Imaging offfff Genitourinaryyyy System ppt

ppt

1. I maging of Genitourinary S ystem dr. Dian Komala Dewi , Sp. Rad(K)

2. ANATOMY KIDNEY Bean shaped (convex laterally & concave medially) Length: ±11,5cm or 3 1 / 2 vertebral body) Width: ±5-8cm Thickness: ±3cm Retroperitoneal Between Th12- L3 Right kidney is lower ± 1cm than left kidney The kidney consists of : (1) an inner renal medulla (2) an outer renal cortex The functional unit of the kidney is the nephron

3. ThE KIDNEY

4. Anatomy

5. ANATOMY URETER Diameter 1mm-1cm Length: 25-30cm Retroperitoneal Three normal narrowing area Pelvoureter junction (PUJ) Pelvic brim where the iliac vessels cross the ureter Vesicoureter junction (VUJ )

6. ANATOMY BLADDER Urine reservoir Posterosuperior to the pubic bone Position: Empty: In the pelvic cavity Full: Extend to the abdominal cavity Capacity Adult: 350-500 cc Children: (Age [in year] + 2) x 30 cc

7. ANATOMY URETHRA Length: Male: 17,5-20cm Female: 4cm Male urethra divided by inferior aspect of urogenital diaphragm into: Anterior part Cavernous/Penile part Bulbar part Posterior part Membranous part Prostatic part

8. ANATOMY

9. ANATOMY Genital/Reproductive System Male Testis Epidydimis Vas deferen Ejaculatory duct Prostate Seminal vesicle Penis Female Uterus Salphynx Ovaries Cervix Vagina

10. ANATOMY Male Reproductive System

11. ANATOMY Female Reproductive System

12. IMAGING MODALITIES Plain abdominal x ray BNO-IVP Retrograde & antegrade pyelography Retrograde uretrography / cystography / urethrocystography Bipolar Urethrocystography Voiding Cystourethrography Ultrasonography CT Scan MRI CT urography Hysterosalphingography

13. Abdominal x ray

14. PLAIN ABDOMINAL X-RAY Routine Good quality films will show the kidney outlines Enlargement (mass/ hydronephrosis ) can be recognized Calcification Opaque calculi in the kidney, ureter or bladder Nephrocalcinosis : calcification in the renal parenchym . Air distribution in the bowel Sentinel loop

15. NORMAL

16. ENLARGEMENT OF THE KIDNEYS

17. KIDNEY STONE

18. URETERAL STONE

19. BLADDER STONE

20. Fluoroscopy

21. BNO-IVP Blass = Urinary bladder, Nier = Kidney, Overzicht = Examination Synonim : Intravenous urography Excretory urography Intravenous pyelography Use contrast media intravenously Anatomic function: Depict the minor calyx, major calyx, renal pelvis, ureter, urinary bladder. Physiologic function: Assess the kidney function in contrast media filtration and excretion.

22. BNO-IVP Preparation 2 days prior to procedure the patient should eat only plain porridge (with soy sauce) For procedure done at 8 am in the morning, the patient start fasting from 8 pm the night before Laxatives (Bisacodyl) are given at 6 and 7 pm the night before 5 grams of Magnesium Sulphate are given at 8 pm and 9 pm the night before Laxative suppositoria is given at 5 pm Normal ureum &creatinine (eGFR) Indication Evaluate mass or cyst Urolithiasis (calculi in the kidney or urinary tract) Pyelonephritis Glomerulonephritis Hydronephrosis Trauma Renal hypertension

23. BNO-IVP Contraindication Allergy Asthma Anuria Renal failure Cardiovascular disease Severe liver function abnormality Diabetes mellitus Sickle cell disease Multiple myeloma Pheochromocytoma Pregnancy

24. BNO IVP 1-3’ : Nephrogram phase 5’ : Excretory function 15’ : Pelvocalyceal system, compression is released 30’ : depict kidney, ureters, and bladder 45-60’ : full bladder Post voiding

25. BNO-IVP Contraindication of compression : Suspected stone Acute abdomen Following abdominal surgery Large abdominal mass Aortic aneurysm  Use trendelenburg position instead

26. Normal BNO IVP

27. IVP: 5’-30’ - Excretion phase of right kidney is seen at 5’ - No excretion phase seen of left kidney until the end of procedure. Full Blass/Full bladder : The bladder is not full filled with regular wall. The contrast filled the bladder and some contrast is out through the vagina The tract which connects bladder with vagina is not visualized. Conclusion : Vesico vagina fistula Excretory function of left kidney is not visualized. Normal excretory function of right kidney. No ureterolithiasis seen. - Normal bladder.

28. Antegrade Pyelography Non-functional examination to assess the urinary tract by inserting contrast agent antegrade (in the direction of urine) into the pelvicalyceal system through a nephrostomy catheter. Indications: Shows the location of an obstruction Shows pelvicalyceal system if it cannot be done by intravenous urography As part of a percutaneous nephrostomy examination

29. Antegrade & Retrograde Pyelography Indication Depict the location, length and lower margin (retrograde) or upper margin ( antegrade ) of obstruction To predict the etiology of the obstruction Depict the pelvocalyceal system if it can not be done by intravenous urography Renal failure Allergy

30. Antegrade Pyelography Contraindication Acute urinary tract infection Contrast media allergy (although the reaction is less severe than intravenous) Pregnancy Hemorrhagic diathesis and hydatid cyst (contraindication to nephrostomy) Preparation Patients with nephrostomy Not pregnant, no history of allergic to contrast No haemorrhagic diastasis

31. Antegrade Pyelopgraphy Normal APG

32. ANTEGRADE PYELOGRAPHY Contrast enters the pelvicalyceal system to the distal left ureter and appears slightly into the urinary bladder. The pelvicalyceal system and proximal ureter are dilated, There is a narrowing of the lumen of the left distal ureter. Impression: The left contrast passage is not smooth. Hydronephrosis grade IV with proximal to distal widening of the ureter e.c. suspected obstruction in the distal left ureter.

33. Retrograde Urethrography To assess the urethra The contrast media is injected from the distal to the proximal part of the urethra (retrograde or ascending)

34. Retrograde Urethrography Indication Urethral rupture Urethral stricture Congenital anomaly Urethral fistule Urethral diverticle Urethral obstruction Hematuria Recurrent urinary tract infection Slow urinary flow Urinary mass Contraindication Acute urinary tract infection

35. , Stenosis urethra pars membranacea

36. Retrograde Urethrography Urethral rupture

37. Retrograde Urethrography Urethral stricture with periurethral abscess

38. Retrograde Cystography To assess the urinary bladder The contrast media is injected through the urinary catheter into the urinary bladder Retrograde to the urinary flow

39. Retrograde Cystography Indication Recurrent urinary tract infection Suspicion of urinary bladder rupture Stone Mass Inflammation Diverticle Fistule Incontinentia Hematuria Measure the urinary volume post micturition Assess the integrity of the anastomosis or suture post operative Contraindication Pregnancy Urethral rupture (contraindication to the urinary catheter insertion)

40. Retrograde Cystography

41. Retrograde Urethrocystography To assess the urinary bladder and the urethra. Combination of the retrograde urethrography and cystography . The contrast media is injected through the external urethral orificium to fill the urethra and then the urinary bladder.

42. Stenosis of urethra pars membranacea

43. Bipolar Urethrocystography To assess the urethra from the proximal and distal aspects. Retrograde from the distal urethra Antegrade from the cystostomy catheter Patient is asked to void so that the contrast media will fill the proximal part of the urethra. Indication Assess the proximal and distal margin of obstruction (stricture, stone, mass) in the urethra Contraindication Allergy to contrast media

44. Bipolar Urethrocystography Preparation : Patient empty the bladder before procedure The patient is supine, tilted about 30-45 degrees Adequate traction of the penis

45. Bipolar urethrocystography

46. Urethrography : Contrast cannot enter the prostatic urethra and urinary bladder. Obstruction of the pars membranous is seen. Cystography : Contrast appears to fill the bladder. Micturition : Bladder neck is not open, visible contrast is restrained on the bladder. Passage of contrast is not smooth, visible obstruction in the pars membranosa along the 5.12 cm. IMPRESSION: - Obstruction of the membranous urethra.

47. Voiding Cystourethrography =micturating cystourethrography To assess the vesicoureter valve Indication Suspicion of vesicoureter reflux Recurrent urinary tract infection in children Stress incontinentia Hydronephrosis Contraindication Urinary tract infection

48. Voiding Cystourethrography

49. International reflux system Grade I: Reflux into ureter Grade II : Reflux into the ureter and pelvicalyceal system that is not dilated. Grade III : Reflux into the ureter and pelvicalyceal system which is slightly dilated. Grade IV : Reflux into the dilated and tortuous ureter and into the dilated pelvicalyceal system. Grade V : Reflux into a very dilated and tortuous ureter and into a very dilated pelvicalyceal system. The angle of the fornix and the impression of the renal papilla are obliterated.

50. Voiding Cystourethrography Grade I Grade IV Grade V

51. Hysterosalpingography Primarily demonstrate the uterus and the salpynx (fallopian tube) Contraindication Pregnancy (performed 7-10 days after the onset of menstruation) Acute pelvic inflammatory disease Active uterine bleeding Indication Infertility assessment Obstruction (can be therapeutic) Anatomic anomaly ( e.g.uterine bicornis ) Intrauterine pathology Endometrial polyps Uterine fibroids Intrauterine adhesion Post operative assessment after tubal ligation or reconstructive surgery

52. hYSTEROSALPHINGOGRAPHY Done on day 9-10 after the first day of menstruation (not pregnant). The patient is prohibited from coitus during this time. Informed consent. The bladder was empty just prior to the examination.

53. HYsterosalphingography

54. Impression: Patent bilateral uterine tubes Uterus within normal limits.

55. Right Fallopian Tube: The caliber of the pars ampulla and the infundibulum appears dilated. Left Fallopian Tube: The caliber of the interstitial and isthmus does not appear wide. The pars ampulla and pars infundibulum were not visualized. There was no contrast spillage from the left fallopian tube. Impression: Right hydrosalphinx . Left fallopian tube obstruction.

56. ULTRASONOGRAPHY

57. Ultrasonography The kidneys are well shown by ultrasound Mass Cyst (simple or polycystic) Hydronephrosis Stone Nephrostomy guiding Transducer : A low-frequency convex probe (2.5-7.5MHz) Patient position : Supine Transducer position : Slightly posterior (7cm) from midaxillary line. Below the subcostal margin. Most visible in the field coronal

58. Ultrasonography Normal Kidneys

59. Ultrasonography Simple cyst Renal mass

60. Ultrasonography Hydronephrosis Nephrolithiasis

61. Ultrasonography The distended urinary bladder is also well shown by abdominal ultrasound Mass Stone Inflammation Infection Diverticle Normal bladder

62. Ultrasonography Bladder mass Vesicolithiasis

63. Pelvis ultrasonography Benign Prostate Hyperplasia

64. Pelvis ultrasonography Cervix cancer with hydrometra

65. CT Scan

66. CT scan Mass, cyst and various lesion of the kidneys are all well shown Gold standard in urinary tract stone Staging in tumour

67. Renal cell Carcinoma

68. CT UROGRAFI mendeteksi berbagai kelainan yang ada di daerah ginjal, ureter dan VU Gabungan ct scan abdomen dan IVP Menilai kelainan pada parenkim ginjal , ureter, vesica urinaria dan kelainn pada raktus urinarius Hampir semua batu urin , termasuk batu asam urat , terlihat dengan CT non kontras Staging tumor

69. Protokol CT Urografi RSHS Scanning Pre Kontras Injeksi kontras 50 ml, NaCl 20 ml , flow 3 ml/s Tunggu 10 menit Injeksi kontras 75 ml, NaCl 20 ml , flow 3 ml/s Fase corticomedullary Fase nephrography + excretory Scan I area ginjal Scan II Area ginjal  pelvis Delayed 50 detik Delayed 50 detik

70. Ginjal Ureter Vesika Urinaria Gambaran 3D potongan coronal CT Urografi dengan pemberian Furosemide 10 mg IV

71. Gambaran normal CT Urografi potongan axial dan coronal

72. Potongan coronal dan axial Simple renal cyst Peripelvic cyst

73. TCC pada ureter Potongan pada coronal dan Rekontruksi 3D

74. Hidronefrosis

75. Ureteric stone with hydronephrosis

76. MRI Staging in tumor Superior to CT in staging the bladder and prostatic tumour Good contrast resolution

77. MRI Renal Mass

78. MRI Cervix Cancer

79. THANK YOU