadequate induction of
maturation of the metanephric.
Type 1. non-communicating cysts
replace normal renal parenchyma.
The kidney is not functional
Type 2. hydronephrotic MCDK, is
thought to occur later in gestation,
representing a severe, in utero
form of UPJ obstruction.
Both forms present with an
abdominal mass detected during
infancy, and are associated with
contralateral UPJ obstruction
Related to maturation:
Renal agenesis
Multicystic/ Dysplastic
Medullary spong kidney
24. Medullary sponge kidney/
renal tubular ectasia
cystic dilatation of the
collecting tubules in
one or more renal pyramid.
Urine stasis in the collecting
tubules may lead to stone
formation within the ectatic
tubules
Related to maturation:
Renal agenesis
Multicystic/ Dysplastic
Medullary spong kidney
25. How kidneys migrate in abdomen
Related to migration:
Renal ectopia
Horse shoe kidney
Ascent in the Abdomen
The metanephros begins its development in the upper sacral area
during the 4th week of gestation, but with the rapid growth of the
lumbar and sacral regions of the fetus, it migrates cephalad into the
retroperitoneum of the upper abdomen.
Horse shoe kidney
Renal ectopia
Rotation
Concommitant with the ascent into the abdomen, the kidneys undergo
a medial rotation, bringing the ureteral pelvic junction to a medial
position relative to the kidney vasculature
26. Horse shoe
kidney on CT
It is a result of contact between
and fusion of the developing
metanephros
An isthmus develops between
the two kidneys, consisting of a
fibrotic band or functioning
renal parenchyma
27. Renal ectopia
Arrest or exaggeration of
normal caudal-to-cranial
ascent of the kidney,
resulting in abnormal
position.
Pelvic kidney
Premature arrest of cranial
ascent of the kidney.
29. Part 2---contents
Renal mass– solid or cyst
Renal parenchymal lesion---pyelonephritis/ GMN/
AIDS or analgesic nephropathy/
30. Renal mass solid or cystic
Renal cyst
Renal cell carcinoma
Angiomyolipoma are hamartomas containing fat, smooth muscle, and
blood vessels
Oncocytoma Radiographic findings include a solid expansile mass with a
pseudocapsule that is isoechoic or heterogeneous on ultrasound with
heterogeneous enhancement on CT. Central stellate scars and a "spoke wheel"
arteriographic pattern also suggests oncocytoma.
Renal abscess CT findings include a well-defined focal renal mass with central
necrosis
Lymphoma Radiographic findings include multiple lymphomatous masses
(hypodense, hypoechoic), diffuse involvement of one or both kidneys, and
associated adenopathy
Metastasis
31. BOSNIAK CLASSIFICATION OF RENAL CYSTS BY CT
I. Simple Cyst ----Nonoperative
II. Septated, minimal calcium described as “egg shell” thin, high-
density cysts (> 20HU), non-enhancing –Nonoperative
III.Multiloculated, hemorrhagic, dense calcifications; nonenhancing
solid component--Renal-sparing surgery
IV.Marginal irregularity, enhancing solid component-Radical
Nephrectomy
32. Polycystic kidney disease
It is one of many pediatric cystic renal diseases.
On imaging, it usually presents on ultrasound with
enlarged echogenic kidneys with multiple small cysts.
Liver-- coarse echotexture, biliary tract cystic changes,
and portal hypertension
4 types----
perinatal type: most common
neonatal type: minimal hepatic fibrosis
infantile type: moderate periportal fibrosis
juvenile type: gross hepatic fibrosis with PH
Autosomal recessive(ARPKD) less common than ADPKD
33. Autosomal dominant polycystic kidney disease
(ADPKD/ a hereditary form of adult cystic renal
disease.
The kineys are normal at birth.
At the age of 30 years, approximately 68% of patients
will develop multiple cyst very well seen on
ultrasound
It could be confirmed on CT or MRI
35. Renal Cell carcinoma
The classic triad of hematuria, flank pain, and a palpable abdominal
On U/s generally hypoechoic
ON CT Enhancing mass does not enhance as intensely as normal
renal parenchyma due to distortion of parenchyma,
36. Renal parenchymal lesion
Small or large kidney
Renal artey stenosis most
common cause of a unilateral small,
smooth kidney
Reflux Nephropathy/ chronic
atrophic pyelonephritis, reflux
nephropathy is the result of
parenchymal scarring caused by
reflux of either sterile or infected
urine leads to renal atrophy with an
irregular contour.
Chronic Medical Renal
Disease It presents as bilaterally
small, smooth, and hyperechoic
kidneys without focal scarring.
Analgesic Nephropathy
Analgesic nephropathy is the
result of chronic ingestion of
large doses of NSAIDS, Findings
include small, irregular kidneys;
diffuse paillary necrosis; and
medullary nephrocalcinosis
(calcification of sloughed
papilla)
AIDS nephritis
Acute GMN
Misc----Acute interstitial
nephritis,
Von hippel lindaou,
Tuberous sclerosis
37. Pyelonephritis
Pyelonephritis is a bacterial infection of the renal
parenchyma and collecting system, a clinical diagnosis
based on fever, flank pain, costovertebral angle
tenderness, and urinary tract infection
Imaging is rarely required for diagnosis, but may be
helpful if a more complicated infection, such as a renal
abscess, is suspected.
CT findings include renal enlargement with wedge-
shaped heterogeneous areas of poor enhancement,
known as a “striated nephrogram”.
39. Xantho glomerulo nephritis-
Classic triad: usually unilateral enlarged kidney, nephrolithiasis, poor or absent
renal function
(limited or no uptake or excretion of contrast agent on CT or MRI)
XGP develops in patients with chronic urinary tract obstructions and
infections that have usually been caused by nephrolithiasis
With chronic obstruction, lipid-laden histiocytes infiltrate the renal
parenchyma, replacing the functional elements of the kidney.
XGP commonly spreads to surrounding tissues, including the
collecting system, peri nephric fat, and through Gerota’s fascia to the
psoas muscle, and may result in renal-cutaneous or renal-enteric
fistulas
40. Xantho granulomatous
Pyelonephritis (XGP)
XGP develops in patients with chronic
urinary tract obstructions and
infections that have usually been
caused by nephrolithiasis, especially
staghorn calculi
With chronic obstruction, lipid-laden
histiocytes infiltrate the renal
parenchyma, replacing the functional
elements of the kidney
XGP commonly spreads to
surrounding tissues, including the
collecting system, perinephric fat, and
through Gerota’s fascia to the psoas
muscle, and may result in renal-
cutaneous or renal-enteric fistulas.
"bear paw" finding on CT
scan
41. AIDS nephropathy—pentad of findings
1 .Proteinuria
2. Azotemia
3. normal-to-large echogenic
kidneys on ultra
sonography images
4.normal blood pressure
5. focal segmental
glomerulo sclerosis on
renal biopsy findings.
There is both
tubulointerstitial
and glomerular
components.
45. Analgesic nephropathy---
Renal papillary necrosis is visible when excreted contrast material,
e.g. at IVP, fills a necrotic cavity located centrally or peripherally in
the papillae.
--
46. Acute Glomerulonephritis Acute interstitial nephritis
Acute glomerulonephritis causes edema due to
diffuse parenchymal inflammation leading to
renal enlargement.
Contrast-enhance CT is contraindicated
in these patients
Ultrasound is the diagnostic modality of
choice
Imaging studies are usually non-specific
and may show only smooth bilateral
renal enlargement during the acute
phase of the disease
The role of imaging in these
patients is to exclude obstruction
Diagnosis usually requires a
biopsy.
Kidney diseases that involve structures
within the kidney yet outside the
glomerulus are broadly referred to as
tubulointerstitial
These diseases generally involve tubules
and/or the interstitium of the kidney and
spare the glomeruli.
By far the most common form of
tubulointerstitial inflammation is
immunologic from lupus or Goodpastures or
from drug hypersensitivity
.
Normal kidney size by ultrasound
examination generally favors but does not
prove a diagnosis of acute
(thus potentially reversible) kidney disease..
47. Misc.-----Von Hippel-Lindau
autosomal dominant disorder
It is characterized by a variety of benign and malignant neoplasms.
Common tumors include ----hemangioblastoma,
clear cell renal cell carcinoma, pheochromocytoma
serous cystadenoma and neuroendocrine tumors of the pancreas
hepatic adenoma, endolymphatic sac tumors of the middle ear
and papillary cystadenoma of the epididymis and broad ligament etc.
Findings highly suspicious of VHL include
multiple simple renal cysts in combination with renal cell carcinoma
and multiple pancreatic cysts
48. Misc.--- Tuberous sclerosis
Tuberous sclerosis is an autosomal recessive disorder caused by
mutation of the tumor suppressor genes TSC1 and TSC2.
Tuberous sclerosis is a neurocutaneous disorder that affects many
organ systems, including the brain, kidneys and skin.
Seizures in these patients are usually a result of CNS damage from
cerebral hamartomas.
Diagnosis is clinical and requires two major criteria or one major
and two minor criteria.
The classic triad of ------seizures, mental retardation, and
facial angiofibromas (Vogt’s triad)
Radiographically, tuberous sclerosis is suspected
when angiomyolipoma is found in patients with simple renal cyst
50. Renal Trauma
Grade 1
Hematuria with normal imaging
studies
Contusions
Nonexpanding subcapsular
hematomas
Grade 2
Nonexpanding perinephric
hematomas confined to the
retroperitoneum
Superficial cortical lacerations less
than 1 cm in depth without collecting
system injury
Grade 3 –
Renal lacerations greater than 1 cm in
depth that do not involve the collecting
system
Grade 4
Renal lacerations extending through
the kidney into the collecting system
Injuries involving the main renal
artery or vein with contained
hemorrhage
Segmental infarctions without
associated lacerations
Expanding subcapsular hematomas
compressing the kidney
Grade 5
Shattered or devascularized kidney
Ureteropelvic avulsions
Complete laceration or thrombus of
the main renal artery or vein
51. What do mean by renal contusion?
It is interstitial edema and hemorrhage as a
result of a parenchymal bruise
Imaging shows an enlarged kidney with
delayed pyelogram and diminished density of
contrast in the calyces and ureter due to
decreased function of the kidney
52. o
m
Extensive perirenal hemorrhage
along the course of the renal artery,
delayed and diminished nephrogram,
and a rim nephrogram
Right upper pole renal
laceration dividing the
renal parenchyma in
two
53. Vesical lesion
Calcification/ calculus or schistosomiasis
Ca bladder: focal mural filling defect
Cystitis: Diffuse thickening of wall
Outpouching of vesical wall: Diverticum, cystocoel, herniation
Intravesical or interstitial air: vesical fistula , emphysematous cystitis
Vesical rupture
Urachal anomaly
55. Urinary schistosomiasis
Bladder schistosomiasis, also known as bilharzia of the
bladder, is an infection by the Schistosoma flukeworm
and is a major health problem in developing parts of the
world predisposing individuals to
vesical squamous cell carcinoma
It contaminates fresh water in some areas of the world
including Central Africa where this parasite is endemic
Clinically urinary schistosomiasis ---
progressive frequency with hematuria & dysuria
56. Imaging findings-- mirror the pathologic course
In the acute phase, nodular bladder wall thickening is
observed at urography/IVP
The chronic phase is characterized by a contracted,
fibrotic, thick-walled bladder with calcifications
These calcifications are typically curvilinear and
represent the large numbers of calcified eggs within
the bladder wall
A mass may be secondary to inflammation or
complicating carcinoma, typically SCC.
57. Schistosoma
There are five species of the blood fluke (trematode
worm) Schistosoma species that cause disease in humans
Schistosoma haematobium
S. mansoni
S. japonicum
S. intercalatum
S. mekongi
59. Cystitis
Cystitis is a clinical diagnosis; in most
patients, imaging is not required.
The diagnosis is generally made by means of
cystoscopy
However, some clinicians use ultrasonography to
exclude secondary causes of cystitis, such as bladder
outlet obstruction and bladder calculi
61. Out pouching vesical wall –mucosa herniates
through vesical wall
It may be solitary or
multiple in nature and
can vary considerably in
size.
Diverticula are often an
incidental finding on
imaging investigations
on ultrasound, CT, MRI
and IVU.
Complications due to
stasis and low-grade
infection including:
Intradiverticular
-transitional cell
carcinoma
-bladder stones
-bladder rupture
64. Vesical rupture– 5 types
Bladder contusion--
incomplete tear of the
mucosa.
Subserosal/interstitial
bladder rupture---rare
Intraperitoneal bladder
rupture –
trauma on distended bladder.
Cystography --
intraperitoneal contrast
material around bowel loops,
between mesenteric folds
and in the paracolic gutters.
Treatment is surgical
repair.
Extraperitoneal bladder
rupture---
common with pelvic fracture
Cystography ---
reveals a variable path of
extra vasated contrast
material.
Treatment is with an
indwelling Foley catheter
Combined bladder
rupture
65. Radio graphic finding
Traditional investigation--- Fluoroscopic cystography
CT cystography----- is performed by instilling
water-soluble contrast into the bladder through
a Foleys catheter
It may be combined with standard CT to evaluate the
upper tracts
67. Intravesical air
Pneumaturia is a word to
describe air bubbles that
pass in your urine
Pneumaturia alone isn't a
diagnosis, but it can be
a symptom of certain
health conditions
causes---
urinary tract infections
vesico- colic fistula
68. Urachal anomaly—due to incomplete involution
of the urachus
Urachus connects the dome of the bladder to
umbilical cord during fetal life located behind the
lower anterior abdominal wall
By birth it is obliterated and becomes vestigial organ
If not obliterated it may persists in a number of
configration
69. 4 types urachal anomaly
Infection is the biggest problem due to stasis
Treatment is not standardized.
Patent urachus–
communication between
bladder and umbilicus
Urachal cyst
Umbilical –urachal
sinus—blind focal
dilatation
Vesico urachal
diverticulum
70. Radiology male pelvis---- prostate and urethra
Radiology of adrenals
separate topics
