Ivp in urinary tract diseases
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Nov 17, 2018
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About This Presentation
Despite recent declines in its popularity, excretory urography still remains the cornerstone of radiological diagnosis of urinary tract
The strength of urography lies in its ability to provide overall survey of urinary tract; anatomic definition of the kidney, collecting system, and the lower urinar...
Slide Content
Digest
Introduction
Abdominal Plain Radiography (Scout film)
Contrast Media
Filming Technique and Sequences
General Findings in Excretory Urography
EU Findings in Certain Specific Conditions
Obstructive Urography
Congenital Anomalies of Urinary Tract
Differential Diagnosis
Introduction
Abdominal Plain Radiography (Scout film)
Contrast Media
Filming Technique and Sequences
General Findings in Excretory Urography
EU Findings in Certain Specific Conditions
Obstructive Urography
Congenital Anomalies of Urinary Tract
Differential Diagnosis
Despite recent declines in its popularity, excretory
urography still remains the cornerstone of radiological
diagnosis of urinary tract
The strength of urography lies in its ability to provide
overall survey of urinary tract; anatomic definition of
the kidney, collecting system, and the lower urinary
tract; as well as information about renal function
The strength of urography is its greatest limitation;
when the ability of the kidneys to excrete the contrast
is impaired, the information obtained from the study is
markedly reduced
The term pyelogram is reserved for retrograde studies
visualizing only collecting system. The commonly used
colloquial term intravenous pyelography should really
be intravenous urogram
urography still remains the cornerstone of radiological
diagnosis of urinary tract
The strength of urography lies in its ability to provide
overall survey of urinary tract; anatomic definition of
the kidney, collecting system, and the lower urinary
tract; as well as information about renal function
The strength of urography is its greatest limitation;
when the ability of the kidneys to excrete the contrast
is impaired, the information obtained from the study is
markedly reduced
The term pyelogram is reserved for retrograde studies
visualizing only collecting system. The commonly used
colloquial term intravenous pyelography should really
be intravenous urogram
EU is no longer routinely indicated in the investigation
of hypertension, renal failure, urinary tract infection, or
complications following renal transplant
Should the findings from other imaging modalities be
equivocal, EU remains available in reserve
In the past two decades there has been development
of alternative, less invasive imaging techniques,
particularly USG
However USG has its disadvantages. It cannot give
the exquisite calyceal detail that EU gives and cannot
differentiate mild pelvicalyceal dilatation in acute
obstruction from normal distension of collecting
system in a well-hydrated individual and is unreliable
in the diagnosis of non-dilated obstruction, to name a
few
of hypertension, renal failure, urinary tract infection, or
complications following renal transplant
Should the findings from other imaging modalities be
equivocal, EU remains available in reserve
In the past two decades there has been development
of alternative, less invasive imaging techniques,
particularly USG
However USG has its disadvantages. It cannot give
the exquisite calyceal detail that EU gives and cannot
differentiate mild pelvicalyceal dilatation in acute
obstruction from normal distension of collecting
system in a well-hydrated individual and is unreliable
in the diagnosis of non-dilated obstruction, to name a
few
Indications
Hematuria
Renal colic
Renal trauma
Persistent pyuria
Prior to percutaneous
urological procedures
Follow-up after
surgeries, stenting, etc.
As part of work-up of a
live donor
When other
investigations are
equivocal
Contraindications
oPrevious serious
reaction to contrast
medium
oPregnancy and in
women who indicate
possibility of pregnancy
oSevere renal
insufficiency
oDiabetic nephropathy
Hematuria
Renal colic
Renal trauma
Persistent pyuria
Prior to percutaneous
urological procedures
Follow-up after
surgeries, stenting, etc.
As part of work-up of a
live donor
When other
investigations are
equivocal
Contraindications
oPrevious serious
reaction to contrast
medium
oPregnancy and in
women who indicate
possibility of pregnancy
oSevere renal
insufficiency
oDiabetic nephropathy
Importance
To detect opacities that
may lie within urinary tract
To demonstrate extraurinary
calcification & foreign bodies
To check positioning and
radiographic exposure
factors
To determine if there is any
other abnormality within the
abdomen which might
account for the patient's
symptoms
The patient is placed supine and a 14 X 17 inch film is obtained
with the symphysis pubis positioned 2 to 3 inches above the
bottom of the film
To detect opacities that
may lie within urinary tract
To demonstrate extraurinary
calcification & foreign bodies
To check positioning and
radiographic exposure
factors
To determine if there is any
other abnormality within the
abdomen which might
account for the patient's
symptoms
The patient is placed supine and a 14 X 17 inch film is obtained
with the symphysis pubis positioned 2 to 3 inches above the
bottom of the film
Old film showing phleboliths A new ROS suggesting calculus
Many common extraurinary calcifications are visible on a scout
film; only a small number, however, have pathological
significance
film; only a small number, however, have pathological
significance
Morphology of abdominal
calcifications
Concretion:
They are precipitates removed
from solution inside a vessel or
hollow viscus with central nidus
(e.g. urinary calculi, biliary
calculi)
Conduit wall calcification:
Conduits are fluid containing
hollow tubes (e.g. vessels, ureter,
vas, bile ducts)
Cystic calcification:
Deposition of calcium in the walls of abnormal fluid-filled masses (e.g. true
epithelial cyst, pseudocyst, aneurysmally dilated aorta)
Solid mass calcification
This includes the maximum variety of pathological calcifications which may
appear as mottled density (typical of calcified mesenteric nodes), whorled
configuration (as in uterine leiomyoma)
calcifications
Concretion:
They are precipitates removed
from solution inside a vessel or
hollow viscus with central nidus
(e.g. urinary calculi, biliary
calculi)
Conduit wall calcification:
Conduits are fluid containing
hollow tubes (e.g. vessels, ureter,
vas, bile ducts)
Cystic calcification:
Deposition of calcium in the walls of abnormal fluid-filled masses (e.g. true
epithelial cyst, pseudocyst, aneurysmally dilated aorta)
Solid mass calcification
This includes the maximum variety of pathological calcifications which may
appear as mottled density (typical of calcified mesenteric nodes), whorled
configuration (as in uterine leiomyoma)
Urinary bladder
calculus
Gall bladder
calculus
calculus
Gall bladder
calculus
Cystic calcification
Conduit wall calcification
Solid calcification
Mesenteric lymph node calcification is the most common type of
parenchymal calcification. They have a “popcorn” appearance
and a characteristic distribution along the mesenteric root
parenchymal calcification. They have a “popcorn” appearance
and a characteristic distribution along the mesenteric root
The presence of unilateral
or even bilateral small
kidneys may be a clue to
the nature of underlying
pathology
Enlargement or
displacement of an organ
often can be detected
Loss of psoas silhouette
may represent underlying
pathology in the
retroperitoneum. (However,
the psoas muscle may not be
clearly seen on one side or the
other in as many as 50% of
patients)
or even bilateral small
kidneys may be a clue to
the nature of underlying
pathology
Enlargement or
displacement of an organ
often can be detected
Loss of psoas silhouette
may represent underlying
pathology in the
retroperitoneum. (However,
the psoas muscle may not be
clearly seen on one side or the
other in as many as 50% of
patients)
They may indicate underlying urinary tract pathology
Epispadiasis
RCC
Neurogenic bladder
CRF
Epispadiasis
RCC
Neurogenic bladder
CRF
Detection of abnormal gas collection also is an important role
of scout film
of scout film
Foreign material
•The abdomen is a Mecca for great variety of foreign material
•Surgical clips, sutures, ingested metallic artifacts like coins, lead
the way
•The abdomen is a Mecca for great variety of foreign material
•Surgical clips, sutures, ingested metallic artifacts like coins, lead
the way
They are the pharmaceuticals that alter tissue
characteristics to enhance information obtained on
diagnostic images
After IV injection of contrast material, a peak level in
plasma occurs within the first minute
This peak is followed by a rapid decline in plasma
level resulting from renal excretion, dilution of the
material from mixing within the vascular spaces, and
rapid diffusion into extravascular and extracellular
compartments
The quality of visualization on excretory urogram is
related to the initial level of contrast material present
within plasma and available for glomerular filtration
and excretion by the kidney
characteristics to enhance information obtained on
diagnostic images
After IV injection of contrast material, a peak level in
plasma occurs within the first minute
This peak is followed by a rapid decline in plasma
level resulting from renal excretion, dilution of the
material from mixing within the vascular spaces, and
rapid diffusion into extravascular and extracellular
compartments
The quality of visualization on excretory urogram is
related to the initial level of contrast material present
within plasma and available for glomerular filtration
and excretion by the kidney
Visibility by urography is related to the concentration
of contrast material in urine and the urine volume
Distension of collecting system further enhances the
yield of a diagnostic urogram
Contrast media are categorized as high-osmolality
contrast media (HOCM) & low-osmolality contrast
media (LOCM)
High-Osmolality Contrast Media:
It is further divided into 3 groups
1.Low-iodine concentration (Used primarily for cystography,
urethrography, retrograde and antegrade pyelography)
2.Medium-iodine concentration (Used primarily for excretory
urography, venography, angiography including DSA) iodine
content is around 300mg/ml
3.High-iodine concentration (Used primarily for aortogaphy
and selective arteriography)
of contrast material in urine and the urine volume
Distension of collecting system further enhances the
yield of a diagnostic urogram
Contrast media are categorized as high-osmolality
contrast media (HOCM) & low-osmolality contrast
media (LOCM)
High-Osmolality Contrast Media:
It is further divided into 3 groups
1.Low-iodine concentration (Used primarily for cystography,
urethrography, retrograde and antegrade pyelography)
2.Medium-iodine concentration (Used primarily for excretory
urography, venography, angiography including DSA) iodine
content is around 300mg/ml
3.High-iodine concentration (Used primarily for aortogaphy
and selective arteriography)
The viscosity will increase with iodine concentration
It is appropriate to use a dosage of approximately 300 mg
of iodine/kg which represents approximately 1 ml/kg in
the most commonly used forms of diatrizoate
The total dose for excretory urography is
3.0 ml/kg in the newborn
2.0 ml/kg in the children
1.0 ml/kg in the adults
for a dye with iodine concentration around
300mg/ml
The physiologic effects related to osmolality include
hypovolemia, cellular diuresis, urinary diuresis, altered
vascular and glomerular endothelial permeability, vessel
dilatation with decreased resistance and BP, sinus
bradycardia and conduction delays
It is appropriate to use a dosage of approximately 300 mg
of iodine/kg which represents approximately 1 ml/kg in
the most commonly used forms of diatrizoate
The total dose for excretory urography is
3.0 ml/kg in the newborn
2.0 ml/kg in the children
1.0 ml/kg in the adults
for a dye with iodine concentration around
300mg/ml
The physiologic effects related to osmolality include
hypovolemia, cellular diuresis, urinary diuresis, altered
vascular and glomerular endothelial permeability, vessel
dilatation with decreased resistance and BP, sinus
bradycardia and conduction delays
Low-Osmolality Contrast Media (LOCM):
They are non-ionic, non-dissociating agents with
reduced osmolality, and without dilution of iodine
concentration (So little or no physiological effects related to
osmolality)
LOCM are more expensive, averaging from 10 to 20
times the price of HOCM
Current criteria for the use of LOCM
1. Patients with a history of previous adverse reaction
to contrast material
2. Patients with a history of asthma or allergy
3. Patients with known cardiac dysfunction
4. Patients with generalized severe debilitation
5. Any other circumstances where, after due
consideration, the radiologist believes there is a
specific indication for the use of LOCM
They are non-ionic, non-dissociating agents with
reduced osmolality, and without dilution of iodine
concentration (So little or no physiological effects related to
osmolality)
LOCM are more expensive, averaging from 10 to 20
times the price of HOCM
Current criteria for the use of LOCM
1. Patients with a history of previous adverse reaction
to contrast material
2. Patients with a history of asthma or allergy
3. Patients with known cardiac dysfunction
4. Patients with generalized severe debilitation
5. Any other circumstances where, after due
consideration, the radiologist believes there is a
specific indication for the use of LOCM
The amount of contrast medium administered varies with
the method of administration
Rapid injection:
Most injections of contrast medium are performed by
rapid injection of bolus (in less than 60 seconds) in most
cases using a butterfly 18-gauge needle in the
antecubital vein
It leads to a better nephrogram and more contrast per
unit of urine
However, rapid injection also increases the incidence of
minor reactions such as nausea and vomiting
To improve the visualization of pyelocalyceal system a
change in dose may be necessary (e.g. an increase in dose
in patients with poor concentrating capacity & decrease in dose in
over- hydrated patients)
the method of administration
Rapid injection:
Most injections of contrast medium are performed by
rapid injection of bolus (in less than 60 seconds) in most
cases using a butterfly 18-gauge needle in the
antecubital vein
It leads to a better nephrogram and more contrast per
unit of urine
However, rapid injection also increases the incidence of
minor reactions such as nausea and vomiting
To improve the visualization of pyelocalyceal system a
change in dose may be necessary (e.g. an increase in dose
in patients with poor concentrating capacity & decrease in dose in
over- hydrated patients)
Pros
Nephrogram is markedly
prolonged
Enhanced diuresis fully
distends PCS & ureter
Collecting system is
visualized for longer time
Ureteral compression
may not be necessary
Cons
oOverloads more iodine
than necessary
oCalyceal blunting may
be produced
oPyelosinus
extravasation & pain in
patients with partial
obstruction
oIncreased diuresis
decreases the
visualization
Drip infusion:
It was popular around 20 years ago and is sparsely used
today
Nephrogram is markedly
prolonged
Enhanced diuresis fully
distends PCS & ureter
Collecting system is
visualized for longer time
Ureteral compression
may not be necessary
Cons
oOverloads more iodine
than necessary
oCalyceal blunting may
be produced
oPyelosinus
extravasation & pain in
patients with partial
obstruction
oIncreased diuresis
decreases the
visualization
Drip infusion:
It was popular around 20 years ago and is sparsely used
today
Anphalactoid/idiosyncratic reactions:
Although unpredictable, such reactions are more likely to occur in
certain patient group: (a) those that have reacted previously; (b) those with
established allergies to other drugs; (c) asthmatic and atopic individuals
Chemotoxic effects
These effects are due to direct organ toxicity of the contrast
medium
Nephrotoxicity: depends on preexisting renal insufficiency, DM,
dehydration, dose & type of contrast, advanced age, CCF, and liver
dysfunction. The speculation on mechanism of contrast-induced ARD has
revolved around structural changes in PCT, contrast induced vasoconstriction
and increased tubular pressure caused by osmotic diuresis associated with the
contrast media
Cardiovascular effects: tachycardia, cardiac arrhythmia, and transient
ischaemic changes
Chemical thrombophlebitis & extravasation of contrast
medium: symptoms ranging from erythema & local pain to severe sloughing
& necrosis
Hematological effects: red cell deformation, platelet aggregation
inhibition
Although unpredictable, such reactions are more likely to occur in
certain patient group: (a) those that have reacted previously; (b) those with
established allergies to other drugs; (c) asthmatic and atopic individuals
Chemotoxic effects
These effects are due to direct organ toxicity of the contrast
medium
Nephrotoxicity: depends on preexisting renal insufficiency, DM,
dehydration, dose & type of contrast, advanced age, CCF, and liver
dysfunction. The speculation on mechanism of contrast-induced ARD has
revolved around structural changes in PCT, contrast induced vasoconstriction
and increased tubular pressure caused by osmotic diuresis associated with the
contrast media
Cardiovascular effects: tachycardia, cardiac arrhythmia, and transient
ischaemic changes
Chemical thrombophlebitis & extravasation of contrast
medium: symptoms ranging from erythema & local pain to severe sloughing
& necrosis
Hematological effects: red cell deformation, platelet aggregation
inhibition
Chlorpheniramine maleate,
Promethazine,
Hydrocorisone,
Atropine,
Salbutamol inhaler,
Salbutamol nebulizer,
Ephedrine,
Normal saline,
Methoxamine,
Dobutamine,
Dopamine,
Adrenaline (1:10,000),
Adrenaline (1:1000), at least 10 ampoules
Promethazine,
Hydrocorisone,
Atropine,
Salbutamol inhaler,
Salbutamol nebulizer,
Ephedrine,
Normal saline,
Methoxamine,
Dobutamine,
Dopamine,
Adrenaline (1:10,000),
Adrenaline (1:1000), at least 10 ampoules
The radiologist should closely monitor the technical
factors employed during urography to optimize the
diagnostic information obtained from the study
The object is to obtain satisfactory contrast and spatial
resolution, which is accomplished by using relatively
low kilovoltage and high milliamperage (Kilovoltage
range is usually 65 to 75 kV & the milliamperage
ranges from 600 to 1000 mA. 90kv is necessary for
oblique views)
“Optimal” urography is most likely to be obtained if the
study is monitored by the radiologist and modified to
answer the clinical question posed
The sequence of filming should allow for visualization
of nephrogram, early and late visualization of
collecting system, and the ureters
factors employed during urography to optimize the
diagnostic information obtained from the study
The object is to obtain satisfactory contrast and spatial
resolution, which is accomplished by using relatively
low kilovoltage and high milliamperage (Kilovoltage
range is usually 65 to 75 kV & the milliamperage
ranges from 600 to 1000 mA. 90kv is necessary for
oblique views)
“Optimal” urography is most likely to be obtained if the
study is monitored by the radiologist and modified to
answer the clinical question posed
The sequence of filming should allow for visualization
of nephrogram, early and late visualization of
collecting system, and the ureters
Patient Preparation
It is never necessary to postpone an urgent
examination to prepare a patient for urogram
Overhydration produces poor contrast density
Although overhydration should be avoided, dehydration is
unnecessary (may precipitate renal shutdown in renal failure, renal vein
thrombosis in infants)
Recent articles have confirmed that in active healthy
outpatients, food or fluid restriction, or administration of
laxatives have little use if any (They may have some value in
sedentary elderly inpatients)
A usual compromise for patients scheduled in early morning is
to omit fluids after 11:00 PM and to omit breakfast (which
decreases the chance of vomiting, as well as produce slight dehydration)
It is never necessary to postpone an urgent
examination to prepare a patient for urogram
Overhydration produces poor contrast density
Although overhydration should be avoided, dehydration is
unnecessary (may precipitate renal shutdown in renal failure, renal vein
thrombosis in infants)
Recent articles have confirmed that in active healthy
outpatients, food or fluid restriction, or administration of
laxatives have little use if any (They may have some value in
sedentary elderly inpatients)
A usual compromise for patients scheduled in early morning is
to omit fluids after 11:00 PM and to omit breakfast (which
decreases the chance of vomiting, as well as produce slight dehydration)
Urograms are best obtained in the
expiratory phase (which allows the best
alignment of kidney and ureter) except for
study of renal movement
There is no universally accepted filming sequence for
an excretory urogram
After injection our sequence is as follows:
1. 5-minute film : 10 X 12, renal area
2. 15-minute film: 14 X 17, supine, abdomen
3. 25-minute film: 14 X 17, prone, abdomen
4. Pre-void film : 10 X 12, pelvic cavity
Abdominal compression
The purpose is to assure that the pelvicalyceal system & the
ureters are adequately filled
After viewing the scout film and the nephrogram the
compression device is placed so that it will compress the
ureters where they cross the pelvic brim
C/I are aneurysm, ureteral obstruction, recent surgery
expiratory phase (which allows the best
alignment of kidney and ureter) except for
study of renal movement
There is no universally accepted filming sequence for
an excretory urogram
After injection our sequence is as follows:
1. 5-minute film : 10 X 12, renal area
2. 15-minute film: 14 X 17, supine, abdomen
3. 25-minute film: 14 X 17, prone, abdomen
4. Pre-void film : 10 X 12, pelvic cavity
Abdominal compression
The purpose is to assure that the pelvicalyceal system & the
ureters are adequately filled
After viewing the scout film and the nephrogram the
compression device is placed so that it will compress the
ureters where they cross the pelvic brim
C/I are aneurysm, ureteral obstruction, recent surgery
Abdominal compression
Oblique Views:
They more precisely localize a suspected defect within
the collecting system (differentiation of extrinsic and intrinsic
renal masses) and the ureter may be better visualized
Special views
For visualizing the ureter, ipsilateral posterior
oblique is necessary
They more precisely localize a suspected defect within
the collecting system (differentiation of extrinsic and intrinsic
renal masses) and the ureter may be better visualized
Special views
For visualizing the ureter, ipsilateral posterior
oblique is necessary
Delayed Views:
• A reasonable schedule would include films at 1, 3, 6, 12, and
24 hours after injection
• They are of value in the cases of obstruction in which an early
nephrogram is seen but collecting system is not visualized
Nephrogram of increasing density is
the most important indication for
delayed film
Delayed films
are
generally
unrewardin
g in the
total
absence of
an early
nephrogram
• A reasonable schedule would include films at 1, 3, 6, 12, and
24 hours after injection
• They are of value in the cases of obstruction in which an early
nephrogram is seen but collecting system is not visualized
Nephrogram of increasing density is
the most important indication for
delayed film
Delayed films
are
generally
unrewardin
g in the
total
absence of
an early
nephrogram
Prone Film:
Useful to evaluate the ureters when the supine films
do not adequately demonstrate the course
Good view for renal ptosis and lesions on anterior
bladder wall
Useful to evaluate the ureters when the supine films
do not adequately demonstrate the course
Good view for renal ptosis and lesions on anterior
bladder wall
Erect Film:
Optimal view for
demonstrating renal
ptosis, bladder hernias,
and cystoceles
Best demonstrates the
emptying of upper
urinary tract
Optimal view for
demonstrating renal
ptosis, bladder hernias,
and cystoceles
Best demonstrates the
emptying of upper
urinary tract
Postvoiding Film:
Traditionally it has been used to evaluate patient's
ability to empty the bladder but is actually of much less
value.
(Residual urine only means that the patient
didn’t void, it doesn’t mean he couldn’t) •However it may
reveal some
significant finding
hidden behind the
distended bladder
•Postvoid film is
useful in
evaluation of
bladder mucosa
Traditionally it has been used to evaluate patient's
ability to empty the bladder but is actually of much less
value.
(Residual urine only means that the patient
didn’t void, it doesn’t mean he couldn’t) •However it may
reveal some
significant finding
hidden behind the
distended bladder
•Postvoid film is
useful in
evaluation of
bladder mucosa
It was widely recognized as a
valuable adjunct to EU
diagnosis once
It was applied whenever the
anatomic information is
obscured because of overlying
bowel content or faint
visualization in impaired renal
function or simply to acquire
better anatomic definition
An arc of 25
o
for screening
tomography and 40
o
for multiple
slices in the 60- to 75-kv range
is considered ideal
valuable adjunct to EU
diagnosis once
It was applied whenever the
anatomic information is
obscured because of overlying
bowel content or faint
visualization in impaired renal
function or simply to acquire
better anatomic definition
An arc of 25
o
for screening
tomography and 40
o
for multiple
slices in the 60- to 75-kv range
is considered ideal
The optimal level
The midcoronal plane of the kidney
often can be determined in the
scout tomogram when the pedicles
of the L2 vertebral bodies are
sharpest. Sections 1 cm above and
1 cm below this level are often
sufficient
The optimal timing
For detection of renal masses, the
tomograms should be carried out
immediately after injection when
nephrogram is at its peak
If evaluation of collecting system is
desired, it is necessary to delay the
timing of the tomogram until
approximately 5 minutes
Better anatomic definition
The midcoronal plane of the kidney
often can be determined in the
scout tomogram when the pedicles
of the L2 vertebral bodies are
sharpest. Sections 1 cm above and
1 cm below this level are often
sufficient
The optimal timing
For detection of renal masses, the
tomograms should be carried out
immediately after injection when
nephrogram is at its peak
If evaluation of collecting system is
desired, it is necessary to delay the
timing of the tomogram until
approximately 5 minutes
Better anatomic definition
Some modifications of basic techniques
Hydration urogram:
In PUJ obstruction where radiographic signs are
frequently intermittent, frusemide 40 mg i.v. may be
useful
‘One-shot’ EU:
A scout film followed by an abdominal radiograph 15 min
after the injection of contrast will suffice in a suspected
colic late pregnancy, as an emergency examination in
suspected colic, and following trauma
High-dose urography:
A double dose (600 mg iodine/kg) of LOCM is given
Useful occasionally in the presence of mild renal failure
and in chronic obstruction with significant hydronephrosis
Hypertensive urography:
Rapid injection of bolus of contrast and sequential
radiographs of kidneys at 1-minute intervals for 5 minutes
Hydration urogram:
In PUJ obstruction where radiographic signs are
frequently intermittent, frusemide 40 mg i.v. may be
useful
‘One-shot’ EU:
A scout film followed by an abdominal radiograph 15 min
after the injection of contrast will suffice in a suspected
colic late pregnancy, as an emergency examination in
suspected colic, and following trauma
High-dose urography:
A double dose (600 mg iodine/kg) of LOCM is given
Useful occasionally in the presence of mild renal failure
and in chronic obstruction with significant hydronephrosis
Hypertensive urography:
Rapid injection of bolus of contrast and sequential
radiographs of kidneys at 1-minute intervals for 5 minutes
5-minute film
3-hour film
Findings suggestive of
renovascular
hypertension:
•discrepancy in renal
size
•asymmetry of contrast
appearance in the
renal collecting systems
•on delayed films,
greater density of
contrast in the
collecting system on the
affected side (the result
of prolonged tubular
transit in collecting
tubules)
3-hour film
Findings suggestive of
renovascular
hypertension:
•discrepancy in renal
size
•asymmetry of contrast
appearance in the
renal collecting systems
•on delayed films,
greater density of
contrast in the
collecting system on the
affected side (the result
of prolonged tubular
transit in collecting
tubules)
Adverse reactions to contrast medium:
Contrast medium induced nephropathy:
Both are contrast media dependent
Spontaneous rupture of the collecting system:
This occurs in acute
calculus obstruction. For
this reason, large
volumes of contrast
medium are avoided and
abdominal compression
contraindicated.
Contrast medium induced nephropathy:
Both are contrast media dependent
Spontaneous rupture of the collecting system:
This occurs in acute
calculus obstruction. For
this reason, large
volumes of contrast
medium are avoided and
abdominal compression
contraindicated.
Kidney:
An understanding of the lobar development of kidney
provides an insight into several anomalies and diseases of
the kidney
The human kidney during embryonic development consists
of a large number of separate renal lobes (renunculi)
When they fuse, the outer areas of two adjacent lobes are
incorporated within the kidney and represent the cortical
renal columns or septa of Bertin
A prominent column projecting into the sinus can produce an intense “stain”
on nephrogram (most common form of pseudotumor)
Where the columns are deficient, (most commonly in the polar areas)
multiple pyramids fuse and form compound calyces
The cortex of the kidney contains both glomeruli and
uriniferous tubules, whereas medulla has only tubules
Near the apex of the pyramid (the papilla) the tubules
coalesce to form the collecting duct of Bellini; these
collecting duct pierce the tip of the papilla and open into a
calyx
An understanding of the lobar development of kidney
provides an insight into several anomalies and diseases of
the kidney
The human kidney during embryonic development consists
of a large number of separate renal lobes (renunculi)
When they fuse, the outer areas of two adjacent lobes are
incorporated within the kidney and represent the cortical
renal columns or septa of Bertin
A prominent column projecting into the sinus can produce an intense “stain”
on nephrogram (most common form of pseudotumor)
Where the columns are deficient, (most commonly in the polar areas)
multiple pyramids fuse and form compound calyces
The cortex of the kidney contains both glomeruli and
uriniferous tubules, whereas medulla has only tubules
Near the apex of the pyramid (the papilla) the tubules
coalesce to form the collecting duct of Bellini; these
collecting duct pierce the tip of the papilla and open into a
calyx
Thus the calyx is the cup recieving the tip of the papilla, and
the fornix is the side projection of calyx surrounding the
papilla (Microcalyces, macrocalyces, polycalicosis, and absent
calyces are some variants)
An average human kidney has 10 to 15 calyces which open
into the renal pelvis through the infundibulum. (Blind-ending
infundibulum is a variant)
Pelvis is obviously extrarenal when they project beyond
the medial border of the kidney
Considerable variation may be found in the degree of
obliquity of renal pelvis. The renal pelvis tends to be more
right-angled in young children. (Any PUJ in adults with
an angle 90 degrees or greater should suggest
possible mass displacement )
The long axis of the kidney usually runs in the same
inclination as the psoas muscle, with the upper pole closer
to spine and the lower pole away from the spine.
(Abnormality should be suspected if the long
axis of the kidney runs vertically or more than
45 degrees from the vertical)
the fornix is the side projection of calyx surrounding the
papilla (Microcalyces, macrocalyces, polycalicosis, and absent
calyces are some variants)
An average human kidney has 10 to 15 calyces which open
into the renal pelvis through the infundibulum. (Blind-ending
infundibulum is a variant)
Pelvis is obviously extrarenal when they project beyond
the medial border of the kidney
Considerable variation may be found in the degree of
obliquity of renal pelvis. The renal pelvis tends to be more
right-angled in young children. (Any PUJ in adults with
an angle 90 degrees or greater should suggest
possible mass displacement )
The long axis of the kidney usually runs in the same
inclination as the psoas muscle, with the upper pole closer
to spine and the lower pole away from the spine.
(Abnormality should be suspected if the long
axis of the kidney runs vertically or more than
45 degrees from the vertical)
Nephrogram
Within 20 seconds of a bolus injection of contrast, a cortical
nephrogram normally appears (which represents contrast in PCT)
Contrast material in the calyces are usually visible
approximately 2 minutes after the injection
A kidney that fails to excrete radiologically detectable contrast is termed
nonexcreting . (This term is preferred over nonvisualized. The term
nonfunctioning is best avoided)
Analysis of excretory phase of urogram begins with the kidneys
Normal renal length is equal to the height of
5 vertebral bodies (including intervening disk spaces) in new
born,
4 1/2 vertebral bodies in infants
4 vertebral bodies in older children
The radiologic size of the kidney is considerably larger due to normal
distention and the magnification (18% approx. in supine position)
The right kidney is usually 0.5 cm smaller than the left (The
kidney is termed enlarged when right kidney is 0.5 cm larger
than the left, or when the left kidney is 1.5 cm larger than the
right)
Within 20 seconds of a bolus injection of contrast, a cortical
nephrogram normally appears (which represents contrast in PCT)
Contrast material in the calyces are usually visible
approximately 2 minutes after the injection
A kidney that fails to excrete radiologically detectable contrast is termed
nonexcreting . (This term is preferred over nonvisualized. The term
nonfunctioning is best avoided)
Analysis of excretory phase of urogram begins with the kidneys
Normal renal length is equal to the height of
5 vertebral bodies (including intervening disk spaces) in new
born,
4 1/2 vertebral bodies in infants
4 vertebral bodies in older children
The radiologic size of the kidney is considerably larger due to normal
distention and the magnification (18% approx. in supine position)
The right kidney is usually 0.5 cm smaller than the left (The
kidney is termed enlarged when right kidney is 0.5 cm larger
than the left, or when the left kidney is 1.5 cm larger than the
right)
The normal fetal lobulation (which is frequently seen) are
easily differentiated from pathological scarring by their
smooth contour and regular spacing (A pyelonephric scar is
usually deeper and is always located adjacent to an
underlying abnormal calyx)
•The distance from the interpapillary
line to the lateral cortex of the
kidney averages 2.5 cm to 3 cm.
(Distances less than 2 cm are
suggestive of parenchymal losses,
and distances more than 3.5 cm are
suggestive of mass lesion or
interstitial infiltration)
•The right renal pelvis usually
opposite the L2 vertebra. The left
renal pelvis is usually 1 to 2 cm
higher
easily differentiated from pathological scarring by their
smooth contour and regular spacing (A pyelonephric scar is
usually deeper and is always located adjacent to an
underlying abnormal calyx)
•The distance from the interpapillary
line to the lateral cortex of the
kidney averages 2.5 cm to 3 cm.
(Distances less than 2 cm are
suggestive of parenchymal losses,
and distances more than 3.5 cm are
suggestive of mass lesion or
interstitial infiltration)
•The right renal pelvis usually
opposite the L2 vertebra. The left
renal pelvis is usually 1 to 2 cm
higher
Corticomedullary thickness ratio is normally 1:2 (range
1:1.5 to 1:2.5)
In megacalyx the medulla is thin, but the cortex remains normal
In obstructive or postobstructive atrophy both cortex and medulla
are thinned
1:1.5 to 1:2.5)
In megacalyx the medulla is thin, but the cortex remains normal
In obstructive or postobstructive atrophy both cortex and medulla
are thinned
It is normal renal tissue that may mimic an abnormal mass
Hypertrophied column of Bertin is the most common cause
A dromedary hump represents a bulge at the end of the
splenic impression (where the kidney reverts to its normal convexity)
The suprahilar and infrahilar areas frequently have an
overgrowth of normal parenchyma that may mimic a mass
just above or below the hilus
Asymmetric fetal lobulation
Renal sinus lipomatosis: Accumulation of fat in renal sinus
Aberrant papilla may project into the renal pelvis or an
infundibulum causing a filling defect
Acquired pseudotumor: The residual normal parenchyma in
kidneys affected by severe focal diseases such as reflux
nephropathy may hypertrophy and mimic a mass
Hypertrophied column of Bertin is the most common cause
A dromedary hump represents a bulge at the end of the
splenic impression (where the kidney reverts to its normal convexity)
The suprahilar and infrahilar areas frequently have an
overgrowth of normal parenchyma that may mimic a mass
just above or below the hilus
Asymmetric fetal lobulation
Renal sinus lipomatosis: Accumulation of fat in renal sinus
Aberrant papilla may project into the renal pelvis or an
infundibulum causing a filling defect
Acquired pseudotumor: The residual normal parenchyma in
kidneys affected by severe focal diseases such as reflux
nephropathy may hypertrophy and mimic a mass
Extracalyceal contrast medium:
•Papillary necrosis, MSK, and tuberculosis may all cause contrast
to be seen inside interpapillary line
•In normal and abnormal conditions, contrast in the collecting duct
of the pyramid may produce a blush (pyramidal blush)
Normal: caused by large doses of contrast, (particularly LOCM) compression of
ureters [Blush is not clearly striated]
Abnormal: in obstruction, medullary sponge kidney (tubular ectasia) [striated]
Patterns of papillary necrosis
•Papillary necrosis, MSK, and tuberculosis may all cause contrast
to be seen inside interpapillary line
•In normal and abnormal conditions, contrast in the collecting duct
of the pyramid may produce a blush (pyramidal blush)
Normal: caused by large doses of contrast, (particularly LOCM) compression of
ureters [Blush is not clearly striated]
Abnormal: in obstruction, medullary sponge kidney (tubular ectasia) [striated]
Patterns of papillary necrosis
Extensive papillary
necrosis causing
calyceal clubbing
Central erosion of papilla
necrosis causing
calyceal clubbing
Central erosion of papilla
B. The calyces are normally
cupped until the necrotic
papilla has sloughed and
passed into the collecting
system when they become
blunt
D: contrast is seen in cavities
in the papilla. There is
scarring opposite to papilla.
The associated papilla has
a moth- eaten, ragged
appearance
cupped until the necrotic
papilla has sloughed and
passed into the collecting
system when they become
blunt
D: contrast is seen in cavities
in the papilla. There is
scarring opposite to papilla.
The associated papilla has
a moth- eaten, ragged
appearance
It is a lesion consisting
of an outpouching of a
portion of collecting
system into the
corticomedullary region
Most commonly seen
arising from the upper
or lower pole
of an outpouching of a
portion of collecting
system into the
corticomedullary region
Most commonly seen
arising from the upper
or lower pole
Ureter:
The ureters are conduits approx. 25 to 29 cm in length. It
is conveniently divided into abdominal & pelvic part
The abdominal portion begins at the junction with renal
pelvis and runs over the anterior surface of the psoas
muscle
A ureter that lies more than 1.5cm lateral to the
transverse process is suspected of being laterally
deviated, a ureter that crosses over the vertebral pedicle
is suspected of being medially deviated, and a ureter
that is medial to the pedicle is usually abnormal
In the prone or inspiratory films, kinking of proximal
portion of ureter is commonly seen
Ureter has three normal areas of narrowing: [(1)
at the PUJ, (2) where the ureter crosses the iliac vessels
at the pelvic brim, and (3) at UVJ]
Peristaltic activity, redundancy, or
crossing vessels may simulate areas of
narrowing
The ureters are conduits approx. 25 to 29 cm in length. It
is conveniently divided into abdominal & pelvic part
The abdominal portion begins at the junction with renal
pelvis and runs over the anterior surface of the psoas
muscle
A ureter that lies more than 1.5cm lateral to the
transverse process is suspected of being laterally
deviated, a ureter that crosses over the vertebral pedicle
is suspected of being medially deviated, and a ureter
that is medial to the pedicle is usually abnormal
In the prone or inspiratory films, kinking of proximal
portion of ureter is commonly seen
Ureter has three normal areas of narrowing: [(1)
at the PUJ, (2) where the ureter crosses the iliac vessels
at the pelvic brim, and (3) at UVJ]
Peristaltic activity, redundancy, or
crossing vessels may simulate areas of
narrowing
AP view
RPO view
RPO view
The abdominal ureter crosses the brim of the pelvis at the
bifurcation of the common iliac artery and becomes pelvic ureter
The pelvic ureter runs abruptly backwards and laterally along the
contour of the pelvis. In the region of the ischial spine, the ureter
turns medially and forward to enter the bladder
The pelvic ureter therefore has a convex lateral appearance. The
usual causes of concavity include bladder diverticulum, enlarged
hypogastric nodes, or aneurysmal dilatation of the hypogastric
artery
Because of x-ray beam divergence, the distal ends of the ureters
may appear to insert abnormally low in prone position and should
not be mistaken for ectopic ureters
Concentrated contrast material ejected from the ureteral orifice by
peristalsis may be seen passing through the less dense contrast in
the bladder (the jet sign). It can be easily distinguished from ureteral
ectopia (The jet crosses the midline and the ectopic ureters do not)
A ureter that remains completely filled in all films,
even though it is not significantly dilated, is
suspected of minimal UVJ obstruction
bifurcation of the common iliac artery and becomes pelvic ureter
The pelvic ureter runs abruptly backwards and laterally along the
contour of the pelvis. In the region of the ischial spine, the ureter
turns medially and forward to enter the bladder
The pelvic ureter therefore has a convex lateral appearance. The
usual causes of concavity include bladder diverticulum, enlarged
hypogastric nodes, or aneurysmal dilatation of the hypogastric
artery
Because of x-ray beam divergence, the distal ends of the ureters
may appear to insert abnormally low in prone position and should
not be mistaken for ectopic ureters
Concentrated contrast material ejected from the ureteral orifice by
peristalsis may be seen passing through the less dense contrast in
the bladder (the jet sign). It can be easily distinguished from ureteral
ectopia (The jet crosses the midline and the ectopic ureters do not)
A ureter that remains completely filled in all films,
even though it is not significantly dilated, is
suspected of minimal UVJ obstruction
•Space-occupying lesions that arise
from the medial aspect of lower pole
may deflect the ureters medially
•Medial deviation of the middle one-
third of ureter may be related to
retroperitoneal tumors or fluid
collections that are lateral to the
ureter, or to a retrocaval ureter
• a ureter that crosses over the
vertebral pedicle is suspected of
being medially deviated, and a
ureter that is medial to the
pedicle is usually abnormal
from the medial aspect of lower pole
may deflect the ureters medially
•Medial deviation of the middle one-
third of ureter may be related to
retroperitoneal tumors or fluid
collections that are lateral to the
ureter, or to a retrocaval ureter
• a ureter that crosses over the
vertebral pedicle is suspected of
being medially deviated, and a
ureter that is medial to the
pedicle is usually abnormal
Most common cause of
lateral displacement of
upper ureter is
retroperitoneal lymph node
enlargement
Unusually large psoas
muscles may deviate distal
portions of the ureter
laterally
Malrotated kidneys also may
laterally displace proximal
ureter
An abdominal aorta
aneurysm may displace mid
ureter laterally A ureter that lies
more than 1.5cm lateral to the
transverse process is suspected of
being laterally deviated
Lateralized ureter:
lateral displacement of
upper ureter is
retroperitoneal lymph node
enlargement
Unusually large psoas
muscles may deviate distal
portions of the ureter
laterally
Malrotated kidneys also may
laterally displace proximal
ureter
An abdominal aorta
aneurysm may displace mid
ureter laterally A ureter that lies
more than 1.5cm lateral to the
transverse process is suspected of
being laterally deviated
Lateralized ureter:
Deviations of the distal one-
third of the ureter are more
common
Frequently, a bladder
diverticulum may deviate the
distal ureter anteromedially
Other causes are enlarged
iliac lymph nodes, pelvic
lipomatosis, retroperitoneal
pelvic hematomas, surgeries
like APR, and severe uterine
and/or bladder prolapse
Pelvic masses (particularly
those of gynecological origin such
as fibroid) cause lateral
deviation
third of the ureter are more
common
Frequently, a bladder
diverticulum may deviate the
distal ureter anteromedially
Other causes are enlarged
iliac lymph nodes, pelvic
lipomatosis, retroperitoneal
pelvic hematomas, surgeries
like APR, and severe uterine
and/or bladder prolapse
Pelvic masses (particularly
those of gynecological origin such
as fibroid) cause lateral
deviation
The adult bladder lies deep in the pelvis when empty,
but flexibility of the detrusor muscle fibres allows the
bladder walls and dome to rise in pelvis when bladder is
full
Bladder ears are seen in
infants and very young
children as inferolateral
protrusions of the bladder,
usually bilaterally, into the
regions of inguinal canal.
(becomes less apparent as the
bladder fills to capacity, and
disappears as the child
grows)
but flexibility of the detrusor muscle fibres allows the
bladder walls and dome to rise in pelvis when bladder is
full
Bladder ears are seen in
infants and very young
children as inferolateral
protrusions of the bladder,
usually bilaterally, into the
regions of inguinal canal.
(becomes less apparent as the
bladder fills to capacity, and
disappears as the child
grows)
Usually occur as a result of bladder outlet obstruction. Rarely
a congenital deficiency in bladder musculature adjacent to UVJ results in
diverticulum adjacent to ureteral orifice (“Hutch” diverticulum)
In children, urethral valve, and neurogenic bladder are
common causes
In adult male, BPH is the most common cause. Acquired
bladder diverticula are rare in women
Multiple bladder diverticula are common, usually arising
from the lateral walls and rarely arising from the bladder
dome
A wide-necked diverticulum empties readily when bladder
empties. A narrow-necked diverticulum empties slowly and
therefore more likely to have residual urine
In urography, bladder is identified by its irregular
trabeculated contour, while the diverticulum has a
smooth thin wall
a congenital deficiency in bladder musculature adjacent to UVJ results in
diverticulum adjacent to ureteral orifice (“Hutch” diverticulum)
In children, urethral valve, and neurogenic bladder are
common causes
In adult male, BPH is the most common cause. Acquired
bladder diverticula are rare in women
Multiple bladder diverticula are common, usually arising
from the lateral walls and rarely arising from the bladder
dome
A wide-necked diverticulum empties readily when bladder
empties. A narrow-necked diverticulum empties slowly and
therefore more likely to have residual urine
In urography, bladder is identified by its irregular
trabeculated contour, while the diverticulum has a
smooth thin wall
Causes are
•Schistosomiasis
•Tuberculosis
•Radiation cystitis
•Cytotoxan cystitis
•Alkaline encrustation
cystitis
•Amyloidosis
•Tumor
•Schistosomiasis
•Tuberculosis
•Radiation cystitis
•Cytotoxan cystitis
•Alkaline encrustation
cystitis
•Amyloidosis
•Tumor
There are multiple causes of
bladder calculi, the most
common being BOO
A significant number of
bladder stones are
asymptomatic
Oblique views of the pelvis
often are helpful in separating
a calcified stone from sacrum
and coccyx, and colonic or
fecal material
Many calcified bladder stones
are less dense than the
contrast medium, and
therefore, cast a negative
shadow within the contrast-
filled bladder
Various
Configurations
Faceted, Laminated (in BPH)
“jackstone” (spiculated)
“mulberry stone” (bumpy)
bladder calculi, the most
common being BOO
A significant number of
bladder stones are
asymptomatic
Oblique views of the pelvis
often are helpful in separating
a calcified stone from sacrum
and coccyx, and colonic or
fecal material
Many calcified bladder stones
are less dense than the
contrast medium, and
therefore, cast a negative
shadow within the contrast-
filled bladder
Various
Configurations
Faceted, Laminated (in BPH)
“jackstone” (spiculated)
“mulberry stone” (bumpy)
Filling defects must be
differentiated from contour
defects
The term filling defect denotes
something lying free within
bladder lumen resulting in a
lucent defect in contrast-filled
bladder on EU. (Examples include
calculi, clot, and foreign bodies)
Contour defects, however, are
mural or mucosal lesions that
alter the contour of contrast-filled
bladder. (Examples include urothelial
tumors, metaplastic and inflammatory
masses, and wall thickening from any
other cause)
differentiated from contour
defects
The term filling defect denotes
something lying free within
bladder lumen resulting in a
lucent defect in contrast-filled
bladder on EU. (Examples include
calculi, clot, and foreign bodies)
Contour defects, however, are
mural or mucosal lesions that
alter the contour of contrast-filled
bladder. (Examples include urothelial
tumors, metaplastic and inflammatory
masses, and wall thickening from any
other cause)
Stone in UVJ
Leiomyoma TCC of bladder
Leiomyoma TCC of bladder
Deviations and impressions
Various conditions in the pelvis extrinsic to the bladder
can cause impression of the bladder, can
circumferentially compress the bladder, or can deviate
the bladder
•Common lesions that may
indent the bladder include
enlarged pelvic lymph
nodes, tumors arising from
the colon, reproductive
organs, or mesenchymal
tissues, presacral teratomas,
iliac artery aneurysms,
hematomas, and abscesses
Various conditions in the pelvis extrinsic to the bladder
can cause impression of the bladder, can
circumferentially compress the bladder, or can deviate
the bladder
•Common lesions that may
indent the bladder include
enlarged pelvic lymph
nodes, tumors arising from
the colon, reproductive
organs, or mesenchymal
tissues, presacral teratomas,
iliac artery aneurysms,
hematomas, and abscesses
Psoas hypertrophyHip implant with cement leak
Poor emptying of the
bladder, a feathery contour
of the bladder suggesting
mild trabeculation or a
corrugated contour when
severe trabeculation is
present, a formation of
frank diverticula, and a
smooth dome-like
impression represent
enlarged prostate in
males
The enlarged prostate
elevates the interureteric
ridge, producing a
characteristic “J-ing” of
distal ureter
Long-standing BPH
causes bilateral
hydronephrosis
bladder, a feathery contour
of the bladder suggesting
mild trabeculation or a
corrugated contour when
severe trabeculation is
present, a formation of
frank diverticula, and a
smooth dome-like
impression represent
enlarged prostate in
males
The enlarged prostate
elevates the interureteric
ridge, producing a
characteristic “J-ing” of
distal ureter
Long-standing BPH
causes bilateral
hydronephrosis
The female bladder may be
impressed on its base,
resulting in a radiographic
pattern similar to that of
enlarged prostate (female
prostate)
Causes include urethral
diverticulum of proximal
urethra (most common),
periurethral inflammation,
urethral tumors, tumors of
anterior vaginal wall,
degenerative or malignant
changes of pubic symphysis,
and post-operative changes
after repair of urinary stress
incontinence
Urethral diverticulum of proximal
urethra clear in postvoid film
impressed on its base,
resulting in a radiographic
pattern similar to that of
enlarged prostate (female
prostate)
Causes include urethral
diverticulum of proximal
urethra (most common),
periurethral inflammation,
urethral tumors, tumors of
anterior vaginal wall,
degenerative or malignant
changes of pubic symphysis,
and post-operative changes
after repair of urinary stress
incontinence
Urethral diverticulum of proximal
urethra clear in postvoid film
Circumferential compression
of the bladder results in a
configuration more
commonly known as
“teardrop”, “vertical”, or “pear-
shaped” bladder
Causes include perivesical
fluid (hematoma), pelvic
lymphadenopathy
(lymphoma), pelvic
lipomatosis, pelvic venous
collaterals due to IVC
obstruction, retroperitoneal
fibrosis, pancreatic
pseudocyst, prominent
iliopsoas muscle (normal
variant)
of the bladder results in a
configuration more
commonly known as
“teardrop”, “vertical”, or “pear-
shaped” bladder
Causes include perivesical
fluid (hematoma), pelvic
lymphadenopathy
(lymphoma), pelvic
lipomatosis, pelvic venous
collaterals due to IVC
obstruction, retroperitoneal
fibrosis, pancreatic
pseudocyst, prominent
iliopsoas muscle (normal
variant)
Bladder herniation
Usually present along with
inguinal hernia
Can occur in varying
degrees and is usually seen
when the bladder is filled
with contrast medium
during EU
Cystocele
•Almost exclusively in
multiparous women
•Prolapse may be mild or
severe enough that a large
portion of bladder
protrudes through introitus
Usually present along with
inguinal hernia
Can occur in varying
degrees and is usually seen
when the bladder is filled
with contrast medium
during EU
Cystocele
•Almost exclusively in
multiparous women
•Prolapse may be mild or
severe enough that a large
portion of bladder
protrudes through introitus
Emphysematous cystitisCystitis cystica
Radiation cystitis
Colovesical fistula
Radiation cystitis
Colovesical fistula
Renal tuberculosis results from hematogenous dissemination
of Mycobacterium tuberculosis usually from lungs or bones
Bacilli lodge in the corticomedullary junction of the kidney,
where most heal without sequelae
Because the initial lesions occur as a result of hematogenous
dissemination , multiple bilateral lesions are initially produced;
however, active tuberculomas form only in one kidney
The characteristics of renal TB include
parenchymal
calcification,
parenchymal scar,
papillary necrosis,
infundibular
stricture,
nonfunction.
of Mycobacterium tuberculosis usually from lungs or bones
Bacilli lodge in the corticomedullary junction of the kidney,
where most heal without sequelae
Because the initial lesions occur as a result of hematogenous
dissemination , multiple bilateral lesions are initially produced;
however, active tuberculomas form only in one kidney
The characteristics of renal TB include
parenchymal
calcification,
parenchymal scar,
papillary necrosis,
infundibular
stricture,
nonfunction.
Infundibular stenosis
The earliest urographic
abnormality is loss of
definition of a minor calyx,
irregularity of the surface of
one or more papillae or
calyces (giving rise to “moth-
eaten” or “feathery”
appearance), at a time renal
size and contour are normal
The walls of tubercular
cavities are typically irregular,
communicating with the
collecting system, but the
communication may be
narrow and ureteral
compression may be needed
to demonstrate it
abnormality is loss of
definition of a minor calyx,
irregularity of the surface of
one or more papillae or
calyces (giving rise to “moth-
eaten” or “feathery”
appearance), at a time renal
size and contour are normal
The walls of tubercular
cavities are typically irregular,
communicating with the
collecting system, but the
communication may be
narrow and ureteral
compression may be needed
to demonstrate it
•Spread of infection causes
stenosis and obstruction in the
collecting system (the common
stricture sites being the neck of a
calyx, PUJ, and lower end of ureter)
•Regional calyectasis is
commonly demonstrated
•A completely stenosed
infundibulum or calyx may lead
to failure of contrast excretion
in the involved parenchyma
(“phantom calyx”). A tiny
infundibular stump (“amputated
calyx”or “cut-off calyx”) may
be seen in such cases
stenosis and obstruction in the
collecting system (the common
stricture sites being the neck of a
calyx, PUJ, and lower end of ureter)
•Regional calyectasis is
commonly demonstrated
•A completely stenosed
infundibulum or calyx may lead
to failure of contrast excretion
in the involved parenchyma
(“phantom calyx”). A tiny
infundibular stump (“amputated
calyx”or “cut-off calyx”) may
be seen in such cases
The concentration of
contrast medium is
surprisingly poor in
proportion to degree of
destruction
Traction from a strictured
infundibulum or
parenchymal fibrosis may
cause kinking of pelvis
(Kerr’s kinks) which
develop independent of TB
ulceration
Occasionally, obstruction
can be of such a high
grade and so prolonged
that marked
hydronephrosis develops
contrast medium is
surprisingly poor in
proportion to degree of
destruction
Traction from a strictured
infundibulum or
parenchymal fibrosis may
cause kinking of pelvis
(Kerr’s kinks) which
develop independent of TB
ulceration
Occasionally, obstruction
can be of such a high
grade and so prolonged
that marked
hydronephrosis develops
Progressive radiological findings during treatment of proven renal
TB
Caseation into
several calyces
with irregular
cavitations
Initial urogram 3 months later 9 months later
Calyceal dilatation
probably due to
infundibular
stricture
Progressive
calyectasis with
pelvic narrowing
and multiple
cavities
TB
Caseation into
several calyces
with irregular
cavitations
Initial urogram 3 months later 9 months later
Calyceal dilatation
probably due to
infundibular
stricture
Progressive
calyectasis with
pelvic narrowing
and multiple
cavities
Calcification within a caseous
pyonephrosis has a rather
characteristic cloudy
appearance within the
distribution of hydronephrotic
calyces
This may progress to produce
almost homogeneous
calcification in hydronephrosis,
so that on plain film the kidney
appears as a lobulated
calcified mass, which
represents a non functioning
kidney (the so called auto-
nephrectomy)
pyonephrosis has a rather
characteristic cloudy
appearance within the
distribution of hydronephrotic
calyces
This may progress to produce
almost homogeneous
calcification in hydronephrosis,
so that on plain film the kidney
appears as a lobulated
calcified mass, which
represents a non functioning
kidney (the so called auto-
nephrectomy)
Amorphous or smudgy
usually in a
granulomatous
lesion
Speckled usually
represent a healed
tuberculoma
Curvilinear likely is
deposition
between caseation
and remaining
renal parenchyma
usually in a
granulomatous
lesion
Speckled usually
represent a healed
tuberculoma
Curvilinear likely is
deposition
between caseation
and remaining
renal parenchyma
Myriad of TB calcifications
Urographic findings
A.Ureter with normal
peristalsis
B,C. Irregular outline of
ureter representing
tubercular ulceration
D.Long ureteral stricture
E.Multiple ureteral
strictures
F.“Beaded ” ureter
representing alternate
stricture and dilatation
G.“Corkscrew” ureter
H.“Pipestem” ureter with
evidence of calcification
TB ureter
A.Ureter with normal
peristalsis
B,C. Irregular outline of
ureter representing
tubercular ulceration
D.Long ureteral stricture
E.Multiple ureteral
strictures
F.“Beaded ” ureter
representing alternate
stricture and dilatation
G.“Corkscrew” ureter
H.“Pipestem” ureter with
evidence of calcification
TB ureter
•Tubercular cystitis leads to
edema of mucosa (if large can
manifest radiologically as filling
defect)
•Advanced disease leads to
contracture with thick walls
and reduction of bladder
capacity (the “thimble
bladder”)
edema of mucosa (if large can
manifest radiologically as filling
defect)
•Advanced disease leads to
contracture with thick walls
and reduction of bladder
capacity (the “thimble
bladder”)
The results of urography
are normal in three quarters
of cases.
Abnormal findings include
(a) diffuse renal enlargement;
(b) decrease in density of
nephrogram;
(c) delay in contrast transit
(d) attenuation of the calyces
due to edema
Urographic features of
other bacterial
infections
are normal in three quarters
of cases.
Abnormal findings include
(a) diffuse renal enlargement;
(b) decrease in density of
nephrogram;
(c) delay in contrast transit
(d) attenuation of the calyces
due to edema
Urographic features of
other bacterial
infections
Chronic pyelonephritis
Typical radiologic findings include demonstration of
parenchymal scars typically in the upper pole
overlying a deformed calyx, and focal areas of
compensatory hypertrophy adjacent to areas of
cortical scarring.
Xanthogranulomatous pyelonephritis has a classical
triad of (a) a staghorn calculus, (b) absent or
diminished excretion of contrast, (c) a poorly defined
mass
It probably represents an
uncommon reaction by
kidney to urinary tract
obstruction in the
presence of infection
Typical radiologic findings include demonstration of
parenchymal scars typically in the upper pole
overlying a deformed calyx, and focal areas of
compensatory hypertrophy adjacent to areas of
cortical scarring.
Xanthogranulomatous pyelonephritis has a classical
triad of (a) a staghorn calculus, (b) absent or
diminished excretion of contrast, (c) a poorly defined
mass
It probably represents an
uncommon reaction by
kidney to urinary tract
obstruction in the
presence of infection
Tumefactions are swellings. They may be congenital,
traumatic, inflammatory, neoplastic, or vascular
Most tumefactions in the urinary tract occur in patients who
are over 40 age or who are under the age of puberty
Size. The simple expediment
of measuring the length of
the two kidneys and the
parenchymal thickness of
each will help in determining
whether or not a tumefaction
is present. It is difficult to
detect a tumefaction less
than 2 cm.
Radiological Appearance & Factors Influencing Them
traumatic, inflammatory, neoplastic, or vascular
Most tumefactions in the urinary tract occur in patients who
are over 40 age or who are under the age of puberty
Size. The simple expediment
of measuring the length of
the two kidneys and the
parenchymal thickness of
each will help in determining
whether or not a tumefaction
is present. It is difficult to
detect a tumefaction less
than 2 cm.
Radiological Appearance & Factors Influencing Them
Superficial tumefaction: When
a cyst projects from the
surface, that part of the
wall which projects is not
surrounded by renal
tissue. It is usually 2 mm or
less in thickness
When examining superficially
located tumefaction, it is important
to examine the part which projects
inward into the renal tissue itself
The nonspecific “rim”
and “claw” sign
suggest superficiality
Location. The deeper the tumefaction within the renal
substance, the more likely it is to distort or invade the
collecting system
a cyst projects from the
surface, that part of the
wall which projects is not
surrounded by renal
tissue. It is usually 2 mm or
less in thickness
When examining superficially
located tumefaction, it is important
to examine the part which projects
inward into the renal tissue itself
The nonspecific “rim”
and “claw” sign
suggest superficiality
Location. The deeper the tumefaction within the renal
substance, the more likely it is to distort or invade the
collecting system
Cortical cyst RCC nonenhancing
surrounded by
normal
parenchyma
surrounded by
normal
parenchyma
The precise effect of the
tumefaction on calyx
depends on its position in
relation to the calyx and its
infundibulum. A tense, benign
cyst or malignant neoplasm may
actually occlude the infundibulum
or calyx (encasement)
Irregularity in outline may be
due to invasion by a
malignant lesion, infections
like TB, clot, and stones
When a tumefaction is seen in the
upper pole of the kidney,
duplicated collecting system with
hydronephrotic upper pole should
be ruled out
tumefaction on calyx
depends on its position in
relation to the calyx and its
infundibulum. A tense, benign
cyst or malignant neoplasm may
actually occlude the infundibulum
or calyx (encasement)
Irregularity in outline may be
due to invasion by a
malignant lesion, infections
like TB, clot, and stones
When a tumefaction is seen in the
upper pole of the kidney,
duplicated collecting system with
hydronephrotic upper pole should
be ruled out
Vascularity
.
Most common parapelvic tumefaction
is simple cyst
A ruptured cyst occasionally
communicates with collecting
system, in which case it is partially
or completely filled with contrast
.
Most common parapelvic tumefaction
is simple cyst
A ruptured cyst occasionally
communicates with collecting
system, in which case it is partially
or completely filled with contrast
The kidney is relatively
protected from injury by
the rib cage, the vertebral
column, and the psoas
muscles. (The fascial
coverings of the kidney and the
retroperitoneal fat provide
additional protection)
Injury of the lower ribs or
the vertebra , is associated
with a higher incidence of
renal injury (Liver and spleen
are most common abdominal
organs associated with renal
injuries)
protected from injury by
the rib cage, the vertebral
column, and the psoas
muscles. (The fascial
coverings of the kidney and the
retroperitoneal fat provide
additional protection)
Injury of the lower ribs or
the vertebra , is associated
with a higher incidence of
renal injury (Liver and spleen
are most common abdominal
organs associated with renal
injuries)
Most commonly, the results of
urography are normal in patients
suffering from minor injuries
In more severe injuries delayed
opacification, incomplete
visualization of the renal
outline, diminished nephrogram
that may be segmental, as well
as non-visualization of the
affected kidney may be
demonstrated
As a rule, evaluation of
the lower urinary
tract should precede
evaluation of upper
urinary tract, when
both are indicated
urography are normal in patients
suffering from minor injuries
In more severe injuries delayed
opacification, incomplete
visualization of the renal
outline, diminished nephrogram
that may be segmental, as well
as non-visualization of the
affected kidney may be
demonstrated
As a rule, evaluation of
the lower urinary
tract should precede
evaluation of upper
urinary tract, when
both are indicated
Although cross-sectional
studies are generally
preferred some urographic
findings are worth mentioning
A filling defect in the
collecting system, in the
setting of trauma usually
indicates a blood clot
A cleft in the
nephrogram indicates
laceration
Extravasation of
contrast may indicate a
laceration that extends
into collecting system, or
PUJ avulsion
Subcapsular hematoma
studies are generally
preferred some urographic
findings are worth mentioning
A filling defect in the
collecting system, in the
setting of trauma usually
indicates a blood clot
A cleft in the
nephrogram indicates
laceration
Extravasation of
contrast may indicate a
laceration that extends
into collecting system, or
PUJ avulsion
Subcapsular hematoma
Complete avulsion of PUJExtravasation of contrast
1)Iatrogenic injury of the
ureter may result from a
variety of gynecologic (radical
hysterectomy), urologic
(uretroscopy, Dormia basketing,
retrograde pyelography),
abdominal and pelvic
procedures
2)Aside from PUJ avulsion,
traumatic injuries of ureter
virtually always occur
secondary to penetrating
trauma
As such, nearly all
ureteral injuries are
associated with
injuries of other
organs
ureter may result from a
variety of gynecologic (radical
hysterectomy), urologic
(uretroscopy, Dormia basketing,
retrograde pyelography),
abdominal and pelvic
procedures
2)Aside from PUJ avulsion,
traumatic injuries of ureter
virtually always occur
secondary to penetrating
trauma
As such, nearly all
ureteral injuries are
associated with
injuries of other
organs
A collapsed or nearly empty
bladder is much less
vulnerable to injury than is
a distended organ
1)Intraperitoneal rupture
occurs as a result of blunt
trauma to the abdomen
2)Extraperitoneal rupture is
associated with one or
more fractures of the
pubic ramus or diastasis
of the pubic symphysis in
virtually all cases
While cystography is highly accurate in the
diagnosis of bladder injury, the
cystographic phase of EU cannot be relied
on to rule out bladder injury
bladder is much less
vulnerable to injury than is
a distended organ
1)Intraperitoneal rupture
occurs as a result of blunt
trauma to the abdomen
2)Extraperitoneal rupture is
associated with one or
more fractures of the
pubic ramus or diastasis
of the pubic symphysis in
virtually all cases
While cystography is highly accurate in the
diagnosis of bladder injury, the
cystographic phase of EU cannot be relied
on to rule out bladder injury
Combined bladder injury “Pie in the sky” bladder
Intrarenal calcifications may lie in renal parenchyma
(nephrocalcinosis) or in renal collecting system
(nephrolithiasis)
Nephrocalcinosis
Calcification of abnormal tissue is termed dystrophic
(the solublity product of calcium and phosphate is exceeded
because of change in pHor may be part of reparative process);
calcification of normal renal tissue due to abnormally
high levels of calcium is termed metastatic
Cortical nephrocalcinosis is located in the periphery and
along the central septa of Bertin. The pyramids are
spared
Medullary nephrocalcinosis is central in location, but with
peripheral extensions along the medullary pyramids. It
is usually bilateral process with multiple stippled
calcifications; the exception is medullary sponge
kidney, which may be unilateral or segmental
(nephrocalcinosis) or in renal collecting system
(nephrolithiasis)
Nephrocalcinosis
Calcification of abnormal tissue is termed dystrophic
(the solublity product of calcium and phosphate is exceeded
because of change in pHor may be part of reparative process);
calcification of normal renal tissue due to abnormally
high levels of calcium is termed metastatic
Cortical nephrocalcinosis is located in the periphery and
along the central septa of Bertin. The pyramids are
spared
Medullary nephrocalcinosis is central in location, but with
peripheral extensions along the medullary pyramids. It
is usually bilateral process with multiple stippled
calcifications; the exception is medullary sponge
kidney, which may be unilateral or segmental
Cortical nephrocalcinosis
Cortical necrosis
Chronic glomerulonephritis
Oxalosis
Alport’s syndrome
Medullary nephrocalcinosis
Hypercalcemic states (e.g.
hyperparathyroidism)
RTA type I
Medullary sponge kidney
Cortical necrosis
Chronic glomerulonephritis
Oxalosis
Alport’s syndrome
Medullary nephrocalcinosis
Hypercalcemic states (e.g.
hyperparathyroidism)
RTA type I
Medullary sponge kidney
It is a complex process involving three main factors: (1) the
concentration of precipitating substance and their solubility, (2) the
promoters, (3) the inhibitors of crystallization and aggregation
Because 90% of urinary tract calculi are radiopaque, the plain
radiograph is important in evaluating a patient suspected of stones.
Some radiolucent stones are of uric acid, xanthine, struvite, matrix
stones
Excretory urography serves two important functions: (a) it delineates
the relationship of the collecting system to the calcification on the
preliminary film, and (b) it demonstrates the degree of obstruction
In patients with an anatomically normal collecting system, a renal
stone is most likely to be held in the renal pelvis, at the point where
the ureter crosses over the iliac vessels, or at the PUJ
concentration of precipitating substance and their solubility, (2) the
promoters, (3) the inhibitors of crystallization and aggregation
Because 90% of urinary tract calculi are radiopaque, the plain
radiograph is important in evaluating a patient suspected of stones.
Some radiolucent stones are of uric acid, xanthine, struvite, matrix
stones
Excretory urography serves two important functions: (a) it delineates
the relationship of the collecting system to the calcification on the
preliminary film, and (b) it demonstrates the degree of obstruction
In patients with an anatomically normal collecting system, a renal
stone is most likely to be held in the renal pelvis, at the point where
the ureter crosses over the iliac vessels, or at the PUJ
If the stone is of the same
density as the excreted
contrast, it will appear to have
disappeared; if the stone is
less dense it appears as a
filling defect
For surgical procedures, it is
imperative to determine
whether the calyceal stones
are anterior or posterior. The
anterior set of calyces usually
project more laterally
If the opacity is in the renal
region but outside collecting
system it is mostly vascular in
origin
density as the excreted
contrast, it will appear to have
disappeared; if the stone is
less dense it appears as a
filling defect
For surgical procedures, it is
imperative to determine
whether the calyceal stones
are anterior or posterior. The
anterior set of calyces usually
project more laterally
If the opacity is in the renal
region but outside collecting
system it is mostly vascular in
origin
•The site of obstruction is often
calyceal for infection stones and
renal pelvis/infundibulum for
non infection related stones
Stone in calyceal diverticulum
Staghorn
calculus
calyceal for infection stones and
renal pelvis/infundibulum for
non infection related stones
Stone in calyceal diverticulum
Staghorn
calculus
In ureteral stones prone film, erect film,
or a postvoid film frequently
exaggerates the difference between
mildly obstructed side and the normal
side. Prone ipsilateral
anterior oblique may be
necessary
Careful examination of the opacified
ureter about the calculus will often show
narrowing of the lumen just distal to the
stone due to edema. Focal distal
ureterectasis and vesical edema leads
to “pseudouretrocele” ; there is diminished
or abolished ureteral peristalsis
or a postvoid film frequently
exaggerates the difference between
mildly obstructed side and the normal
side. Prone ipsilateral
anterior oblique may be
necessary
Careful examination of the opacified
ureter about the calculus will often show
narrowing of the lumen just distal to the
stone due to edema. Focal distal
ureterectasis and vesical edema leads
to “pseudouretrocele” ; there is diminished
or abolished ureteral peristalsis
To develop an obstructive nephrogram, renal blood flow,
glomerular filtration, tubular function should be near
normal. Such is the case with acute obstruction on
previously healthy kidney.
On the other hand, chronic obstruction typically impairs
these functions such that an obstructive nephrogram is
rarely seen (except in acute-on-chronic obstruction)
Upon, sudden complete obstruction of ureter, renal
blood flow increases transiently, but over the next 6-12
h renal vascular resistance increases [delayed
nephrogram]
There are two mechanisms that act to temporarily
decompress the nephron. (1) pyelosinus and
pyelovenous backflow via fornix tear; and (2) enhanced
reabsorption of fluid from tubules [increasingly dense
nephrogram]
glomerular filtration, tubular function should be near
normal. Such is the case with acute obstruction on
previously healthy kidney.
On the other hand, chronic obstruction typically impairs
these functions such that an obstructive nephrogram is
rarely seen (except in acute-on-chronic obstruction)
Upon, sudden complete obstruction of ureter, renal
blood flow increases transiently, but over the next 6-12
h renal vascular resistance increases [delayed
nephrogram]
There are two mechanisms that act to temporarily
decompress the nephron. (1) pyelosinus and
pyelovenous backflow via fornix tear; and (2) enhanced
reabsorption of fluid from tubules [increasingly dense
nephrogram]
Delayed Nephrogram Dense Nephrogram
•During the acute episode there are features on IVU of severe
•acute obstruction, which include a delayed, increasingly dense
•nephrogram and delayed appearance (sometimes up to 24 h or
•more) of contrast within the collecting system. When opacification
•occurs it demonstrates clubbed calyces and a dilated pelvis. Prior to
•opacification of the pelvicalyceal system there may he a negative
•pyelogram, i.e. dilated calyces appearing as radiolucent areas surrounded
•by the denser areas of the nephrogram (Fig. 30.25).
•Contrast may be seen with a curvilinear configuration just peripheral
•to the calyces. This appearance has been termed `crescents' and
•i s thought to represent contrast stasis in collecting ducts displaced
•around distended calyces (Fig. 30.26). The PUJ is tightly closed
•and the ureter is often not opacified.
•acute obstruction, which include a delayed, increasingly dense
•nephrogram and delayed appearance (sometimes up to 24 h or
•more) of contrast within the collecting system. When opacification
•occurs it demonstrates clubbed calyces and a dilated pelvis. Prior to
•opacification of the pelvicalyceal system there may he a negative
•pyelogram, i.e. dilated calyces appearing as radiolucent areas surrounded
•by the denser areas of the nephrogram (Fig. 30.25).
•Contrast may be seen with a curvilinear configuration just peripheral
•to the calyces. This appearance has been termed `crescents' and
•i s thought to represent contrast stasis in collecting ducts displaced
•around distended calyces (Fig. 30.26). The PUJ is tightly closed
•and the ureter is often not opacified.
1. Infundibular stricture
2. Renal pelvic calculus
3. Benign polyp or transitional cell
carcinoma of pelvis
4. RCC causing extrinsic obstruction
5. PUJ obstruction
6. Ureteral calculus, clot, polyp, etc.
7. Uretral valve
8,9. Retroperitonial mass, retrocaval
ureter
10. Calculus in UVJ
11. Uretrocele
12. Bladder mass
Bladder outlet obstruction
15. BPH, ca prostate
16. Posterior urethral valve
17. Urethral stricture
Site of obstruction & causes
2. Renal pelvic calculus
3. Benign polyp or transitional cell
carcinoma of pelvis
4. RCC causing extrinsic obstruction
5. PUJ obstruction
6. Ureteral calculus, clot, polyp, etc.
7. Uretral valve
8,9. Retroperitonial mass, retrocaval
ureter
10. Calculus in UVJ
11. Uretrocele
12. Bladder mass
Bladder outlet obstruction
15. BPH, ca prostate
16. Posterior urethral valve
17. Urethral stricture
Site of obstruction & causes
In high grade obstruction, it may take hours for enough
contrast to ooze into collecting system to be recognized
against the backdrop of obstructive nephrogram
Ideally there should be one film taken after opacification of
collecting system when the ureter has ‘standing column’ of
radio-opaque urine down to the point of obstruction for
which ‘rule of eight’ is useful
For kidneys with intrarenal pelvis the
level of obstruction doesn’t have much
to do with amount of pyelocaliectasis as
once thought. (Most PUJ obstruction is associated with
extrarenal pelvis which are considerably more distensible. This gave
the false idea that high obstruction caused more ectasia.)
Contrast medium has a high specific gravity causing it to
layer down in the dependent portions of static urinary
system. (By taking radiographs with the patients prone or erect,
gravity is enlisted to hasten the contrast material down the ureter to the
point of obstruction)
contrast to ooze into collecting system to be recognized
against the backdrop of obstructive nephrogram
Ideally there should be one film taken after opacification of
collecting system when the ureter has ‘standing column’ of
radio-opaque urine down to the point of obstruction for
which ‘rule of eight’ is useful
For kidneys with intrarenal pelvis the
level of obstruction doesn’t have much
to do with amount of pyelocaliectasis as
once thought. (Most PUJ obstruction is associated with
extrarenal pelvis which are considerably more distensible. This gave
the false idea that high obstruction caused more ectasia.)
Contrast medium has a high specific gravity causing it to
layer down in the dependent portions of static urinary
system. (By taking radiographs with the patients prone or erect,
gravity is enlisted to hasten the contrast material down the ureter to the
point of obstruction)
‘standing column’
In acute obstruction
Modest kidney enlargement
Increasingly dense
“obstructive” nephrogram
(except in infections & pre-
existing diseases)
Delayed calyceal opacification
Minimal to modest dilatation
of the collecting system
Spontaneous pyelosinus
extravasation
Contrast in liver/bowel in
delayed films
In chronic obstruction
Kidney size is large in (partial
obstruction), small in (complete
obstruction)
Normal or decreased
nephrogram density
Reduced parenchymal
thickness (crescents, rim, soap-
bubbles)
“Negative” pyelogram in
nephrogenic phase, “ball”
pyelogram
Dilated and tortuous ureter,
longitudinal striations
Modest kidney enlargement
Increasingly dense
“obstructive” nephrogram
(except in infections & pre-
existing diseases)
Delayed calyceal opacification
Minimal to modest dilatation
of the collecting system
Spontaneous pyelosinus
extravasation
Contrast in liver/bowel in
delayed films
In chronic obstruction
Kidney size is large in (partial
obstruction), small in (complete
obstruction)
Normal or decreased
nephrogram density
Reduced parenchymal
thickness (crescents, rim, soap-
bubbles)
“Negative” pyelogram in
nephrogenic phase, “ball”
pyelogram
Dilated and tortuous ureter,
longitudinal striations
Negative pyelogram is
usually seen in nephrogram
phase of acute-superimposed-
on-chronic obstruction
Crescents
usually seen in nephrogram
phase of acute-superimposed-
on-chronic obstruction
Crescents
Urographic signs in chronic obstruction
a.Calyceal crescents:
opacified collecting tubules
rearranged about the periphery
of dilated calyces
b.Dilated papillary (Bellini’s)
duct seen end-on
c.Ball pyelogram: opaque
contrast material settles in
dependent portion of the
dilated calyces
d.Lacunae: communicating urinomas in renal sinus thought to result from
epithelialized tears of calyceal fornices
e.“Soap bubble” nephrogram: what remains of the nephrogram of a
chronically and severely obstructed kidney (“rim” or “shell”
nephrogram)
a.Calyceal crescents:
opacified collecting tubules
rearranged about the periphery
of dilated calyces
b.Dilated papillary (Bellini’s)
duct seen end-on
c.Ball pyelogram: opaque
contrast material settles in
dependent portion of the
dilated calyces
d.Lacunae: communicating urinomas in renal sinus thought to result from
epithelialized tears of calyceal fornices
e.“Soap bubble” nephrogram: what remains of the nephrogram of a
chronically and severely obstructed kidney (“rim” or “shell”
nephrogram)
A.Grade 1: no
hydronephrosis
B.Grade 2: obvious blunting
of fornices and
enlargement of calyces
but the intruding papillary
shadows though flattened
are still visible (mild)
C.Grade 3: rounding of
calyces with obliteration
of papillae (moderate)
D.Grade 4: extreme
calyceal ballooning
(severe)
Grading of Hydronephrosis
hydronephrosis
B.Grade 2: obvious blunting
of fornices and
enlargement of calyces
but the intruding papillary
shadows though flattened
are still visible (mild)
C.Grade 3: rounding of
calyces with obliteration
of papillae (moderate)
D.Grade 4: extreme
calyceal ballooning
(severe)
Grading of Hydronephrosis
Postobstructive atrophy
Relief of a total but short-lived obstruction leads to full
restoration of GFR (if there is no infection or pre-existing
diseases)
Longer periods of total obstruction cause progressive
nephron, loss and cortical and medullary atrophy
There is variable caliceal blunting and parenchymal
thinning
The calices, pelvis, and ureter remain unusually
distensible when abdominal compression is applied
Concentration of contrast medium is impaired
An atypical form of atrophy is the kidney shrinks
dramatically in weeks after relief of obstruction, but the
papillae and calices resume their normal shape and size.
The renal contour remains smooth. (The pattern suggests
predominantly ischaemic damage)
Relief of a total but short-lived obstruction leads to full
restoration of GFR (if there is no infection or pre-existing
diseases)
Longer periods of total obstruction cause progressive
nephron, loss and cortical and medullary atrophy
There is variable caliceal blunting and parenchymal
thinning
The calices, pelvis, and ureter remain unusually
distensible when abdominal compression is applied
Concentration of contrast medium is impaired
An atypical form of atrophy is the kidney shrinks
dramatically in weeks after relief of obstruction, but the
papillae and calices resume their normal shape and size.
The renal contour remains smooth. (The pattern suggests
predominantly ischaemic damage)
A.Normal
B.Mild: Slight blunting of calyceal fornices and
decrease in parenchymal thickness
C.Moderate: Pyelocalyectasis with parenchynal wasting
D.Severe: Marked parenchymal wasting and useful
function is doubtful
E.Atypical: calyces appear normal, but kidney is small
and parenchyma thinned
B.Mild: Slight blunting of calyceal fornices and
decrease in parenchymal thickness
C.Moderate: Pyelocalyectasis with parenchynal wasting
D.Severe: Marked parenchymal wasting and useful
function is doubtful
E.Atypical: calyces appear normal, but kidney is small
and parenchyma thinned
Renal anomalies
In general ,renal anomalies have a left-side preponderance
Anomalies of rotation:
The metanephros has its origin in the fetal pelvis and, in this site,
has its renal pelvis oriented anteriorly
As the kidney ascends, the renal pelvis and hilum normally rotates
90 degrees medially
• Rarely they may be over-rotated (D)
or reverse rotated (A)
• Occasionally the appearance of
malrotated kidney may be mistaken for a
more significant renal abnormality, such
as the presence of medially located mass
•Those that fail to ascend completely
maintain some degree of anterior
orientation
In general ,renal anomalies have a left-side preponderance
Anomalies of rotation:
The metanephros has its origin in the fetal pelvis and, in this site,
has its renal pelvis oriented anteriorly
As the kidney ascends, the renal pelvis and hilum normally rotates
90 degrees medially
• Rarely they may be over-rotated (D)
or reverse rotated (A)
• Occasionally the appearance of
malrotated kidney may be mistaken for a
more significant renal abnormality, such
as the presence of medially located mass
•Those that fail to ascend completely
maintain some degree of anterior
orientation
Anomalies of position (ectopy) & Fusion anomalies
Often associated with anomalies of other organ systems (spinal
anomalies, cardiac anomalies, limb anomalies, & anomalies of the GIT)
Embryology of adrenals is independent of the kidney & it will
be in its expected position
Ipsilateral Renal Ectopia (simple uncrossed renal ectopia)
Inferior Ectopia (Pelvic Kidney)[1:500-1:1200 births]:
Mainly an anomaly of ascent (often associated with variations in
rotation of the pelvicalyceal system and persistence of a more primitive
vascular supply)
• There is increased incidence of trauma, VUR
(in the pelvic and contralateral kidney)
• They can be in lower abdominal, pelvic, or
sacral region
Often associated with anomalies of other organ systems (spinal
anomalies, cardiac anomalies, limb anomalies, & anomalies of the GIT)
Embryology of adrenals is independent of the kidney & it will
be in its expected position
Ipsilateral Renal Ectopia (simple uncrossed renal ectopia)
Inferior Ectopia (Pelvic Kidney)[1:500-1:1200 births]:
Mainly an anomaly of ascent (often associated with variations in
rotation of the pelvicalyceal system and persistence of a more primitive
vascular supply)
• There is increased incidence of trauma, VUR
(in the pelvic and contralateral kidney)
• They can be in lower abdominal, pelvic, or
sacral region
Superior Ectopia (Thoracic Kidney) [1:15,000births]:
The kidney may continue the ascent to enter the thorax (in
the posterior mediastinum which non chest radiography may mimic
neurogenic tumors )
It may be an isolated lesion, but is more often a part of a
larger intra thoracic herniation of subdiaphragmatic
structures through the foramen of Bochdalek (and hence
more frequently left sided)
The kidney may continue the ascent to enter the thorax (in
the posterior mediastinum which non chest radiography may mimic
neurogenic tumors )
It may be an isolated lesion, but is more often a part of a
larger intra thoracic herniation of subdiaphragmatic
structures through the foramen of Bochdalek (and hence
more frequently left sided)
Crossed Renal Ectopia [1:1000 births]
Bulk of both kidney is present on one side of the
spine (a portion of lower kidney, the one that has usually
moved from its normal position, may extend into the spine)
Boys are more often affected
• Approximately 90% of these
kidneys will be fused
• The ureter of the lower kidney
usually crosses the midline to
insert into the bladder in its
normal position
• As expected, there is
malrotation and anomalous
vascularity of the lower kidney
Bulk of both kidney is present on one side of the
spine (a portion of lower kidney, the one that has usually
moved from its normal position, may extend into the spine)
Boys are more often affected
• Approximately 90% of these
kidneys will be fused
• The ureter of the lower kidney
usually crosses the midline to
insert into the bladder in its
normal position
• As expected, there is
malrotation and anomalous
vascularity of the lower kidney
Horseshoe Kidney [1:400 births]
Associated with trisomy 18, imperforate anus, Turner’s
syn.
The bridging tissue (isthmus) is commonly composed
of functioning parenchyma, or less commonly, fibrous
tissue
Increased incidence of ureteral duplication, PUJ
obstruction, VUR, and traumatic injury
There is reversed renal axis, ectopy, and malrotation
Associated with trisomy 18, imperforate anus, Turner’s
syn.
The bridging tissue (isthmus) is commonly composed
of functioning parenchyma, or less commonly, fibrous
tissue
Increased incidence of ureteral duplication, PUJ
obstruction, VUR, and traumatic injury
There is reversed renal axis, ectopy, and malrotation
Inferior mesenteric artery
always runs in front of
isthmus. Isthmus is usually
anterior to aorta and IVC
If the isthmus is less than one-
third of kidney then the pelvis
is anterior and medial. If more
than one-third it is anterior and
lateral
The lower calyces of both
kidneys are directed towards
the isthmus (“hand-holding”
calyces)
If the lower calyces are medial
to ureter, horse-shoe kidney is
suspected
always runs in front of
isthmus. Isthmus is usually
anterior to aorta and IVC
If the isthmus is less than one-
third of kidney then the pelvis
is anterior and medial. If more
than one-third it is anterior and
lateral
The lower calyces of both
kidneys are directed towards
the isthmus (“hand-holding”
calyces)
If the lower calyces are medial
to ureter, horse-shoe kidney is
suspected
As ureter crosses the
isthmus, it curves laterally.
It continues medially and
assumes a more normal
course after crossing the
isthmus. This unusual
configuration of ureter
gives the “flower-vase”
appearance
PUJ obstruction
isthmus, it curves laterally.
It continues medially and
assumes a more normal
course after crossing the
isthmus. This unusual
configuration of ureter
gives the “flower-vase”
appearance
PUJ obstruction
Renal agenesis [1:1000 births]
Thought to be due to failure of formation of ureteral bud or
because of an inherent deficiency of metanephric
blastema
Compensatory hypertrophy of contralateral kidney
Associated with genital abnormalities suggesting an
etiology that also affects the mesonephric duct. (In males
associated with seminal vesicle cyst, absence of vas, hypoplasia or
agenesis of testis, and hypospadiasis. In females associated with a
unicornuate or bicornuate uterus, Rokitansky-Meyer-Hauser
syndrome)
Bilateral renal agenesis is extremely rare and
incompatible with life. (more common in males, associated with
Potter’s facies)
Renal hypoplasia
50% or more smaller than normal, contains fewer calyces.
Should be differentiated from more common acquired
causes of small kidney (chronic ischemia, reflux, long standing
obstruction)
Thought to be due to failure of formation of ureteral bud or
because of an inherent deficiency of metanephric
blastema
Compensatory hypertrophy of contralateral kidney
Associated with genital abnormalities suggesting an
etiology that also affects the mesonephric duct. (In males
associated with seminal vesicle cyst, absence of vas, hypoplasia or
agenesis of testis, and hypospadiasis. In females associated with a
unicornuate or bicornuate uterus, Rokitansky-Meyer-Hauser
syndrome)
Bilateral renal agenesis is extremely rare and
incompatible with life. (more common in males, associated with
Potter’s facies)
Renal hypoplasia
50% or more smaller than normal, contains fewer calyces.
Should be differentiated from more common acquired
causes of small kidney (chronic ischemia, reflux, long standing
obstruction)
Hypoplasia and dysplasia (with ectopic ureteral insertion)
The abnormal origin from the wolfian duct produces an
abnormal relationship between ureter and mesonephric
blastema (The ureter does not reach the greatest
concentration of blastema, and the kidney thus is induced
both hypo- and dysplastic)
More common in girls, associated with ureteral atresia,
distal uretal obstruction (simple uretrocele) or ectopic uretral
insertion (most commonly in vagina)
Multicystic dysplastic kidney
It is a nonheritable disorder and is associated with
obstruction of urinary drainage on the affected side
Multicystic dysplastic kidney has no discernable renal
parenchyma and has centrally located cysts that may
simulate a dilated pelvis
The affected has negligible or no renal function
The abnormal origin from the wolfian duct produces an
abnormal relationship between ureter and mesonephric
blastema (The ureter does not reach the greatest
concentration of blastema, and the kidney thus is induced
both hypo- and dysplastic)
More common in girls, associated with ureteral atresia,
distal uretal obstruction (simple uretrocele) or ectopic uretral
insertion (most commonly in vagina)
Multicystic dysplastic kidney
It is a nonheritable disorder and is associated with
obstruction of urinary drainage on the affected side
Multicystic dysplastic kidney has no discernable renal
parenchyma and has centrally located cysts that may
simulate a dilated pelvis
The affected has negligible or no renal function
Supernumerary kidney
(extremely rare)
Cleavage of metanephric
blastema has been
suggested
Most supernumerary
kidneys are caudally placed
and are hypoplastic
May be connected to
ipsilateral, dominant kidney
(a separate collecting
system is generally found)
(extremely rare)
Cleavage of metanephric
blastema has been
suggested
Most supernumerary
kidneys are caudally placed
and are hypoplastic
May be connected to
ipsilateral, dominant kidney
(a separate collecting
system is generally found)
Anomalies in course
Circumcaval ureter: (1:1100)
Persistence of right subcardinal
veins traps the ureter behind IVC
More common in boys
The right ureter, in its course to
bladder, passes behind the IVC,
emerges between the cava and
the aorta, and then curves in front
of the cava to return to its normal
position in the pelvis
“Reversed J” appearance in EU
Compression by IVC, a kink, local
adhesions, an intrinsic stricture,
adynamic segment may cause
obstruction
Retroiliac ureter: (rare)
•The affected ureter courses
behind one or both iliac
vessels (rather than in front of
them)
Circumcaval ureter: (1:1100)
Persistence of right subcardinal
veins traps the ureter behind IVC
More common in boys
The right ureter, in its course to
bladder, passes behind the IVC,
emerges between the cava and
the aorta, and then curves in front
of the cava to return to its normal
position in the pelvis
“Reversed J” appearance in EU
Compression by IVC, a kink, local
adhesions, an intrinsic stricture,
adynamic segment may cause
obstruction
Retroiliac ureter: (rare)
•The affected ureter courses
behind one or both iliac
vessels (rather than in front of
them)
Autopsy incidence of partial duplication is 1 in 150 cases, while
complete duplication is found approximately once in every 500
cases
Complete duplications are bilateral in up to 20%
Relevant embryology
The ureter forms as a bud from mesonephric bud. (Normal kidney is
formed when this bud invaginates the metanephric blastema and, through
multiple branchings, forms the collecting system)
Partial duplication results from the branching of the uretral bud
before it connects with metanephric blastema (The bifurcation may
occur anywhere from the bladder wall to pelvis; the later result in bifid renal
pelvis)
When a bifurcated branch fail to reach the kidney, it becomes a
blind-ending stump connected to the functional ureter. This
branch referred to as a uretral diverticulum
complete duplication is found approximately once in every 500
cases
Complete duplications are bilateral in up to 20%
Relevant embryology
The ureter forms as a bud from mesonephric bud. (Normal kidney is
formed when this bud invaginates the metanephric blastema and, through
multiple branchings, forms the collecting system)
Partial duplication results from the branching of the uretral bud
before it connects with metanephric blastema (The bifurcation may
occur anywhere from the bladder wall to pelvis; the later result in bifid renal
pelvis)
When a bifurcated branch fail to reach the kidney, it becomes a
blind-ending stump connected to the functional ureter. This
branch referred to as a uretral diverticulum
NormalPartial
duplicatio
n
Complete
duplication
duplicatio
n
Complete
duplication
Complete duplication occurs when two separate buds arise
from the mesonephric duct and invaginate the metanephric
blastema separately (resulting in formation of separate upper
and lower moiety)
Typically, the upper moiety is smaller of the two, containing
only 2 or 3 calices on average
•The Meyer-Wiegert
law states that the ureter
from the upper moiety
will enter the bladder
inferiorly and medially
(ectopic) in relation to
the ureter draining the
upper moiety
(orthotopic)
from the mesonephric duct and invaginate the metanephric
blastema separately (resulting in formation of separate upper
and lower moiety)
Typically, the upper moiety is smaller of the two, containing
only 2 or 3 calices on average
•The Meyer-Wiegert
law states that the ureter
from the upper moiety
will enter the bladder
inferiorly and medially
(ectopic) in relation to
the ureter draining the
upper moiety
(orthotopic)
In uncomplicated complete duplications, the two orifices enter the
bladder adjacent to each other in a relatively normal position
Four distinct abnormalities of the termination of the ureters in
complete duplication can lead to significant pathological
changes in the duplicated kidney
a)Stenosis of orifice of the upper pole ureter (resulting in
hydronephrosis of the upper collecting system)
b)Maldevelopment of valve mechanism at the ureterovesical
junction of the lower pole ureter (resulting in reflux)
c)Ectopic insertion of the upper pole ureter outside the bladder;
and
d)Ectopic uretrocele also involving the ureter draining the
upper moiety
bladder adjacent to each other in a relatively normal position
Four distinct abnormalities of the termination of the ureters in
complete duplication can lead to significant pathological
changes in the duplicated kidney
a)Stenosis of orifice of the upper pole ureter (resulting in
hydronephrosis of the upper collecting system)
b)Maldevelopment of valve mechanism at the ureterovesical
junction of the lower pole ureter (resulting in reflux)
c)Ectopic insertion of the upper pole ureter outside the bladder;
and
d)Ectopic uretrocele also involving the ureter draining the
upper moiety
PUJ obstruction and congenital megaureter
Both conditions are caused by deficiency and derangement of the
ureteric smooth muscle fibres with associated fibrosis, resulting in
a failure of normal peristalsis in the affected segment and
subsequent functional obstruction
PUJ obstruction: [3:1000 births]
More often in boys, more often on the right side, bilateral in 10%
of the cases, associated with duplication and inferior ectopia
PUJ is the most common cause of abdominal mass in a neonate
In EU there is delayed opacification and delayed excretion,
caliectasis and caliceal crescents
Delayed films are necessary to visualize renal pelvis; prone films
are most useful because they move contrast from calices to the
anteriorly located pelvis. ( Prone film also promote filling of ureter, allowing
differentiation of a PUJ obstruction from a UVJ obstruction)
Both conditions are caused by deficiency and derangement of the
ureteric smooth muscle fibres with associated fibrosis, resulting in
a failure of normal peristalsis in the affected segment and
subsequent functional obstruction
PUJ obstruction: [3:1000 births]
More often in boys, more often on the right side, bilateral in 10%
of the cases, associated with duplication and inferior ectopia
PUJ is the most common cause of abdominal mass in a neonate
In EU there is delayed opacification and delayed excretion,
caliectasis and caliceal crescents
Delayed films are necessary to visualize renal pelvis; prone films
are most useful because they move contrast from calices to the
anteriorly located pelvis. ( Prone film also promote filling of ureter, allowing
differentiation of a PUJ obstruction from a UVJ obstruction)
More common in males , is frequently bilateral (especially in
children <1 year), and is often left sided when unilateral
The dilatation is often limited to, or is most marked in the
lower half of the ureter
The ureter is usually straight or only mildly tortuous, in
contrast to megaureters resulting from reflux, lower
urinary tract obstruction, or prune-belly syndrome in which
ureters tend to be elongated and tortuous
Other organic causes of megaureter are uretrocele,
acquired distal uretal obstruction (calculus, clot), stricture
Retrograde urography is more informative than excretory
urography
children <1 year), and is often left sided when unilateral
The dilatation is often limited to, or is most marked in the
lower half of the ureter
The ureter is usually straight or only mildly tortuous, in
contrast to megaureters resulting from reflux, lower
urinary tract obstruction, or prune-belly syndrome in which
ureters tend to be elongated and tortuous
Other organic causes of megaureter are uretrocele,
acquired distal uretal obstruction (calculus, clot), stricture
Retrograde urography is more informative than excretory
urography
An ectopic ureter is defined as a ureter that does not
terminate in the normal location on the trigone of the
bladder
More common in females (6:1)
More than two-thirds of all extravesical ectopic ureteral
insertions are associated with complete duplication,
typically resulting in obstruction and possible dysplasia
of the upper moiety
Generally speaking, the more distal the ectopic orifice,
the more dysplastic the upper moiety it drains will be
Remnants of the embryonic mesonephric mesonephric
duct can be found in the walls of the vagina, uterus, and
broad ligaments in approximately one-fourth of all adult
females. (These vestigial structures explain the ectopic insertion in
these organs)
terminate in the normal location on the trigone of the
bladder
More common in females (6:1)
More than two-thirds of all extravesical ectopic ureteral
insertions are associated with complete duplication,
typically resulting in obstruction and possible dysplasia
of the upper moiety
Generally speaking, the more distal the ectopic orifice,
the more dysplastic the upper moiety it drains will be
Remnants of the embryonic mesonephric mesonephric
duct can be found in the walls of the vagina, uterus, and
broad ligaments in approximately one-fourth of all adult
females. (These vestigial structures explain the ectopic insertion in
these organs)
Ectopic uretrocele
Extravesical insertion
•fm
•More commonly associated
with complete duplication
•Ectopic ureters are commonly
beyond sphincter control
•Typically present with
continual dribbling of urine
•m
•Majority of ectopic ureters
drain single system
•All ectopic orifices occur above
external ureteral sphincter.
•Typically present with chronic,
recurrent epididymitis
•fm
•More commonly associated
with complete duplication
•Ectopic ureters are commonly
beyond sphincter control
•Typically present with
continual dribbling of urine
•m
•Majority of ectopic ureters
drain single system
•All ectopic orifices occur above
external ureteral sphincter.
•Typically present with chronic,
recurrent epididymitis
Ureterocele:
It is a globular expansion of terminal segment of the submucosal
portion of ureter projecting into the lumen of the bladder
Intravesical ureterocele (located entirely within bladder)
Stenotic, orthotopic, simple, or adult-type ureterocele
More common in females
Embryologically, it may be due to persistence of Chwalla’s
membrane
• Often an incidental,
asymptomatic finding
• In EU the contrast
outlines a cystic mass
surrounded by a radiolucent
halo which represents the
bladder mucosa (cobra head)
It is a globular expansion of terminal segment of the submucosal
portion of ureter projecting into the lumen of the bladder
Intravesical ureterocele (located entirely within bladder)
Stenotic, orthotopic, simple, or adult-type ureterocele
More common in females
Embryologically, it may be due to persistence of Chwalla’s
membrane
• Often an incidental,
asymptomatic finding
• In EU the contrast
outlines a cystic mass
surrounded by a radiolucent
halo which represents the
bladder mucosa (cobra head)
Edling’s sign
Ectopic ureterocele
Most common cause of bladder outlet obstruction in girls
90% present under 3 years, 90% unilateral, more frequent
in boys
Most often in upper moiety of a duplicated system
Ectopic uretrocele has a broad base and tends to be larger
than simple intravesical type, and characteristically is
located more inferiorly in the bladder and extend into
bladder neck area
May obstruct the bladder neck or the opposite ureteral
orifice, may deform musculature in adjacent ureter so that
reflux into the lower pole ureter occurs (up to 50%)
Ureter connected to uretrocele is often dilated and tortuous
The EU shows no function of renal parenchyma drained by
uretrocele-bearing ureter in 90% of the cases. The affected
ureter is seldom visualized and the visualized pelvocaliceal
is displaced downwards and laterally (The EU in patients with
ectopic uretrocele in a single unduplicated ureter usually shows no
function on the side of the lesion)
Most common cause of bladder outlet obstruction in girls
90% present under 3 years, 90% unilateral, more frequent
in boys
Most often in upper moiety of a duplicated system
Ectopic uretrocele has a broad base and tends to be larger
than simple intravesical type, and characteristically is
located more inferiorly in the bladder and extend into
bladder neck area
May obstruct the bladder neck or the opposite ureteral
orifice, may deform musculature in adjacent ureter so that
reflux into the lower pole ureter occurs (up to 50%)
Ureter connected to uretrocele is often dilated and tortuous
The EU shows no function of renal parenchyma drained by
uretrocele-bearing ureter in 90% of the cases. The affected
ureter is seldom visualized and the visualized pelvocaliceal
is displaced downwards and laterally (The EU in patients with
ectopic uretrocele in a single unduplicated ureter usually shows no
function on the side of the lesion)
A.Approximately one half of ectopic uretroceles terminate
in the bladder
B.The remainder extend through the bladder neck and
terminate in the proximal urethra
in the bladder
B.The remainder extend through the bladder neck and
terminate in the proximal urethra
Bladder extrophy
[1:50,000]
It is the result of a
deficiency in development
of the lower abdominal
wall musculature, so that
the bladder is open and
the bladder mucosa is
continuous with the skin
and urethra opens dorsally
More common in males
Skeletal and GIT
anomalies
In most cases upper
urinary tract is normal, but
there may be widening of
the distal ureter (“Hurley
stick” deformity)
[1:50,000]
It is the result of a
deficiency in development
of the lower abdominal
wall musculature, so that
the bladder is open and
the bladder mucosa is
continuous with the skin
and urethra opens dorsally
More common in males
Skeletal and GIT
anomalies
In most cases upper
urinary tract is normal, but
there may be widening of
the distal ureter (“Hurley
stick” deformity)
Differential DiagnosisDifferential Diagnosis
(An Incomplete List)(An Incomplete List)
(An Incomplete List)(An Incomplete List)
1.Polycystic kidney disease
2.Bilateral duplex collecting
system
3.Bilateral obstruction
4.Acute glomerulonephritis
5.Nephrotic syndrome
6.Diabetes
7.Amyloidosis
8.Leukemia (in children)
BPH
Leukemia
2.Bilateral duplex collecting
system
3.Bilateral obstruction
4.Acute glomerulonephritis
5.Nephrotic syndrome
6.Diabetes
7.Amyloidosis
8.Leukemia (in children)
BPH
Leukemia
1.Obstruction of any kind,
including PUJ obstruction
2.Partial or complete
duplication of collecting
system
3.Neoplasm or cyst
4.Renal vein thrombosis
5.Compensatory hypertrophy
6.Multicystic dysplastic kidney
7.Pyonephrosis
8.Normal variant
PUJ obstruction
including PUJ obstruction
2.Partial or complete
duplication of collecting
system
3.Neoplasm or cyst
4.Renal vein thrombosis
5.Compensatory hypertrophy
6.Multicystic dysplastic kidney
7.Pyonephrosis
8.Normal variant
PUJ obstruction
1.Neoplasm or cyst
2.Acute lobar
pyelonephritis
3.Abscess
4.Enlarged septum of
Bertin
5.Dromedary hump
6.Renal hematoma
(often posttraumatic)
7.Renal lobe supplied by
aberrant renal artery
Renal lobe supplied by
aberrant renal artery
2.Acute lobar
pyelonephritis
3.Abscess
4.Enlarged septum of
Bertin
5.Dromedary hump
6.Renal hematoma
(often posttraumatic)
7.Renal lobe supplied by
aberrant renal artery
Renal lobe supplied by
aberrant renal artery
1.Chronic glomerulonephritis
2.Vascular atrophy (usually
atherosclerosis)
3.Long standing hypertension
4.Chronic reflux pyelonephritis
5.Papillary necrosis (late)
1.Vascular ischaemia
2.Postobstructive atrophy
3.Segmental renal infarct
4.Chronic reflux
pyelonephritis with
relative sparring of the
opposite kidney
2.Vascular atrophy (usually
atherosclerosis)
3.Long standing hypertension
4.Chronic reflux pyelonephritis
5.Papillary necrosis (late)
1.Vascular ischaemia
2.Postobstructive atrophy
3.Segmental renal infarct
4.Chronic reflux
pyelonephritis with
relative sparring of the
opposite kidney
1.Chronic reflux
pyelonephritis
2.Postobstructive atrophy
3.Fetal lobation
4.Segmental renal infarct
5.Trauma
6.Extrinsic compression
7.Postsurgical change
8.TB
TB
pyelonephritis
2.Postobstructive atrophy
3.Fetal lobation
4.Segmental renal infarct
5.Trauma
6.Extrinsic compression
7.Postsurgical change
8.TB
TB
1. Obstructive nephrogram
(increasingly dense)
2. Hypotensive nephrogram
3. Renal vein thrombosis
4. Acute tubular necrosis
(immediate, dense,
persistent)
Increased/persistent nephrogram:
(increasingly dense)
2. Hypotensive nephrogram
3. Renal vein thrombosis
4. Acute tubular necrosis
(immediate, dense,
persistent)
Increased/persistent nephrogram:
Decreased nephrogram:
1. Chronic renal failure
2. Renal artery occlusion
3. Renal transplant
rejection
4. Renal infection
5. Long-standing
obstruction
6. Hypotension
7. Contrast material
reaction
8. Inadequate contrast
9. Spurious
PUJ obstruction
CRF
1. Chronic renal failure
2. Renal artery occlusion
3. Renal transplant
rejection
4. Renal infection
5. Long-standing
obstruction
6. Hypotension
7. Contrast material
reaction
8. Inadequate contrast
9. Spurious
PUJ obstruction
CRF
1.Cyst
2.Neoplasm
3.Abscess
4.Hydrocalyx or
hydronephrosis
5.Intrarenal hematoma
6.Polycystic kidney disease
7.Xanthogranulomatous
pyelonephritis
Simple serous cyst
2.Neoplasm
3.Abscess
4.Hydrocalyx or
hydronephrosis
5.Intrarenal hematoma
6.Polycystic kidney disease
7.Xanthogranulomatous
pyelonephritis
Simple serous cyst
1.Pelvic kidney
2.Acute obstruction
3.Chronic obstruction,
including PUJ obstruction
4.Crossed renal ectopia
5.Multicystic dysplatic
kidney
6.Surgical removal
7.Trauma
8.Advanced ischaemic
atrophy
9.Renal arterial thrombosis
Renal agenesis
2.Acute obstruction
3.Chronic obstruction,
including PUJ obstruction
4.Crossed renal ectopia
5.Multicystic dysplatic
kidney
6.Surgical removal
7.Trauma
8.Advanced ischaemic
atrophy
9.Renal arterial thrombosis
Renal agenesis
1.Vascular markings
2.Calculi
3.Papillae seen face-on
4.Blood clots
5.Air bubbles (due to
intervention and
fistulae)
6.Neoplasm
7.Parapelvic cyst
Pyelouretritis cystica
2.Calculi
3.Papillae seen face-on
4.Blood clots
5.Air bubbles (due to
intervention and
fistulae)
6.Neoplasm
7.Parapelvic cyst
Pyelouretritis cystica
1.Lack of ureteral
compression
2.Ineffective
compression
3.Renal sinus
lipomatosis
4.Parapelvic cyst
5.Neoplasm
6.Extrarenal pelvis
7.Renal TB
TCC of the infundibulum
compression
2.Ineffective
compression
3.Renal sinus
lipomatosis
4.Parapelvic cyst
5.Neoplasm
6.Extrarenal pelvis
7.Renal TB
TCC of the infundibulum
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