ULTRASOUND IN UROLOGY

ULTRASOUND IN UROLOGY

1. Dept of Urology
Govt Royapettah Hospital and Kilpauak Medical College
Chennai

2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. INTRODUCTION
 urologist’s stethoscope
An ultrasound exam (or "sonogram") is a painless diagnostic technique
A Mode = Amplitude
B Mode = Brightness
C Mode = Color Doppler
3 Dept of Urology, GRH and KMC, Chennai.

4. History
•In 1963, Takahashi and Ouchi became the first
to attempt ultrasonic examination of the
prostate.

•In (1974), Watanabe and colleagues, Magician’s
Chair,”
•In 1971 Goldberg and Pollack, A-mode
ultrasonography –nephrosonography

•In 1974 Holm and Northeved introduced a
transurethral ultrasonic device

•in 1976 Perri and colleagues were the first to use
Doppler as a sonic “stethoscope” in their work-
up of patients with an acute scrotum



4 Dept of Urology, GRH and KMC, Chennai.

5. Diagnostic

Imaging
0 20 Hz 20 kHz 1 MHz 30 MHz
Infrared Audible
Sound Sound
Sound Spectra
5 Dept of Urology, GRH and KMC, Chennai.

6. Ultrasound Principle
Pulse – echo principle
US beam produced from transducer
Travels through tissue
Reflected from surface
Perceived by transducer
Generates electric voltage according to the strength of returning
echo
Plotted as image
6 Dept of Urology, GRH and KMC, Chennai.

7. ‘piezo’ means pressure
 Piezoelectric means pressure electricity
Pressure generated when electric field is applied
Pressure converted to sound waves
Piezoelectric crystal
Piezoelectric Ceramics (man-made materials)
Barium Titanate (BaTiO
3)
Lead Titanate Zirconate (PbZrTiO
3) = PZT, most widely used

7 Dept of Urology, GRH and KMC, Chennai.

8. MODES OF ULTRASONOGRAPHY

Gray-Scale Ultrasonography: most commonly employed,pulsed-wave technique
produces real-time two-dimensional images consisting of shades of gray
Doppler Ultrasonography:depends on the physical principle of frequency
shift when sound waves strike a moving object.
Harmonic Scanning:asymmetrically propagated waves generate fewer harmonics
having larger amplititude
Spatial Compounding:mode whereby the direction of insonation is electronically
altered,there by increasing resolution
Sonoelastography:ability to evaluate the elasticity (compressibility and
displacement) of biologic tissues.
Three-Dimensional Scanning
8 Dept of Urology, GRH and KMC, Chennai.

9. DOCUMENTATION AND IMAGE STORAGE
Essential for insuring high-quality patient care

Include report and acquired images

1.Report:include specific information eg. patient identification details, date
of the examination,measurement parameters and a description of findings
of the examination

2. Acquired images:include patient identification details, the date and
time of each image, and clear image orientation & measurements
9 Dept of Urology, GRH and KMC, Chennai.

10. Probes
Curvilinear or Abdomen
Linear or
Vascular
Phased Array or Cardiac
10 Dept of Urology, GRH and KMC, Chennai.

11. Imaging Planes


Transverse or Axial


Longitudinal or Saggital


Coronal

11 Dept of Urology, GRH and KMC, Chennai.

12. 12 Dept of Urology, GRH and KMC, Chennai.

13. Sections
Sagittal section Transverse section
13 Dept of Urology, GRH and KMC, Chennai.

14. Renal outline - apparent
because the capsule differs in
echogenicity from surrounding
fat.
The cortex - slightly
hypoechoic compared to liver
Young people - similar
echogenicity
Elderly - comparatively
hyperechoic and thin.

KIDNEY
14 Dept of Urology, GRH and KMC, Chennai.

15. Medullary pyramids
Regularly spaced
Echo-poor triangular
structures
Between the cortex
and the renal sinus
15 Dept of Urology, GRH and KMC, Chennai.

16. RENAL SINUS
Hyperechoic due to sinus fat which
surrounds the vessels.
The main artery and vein
demonstrable at the renal hilum
Confused with a mild degree of PCS
dilatation.

16 Dept of Urology, GRH and KMC, Chennai.

17. ADRENAL
Cortex- hypoechoic
Medulla – hyperechoic
R adrenal easily seen
Easily seen in children

17 Dept of Urology, GRH and KMC, Chennai.

18. Normal bladder anatomy
Bladder wall
Symmetrical ,Smooth curved
surface
Surrounded by echogenic line
Urine Lacks echoes
BWT </= 6mm [ 3mm when full
5mm when empty
calculated volumes are within 10%
to 20% of the actual bladder volume
18 Dept of Urology, GRH and KMC, Chennai.

19. Ureter
Ureteric orifices - bladder
base.
Ureteric jets demonstrated
with colour Doppler
Within 10 min of observation

19 Dept of Urology, GRH and KMC, Chennai.

20. Prostate

Measurement is made from the bladder neck to the apex of the prostate.

20 Dept of Urology, GRH and KMC, Chennai.

21. TESTIS
Imaging of choice
High freq probe[10 MHz]
Colour doppler for vascular flow
Testis
Granular , 4x3 cm
Small amt of fluid in TV sac
Epididymis – hyper/isoechoic


21 Dept of Urology, GRH and KMC, Chennai.

22. Technique of renal usg
Curved array transducer of 3.5 to 5.0 mhz.
For intraoperative and laparoscopic renal ultrasonography, a linear array
transducer of 6 to 10 mhz is typically employed.
 The right kidney
Supine
Beginning in the mid clavicular line in the right upper quadrant,In the
sagittal plane
The mid transverse plane demonstrates the renal hilum containing the renal
vein.
The kidney is scanned from upper pole to lower pole.
22 Dept of Urology, GRH and KMC, Chennai.

23. Left kidney
Identical to RT kidney
lateral position
Bowel gas is more problematic on the left because of the position of the
splenic flexure of the colon.
left kidney is slightly more cephalad than the right kidney.


23 Dept of Urology, GRH and KMC, Chennai.

24. Approach to Scanning
Right kidney scanning
approach: anterior,
lateral, posterior
Left kidney: requires a
posterior approach,
I
LIVER STOMACH
IVC
AORTA
K K
S
24 Dept of Urology, GRH and KMC, Chennai.

25. Thickness
•The precise location for making this
measurement is subjective.
•Renal measurements should be obtained in
the midsagittal plane and midtransverse plane.
•Cortex – 1-1.5 cm thick(>7mm)
•Paranchyma 11-18 mm in male , 11-16 mm
female (15mm)
25 Dept of Urology, GRH and KMC, Chennai.

26. Artifact

Acoustical shadowing:significant attenuation or reflection of sound eg.
stone
Increased through-transmission:significant attenuation or reflection
of sound eg.cyst
edging artifact:sound waves strike a curved surface at an incident angle,
resulting in refraction of the wave resulting in a hypoechoic “shadow eg.
TRUS
Reverberation artifact :when there are large differences in impedance
between two adjacent tissues or surfaces eg. Bowel and kideny
26 Dept of Urology, GRH and KMC, Chennai.

27. Application in urology
27 Dept of Urology, GRH and KMC, Chennai.

28. RENAL TRACT CALCIFICATON
Renal tract stones
More sensitive than x ray
High impedence of wave
Distal Acoustic shadowing
Identifies hydronephrosis
Guides renal drainage

28 Dept of Urology, GRH and KMC, Chennai.

29. Staghorn calculi
casts a dense shadow from the PCS
Mistaken for renal sinus echoes
May mask hydronephrosis
May cause pyonephrosis


29 Dept of Urology, GRH and KMC, Chennai.

30. Nephrocalcinosis
Deposition of calcium in the renal
parenchyma.
Symmetric echogenic areas where
renal pyramids lie
Shadow if large calcific foci are
present
30 Dept of Urology, GRH and KMC, Chennai.

31. 31 Dept of Urology, GRH and KMC, Chennai.

32. Hydronephrosis
Anechoic or hypoechoic fluid collection
assumes shape of calyces and renal pelvis(pelvicaliectasis)

32 Dept of Urology, GRH and KMC, Chennai.

33. Moderate & Severe hydronephrosis
33 Dept of Urology, GRH and KMC, Chennai.

34. Dilatation of the pelvicaliceal system
D/d
cortical cyst
parapelvic cyst ,
congenital megacalyx,
megacystic megaureter ( without obstruction )
Dilatation vs cortical cyst
Can resemble multiple renal cysts, but dilated calices, unlike cysts, show
continuity with the renal pelvis
With prolonged obstruction, thinning of the cortex due to atrophy will be seen.
Ultrasound may demonstrate a pelvic mass, such as a uterine or ovarian
mass, causing external compression of the collecting system.
34 Dept of Urology, GRH and KMC, Chennai.

35. Renal Cysts
Arise in the renal cortex, commonly single rather than multiple
Cysts do not communicate; hydronephrosis does
Shape is round or oval
Echo free , increased echoes behind the cyst, because of increased
through transmission of the sound, known as ‘acoustic enhancement’.
solitary or multiple, unilocular or have septations.
Sharp interface between the cyst and renal tissue
Large renal cysts may be mistaken for aortic aneurysms/
hydronephrosis

35 Dept of Urology, GRH and KMC, Chennai.

36. Renal Cysts
36 Dept of Urology, GRH and KMC, Chennai.

37. Complicated cysts
Irregular thick wall , septa
Calcifications
Dense cyst fluid
Solid components
37 Dept of Urology, GRH and KMC, Chennai.

38. Renal parenchymal masses
Most solitary masses arising within the renal parenchyma are either
malignant tumours or simple cysts.
Other causes
renal abscess,
benign tumour (notably oncocytoma or angiomyolipoma),
hydatid cyst and metastasis.
Multiple renal masses include
multiple simple cysts
polycystic disease
malignant lymphoma
metastases
inflammatory masses.

38 Dept of Urology, GRH and KMC, Chennai.

39. Renal Masses
Ultrasound visualizes most solid and cystic renal masses
Appearance
Irregular borders , calcifications.
Poorly defined interfaces between mass and kidney
Complex masses
Cysts or solid masses may represent infection or hemorrhage
May have fluid levels
numerous internal echoes of varying intensity.
extension into the renal vein and inferior vena cava, liver and retroperitoneal
metastases, and examine the opposite kidney.
Angiomyolipomas are a fairly frequent incidental finding, appearing as small
highly echogenic masses.
39 Dept of Urology, GRH and KMC, Chennai.

40. Renal cell carcinoma (RCC)
Large
Shape of the kidney
deformed
Heterogeneous mass –
iso/hypoechoic
Areas of cystic
degeneration
/calcification
Doppler - disorganized
and increased blood flow
pattern
Small RCCs - hyperechoic
confused with AML
40 Dept of Urology, GRH and KMC, Chennai.

41. Wilms’ tumour
Well-defined
Heterogeneous mass, predominantly
solid
Necrotic or haemorrhagic areas
41 Dept of Urology, GRH and KMC, Chennai.

42. 42 Dept of Urology, GRH and KMC, Chennai.

43. ADPKD
Bilateral
Enlarged kidneys with multiple cysts
of various sizes
No demonstrable parenchyma
Liver, spleen and pancreas -
associated cysts

43 Dept of Urology, GRH and KMC, Chennai.

44. Adenoma
Located in renal cortex
Small , less than 3 cm
Well-defined hyperechoic lesion
Similar to AML
May cause a bulging in renal
outline


44 Dept of Urology, GRH and KMC, Chennai.

45. Angiomyolipoma
Homogeneous,
Highly echogenic,
Smooth rounded lesion
May extend to renal vein and
thrombosis
Color flow enhancement ,
Microbubble contrast s/o hyper
vasculature
45 Dept of Urology, GRH and KMC, Chennai.

46. Acute infections of the upper urinary tracts
The ultrasound is either normal or demonstrates diffuse or focal swelling
of the kidney, with diminished echoes due to cortical oedema

Underlying obstruction or stones.

Identify any stones or scarring, and to demonstrate or rule out
hydronephrosis or hydroureter.

46 Dept of Urology, GRH and KMC, Chennai.

47. Pyelonephritis
Acute pyelonephritis
Enlarged and hypoechoic
CMD – indistinct
Reduced cortical vascularity
 presence of Gas


47 Dept of Urology, GRH and KMC, Chennai.

48. Chronic pyelonephritis
Small
Scar tissue
Hyperechoic
Linear lesion - affects the smooth renal
outline crosses the renal cortex
Renal cortex
Thin
Hyperechoic.

48 Dept of Urology, GRH and KMC, Chennai.

49. Focal pyelonephritis
Changes are subtle
Hypo /hyper echoic
Mass effect (mimicking a
tumour)
Kidney outline preserved


49 Dept of Urology, GRH and KMC, Chennai.

50. Renal abscess
Complex mass
distal acoustic enhancement
Low-level echoes from pus, frequently be
a layer of echogenic debris in the
dependent portion of the cyst.
Margins
ill defined - first
Thick rim – later
may have thick walls and
both cystic and solid components (ct )
Colour doppler- flow seen in the capsule
initial imaging investigation in most
suspected renal abscesses
50 Dept of Urology, GRH and KMC, Chennai.

51. Perinephric abscesses
may conform to the shape of the underlying kidney.
both solid and cystic elements
The cystic portions frequently contain internal echoes at ultrasound owing to
debris within the kidney,
an underlying renal abnormality is often demonstrable.
Pyonephrosis
occurs in collecting systems that are obstructed.
demonstrate multiple echoes within the collecting system from infected
debris.
51 Dept of Urology, GRH and KMC, Chennai.

52. Rt upper ureter calculus with pyonephrosis Renal abscess
52 Dept of Urology, GRH and KMC, Chennai.

53. Xanthogranulomatous pyelonephritis
Pelvic stone
The calyces enlarge
Filled with infected debris
The cortex - eroded and thin
Dd
TB
Pyonephrosis (no pelvis dilatation)
Tumour

53 Dept of Urology, GRH and KMC, Chennai.

54. Echinococcosis
Multicystic , multiloculated mass
Anechoeic lesion with well defined margin
Gharbi et all
Type 1 – well defined , simple cyst with distal enhancement
Type 2 – cyst with detachment of membrane
Type 3 – multilocular cyst with honeycomb pattern
Type 4 – heterogenous cyst with solid component
Type 5 – calcified cyst

54 Dept of Urology, GRH and KMC, Chennai.

55. Fungal infections
Immunocompromised
Hyperechoic fungal balls
within collecting system
Mucosal thickening of pelvis
and calyces noted in
candidiasis
D/D
Early TCC,
Epithelial hyperplasia

55 Dept of Urology, GRH and KMC, Chennai.

56. Tuberculosis
early stages of the disease, the ultrasound may be normal

calcifications and pelvicaliceal dilatation and cavities

Mucosal thickening+/- ureter and bladder envolvement

Signs of tubercular abscesses
56 Dept of Urology, GRH and KMC, Chennai.

57. Renal trauma
kidney and the spleen are the most frequent
small capsular haematomas produces swelling of the parenchyma, which
compresses the calices.
If the kidney substance is torn, the renal outline is irregular and the
calices are separated.
Retroperitoneal haemorrhage may displace the kidney.
Fragmentation Rupture of the bladder may be revealed sonographically by
the presence of a perivesical fluid collection
but the actual site of a tear will not be seen
57 Dept of Urology, GRH and KMC, Chennai.

58. Renal subcapsular haematoma
58 Dept of Urology, GRH and KMC, Chennai.

59. Congenital anomalies of the urinary tract
Bifid collecting systems
 most frequent congenital variations.
The condition may be unilateral or bilateral
Ectopic kidney
Horseshoe kidney
 isthmus
 inveted triangular appearence
59 Dept of Urology, GRH and KMC, Chennai.

60. 60 Dept of Urology, GRH and KMC, Chennai.

61. Medical renal disease
To differentiate CRF & ARF

CRF -- kidneys are small, contracted, & thinned out renal cortex
-- hyperechoic
-- loss of normal cortico medullary differentiation
ARF -- kidneys are enlarged thickened with oedematous cortex
-- prominent and more hypoechoic pyramids

61 Dept of Urology, GRH and KMC, Chennai.

62. Findings
Hours/days
Kidney – swollen
Pyramids – more prominent
sonolucent
Central sinus – decrease in size &
echoes
Resistive index - >0.75

Months to years
Parenchyma – echogenic
Size – small

ATN
Mc complication in first 48 hrs
Same features as acute rejection


Acute rejection

Chronic rejection

62 Dept of Urology, GRH and KMC, Chennai.

63. •Altered flow distal to stenosis
•Reduced diastolic flow
•PSV > 180 cm /s [100+/-25cm/s]
•Renal aortic ratio = renal PSV/aortic PSV
>3.5 – severe stenosis >60%
•Decreased renal size
63 Dept of Urology, GRH and KMC, Chennai.

64. Renal A stenosis

Renal A thrombosis

Altered flow distal to stenosis
Slow acceleration to peak velocity
[ tardus parvus wave form]

Renal v thrombosis
Rare, first week
Enlarge ,hypoechoic kidney
Absent flow in renal vein
High resistance arterial flow with reversed diastolic flow
RI > 1

Rare , early postop
Absent arterial ,venous flow pattern

64 Dept of Urology, GRH and KMC, Chennai.

65. Normal Variants
Dromedary humps:
Lateral kidney bulge, same echogenicity as the cortex
Hypertrophied column of Bertin:
Cortical tissue indents the renal sinus
Horseshoe kidney:
Kidneys are connected, usually at the lower pole
Renal ectopia:
One or both kidneys outside the normal renal fossa
65 Dept of Urology, GRH and KMC, Chennai.

66. Duplex kidney of mild
degree showing two
separate intrarenal
collecting systems.

66 Dept of Urology, GRH and KMC, Chennai.

67. Fetal lobulations
Fetal lobes fuse to form
kidney
May persist in adult

67 Dept of Urology, GRH and KMC, Chennai.

68. Columns of bertin
Invagination of renal cortex
down to the renal sinus

Occurs at the junctions of fetal
lobulations

Prominent, hypertrophied
columns of Bertin - mimic a
renal tumour.


68 Dept of Urology, GRH and KMC, Chennai.

69. Bladder
Normal thickness of bladder wall is less then 5 mm
Bladder tumours are seen as soft tissue masses protruding into the fluid
filled bladder or as localized bladder wall thickening,
Detecting extravesical spread is poor
Bladder diverticula
Bladder calcification
Neurogenic bladder
The large, smooth walled bladder and a large residual volume.
 bladder outflow obstruction.
The bladder is of small volume, thick wall with diverticula
69 Dept of Urology, GRH and KMC, Chennai.

70. 70 Dept of Urology, GRH and KMC, Chennai.

71. recurrent cystitis reveals irregular thickening of
the bladder wall and debris
71 Dept of Urology, GRH and KMC, Chennai.

72. Diverticulam

72 Dept of Urology, GRH and KMC, Chennai.

73. Ca bladder
73 Dept of Urology, GRH and KMC, Chennai.

74. Schistosomiasis bladder
74 Dept of Urology, GRH and KMC, Chennai.

75. Ureterocele with calculus
75 Dept of Urology, GRH and KMC, Chennai.

76. Posterior urethral valves
Congenital valves in the posterior
urethra
The diagnosis may be first
suspected at antenatal
ultrasound, when there is
bilateral hydronephrosis.
After birth, ultrasound confirms
bilateral hydronephrosis and
hydroureters and a thick walled
bladder outflow obstruction in
male
Key hole sign on ultrasound
76 Dept of Urology, GRH and KMC, Chennai.

77. Transrectal Ultrasonography of the Prostate
Provides exquisite anatomic detail of the prostate and periprostatic tissues
High-frequency 7.5-10 MHz transducer is used.
This can be a biplanar or singleplane transducer (i.e., “end fire” or “side fire”)
DRE before TRUS
After probe insertion, a “survey” scan is performed of the prostate from base to apex
including the seminal vesicles and rectal wall.
Seminal vesicles are then examined in the transverse plane
Midsagittal transverse and longitudinal image of the prostate is examined, and
anteroposterior, height, and length measurements are taken
77 Dept of Urology, GRH and KMC, Chennai.

78. Sonographic capsule” can be identified because of the impedance difference between
the prostate and surrounding fat.
Prominence of the urethra is related to urethral muscles.
 In the young male prostateperipheral zone is often hyperreflective to the central and
transition zones
In an older man, the glandular and stromal elements enlarge increasing the size of the
transition zone and occasionally the peripheral zone.
The base of the prostate is located at the superior aspect of the prostate contiguous
with the base of the bladder.
The apex of the prostate is located at the inferior aspect of the prostate continuous
with the striated muscles of the urethral sphincter.
78 Dept of Urology, GRH and KMC, Chennai.

79. 79 Dept of Urology, GRH and KMC, Chennai.

80. Scrotum
*high resolution probe (7.5mhz-10mhz)
*Indications:
1.hydrocele
2.epididymo orchitis
3.testicular tumor
4.testicular torsion
5.epididymal cysts
6.spermatocele
7.varicocele

80 Dept of Urology, GRH and KMC, Chennai.

81. scrotal ultrasonogram homogeneous
texture of the testis
normal head of the epididymis
81 Dept of Urology, GRH and KMC, Chennai.

82. orchitis
Color Doppler - patient with acute left
testicular pain and fever revealed diffuse
increased vascularity in the testis
82 Dept of Urology, GRH and KMC, Chennai.

83. patient with acute right testicular pain
reveals no blood flow on color Doppler -
diagnostic of testicular infarction
asymptomatic patient reveals
normal testicular blood flow
83 Dept of Urology, GRH and KMC, Chennai.

84. Spermatocele
84 Dept of Urology, GRH and KMC, Chennai.

85. Varicocele
85 Dept of Urology, GRH and KMC, Chennai.

86. Varicocele
o Grading's :
Grade O: Sub Clinical.
Grade I: Detected By Usg
Grade Ii: By Palpation.
Grade Iii: Diagnosed By Inspection.
86 Dept of Urology, GRH and KMC, Chennai.

87. Epididymal cyst
87 Dept of Urology, GRH and KMC, Chennai.

88. Epididymitis
88 Dept of Urology, GRH and KMC, Chennai.

89. Penile
 12- to 18-MHz linear array transducer
Transverse scanning
two corpora cavernosa dorsally and the urethra
ventrally.
The sagittal view
corpora cavernosa with a hyperechoic, double
linear structure representing the cavernosal
artery
The corpus spongiosum is isoechoic to
slightly hypoechoic and contains the urethra.
The urethra is collapsed except during
voiding.
89 Dept of Urology, GRH and KMC, Chennai.

90. indication
1.Evaluation of penile vascular dysfunction
2.Documentation of fibrosis of the corpora cavernosa
3.Evaluation of priapism
4.Localization of foreign body
5.Evaluation of urethral stricture
6.Evaluation of urethral diverticulum
7.Assessment of penile trauma or pain
8. Evaluation of penile tumors
90 Dept of Urology, GRH and KMC, Chennai.

91. ERECTILE DYSFUNCTION
91 Dept of Urology, GRH and KMC, Chennai.

92. Erectile DYSFUCTION
PSV less than 25 cm/sec,
Cavernosal artery dilation less than 75%, and
Acceleration time greater than 110 msec.
RI less than 0.7 s/o venoclussive diseases
92 Dept of Urology, GRH and KMC, Chennai.

93. Penile haematoma
93 Dept of Urology, GRH and KMC, Chennai.

94. Fracture penis
94 Dept of Urology, GRH and KMC, Chennai.

95. Sonourethrography
McAninch in 1985 at San Francisco , to study urethral stricture length
estimation.
simple and safe technique.
comparable efficiency to retrograde urethrography in detection of anterior
urethral stricture disease.
 Sonourethrography accurately estimates the stricture length, diameter
and periurethral fibrosis
It can provide useful information particularly in patients in whom the
need for definitive surgical treatment is clear
95 Dept of Urology, GRH and KMC, Chennai.

96. The glans penis and urethral meatus are disinfected.
Xylocaine jelly or sterile water (20-30ml) is injected slowly by means of an
appropriate catheter tip syringe in the urethral meatus, taking care not to
inject air bubbles.
7.5 to 20 MHz frequency linear array transducer is used for the procedure.
The transducer is applied directly over the ventral surface of the penis,
scrotum and the perineum
96 Dept of Urology, GRH and KMC, Chennai.

97. Images --sequentially from the pendulous urethra proximally towards the
deep bulbar area.
 By dilating the anterior urethra with saline or xylocaine jelly ,longitudinal
and transverse images are obtained.
The length of the stricture, the intra-luminal diameter and the wall
thickness are determined accurately

97 Dept of Urology, GRH and KMC, Chennai.

98. Normal
SUG
Normal
RGU

98 Dept of Urology, GRH and KMC, Chennai.

99. Grading
I.Short stricture with minimal spongiosal tissue involvement
II.Short stricture with moderate spongiosal tissue involvement
III.Short stricture with extensive spongiosal tissue involvement
IV.Long or multiple stricture with moderate spongiosal tissue involvement
V.Long or multiple stricture with extensive spongiosal tissue involvement
On basis of lumen involved
A.Less than 1/3 rd
B.1/3 rd to ½
C.More than ½

99 Dept of Urology, GRH and KMC, Chennai.

100. 100 Dept of Urology, GRH and KMC, Chennai.

101. Advantages
No radiation hazard
 Contrast is not required.
 Reproducible.
 Short segment strictures can be identified.
 Extent of spongiofibrosis can be assessed as therapeutic options are based
on this.
 Soft tissues around the urethra can also be examined.
101 Dept of Urology, GRH and KMC, Chennai.

102. Disadvantages
Minor bleeding
Dysuria
Intravasation of contrast
Minor allergic reactions to lignocaine jelly.
Posterior urethra can not be assessed reliably
 Underestimates the length of stricture as long
strictures may not be imaged in a single field of
view
Clots within the urethra –
complication
.

cl
o
t
s
urethral
lumen
102 Dept of Urology, GRH and KMC, Chennai.

103. NEW METHODS

US imaging provides resolution of 1-2mm over an
imaging field of 4-20cm

It is not sufficient to visualize the layers of
bladder,ureteral,urethral wall

103 Dept of Urology, GRH and KMC, Chennai.

104. HIGH –FREQUENCY ENDOLUMINAL
ULTRASOUND

40-100MHz frequency

Resolution ranging from 30-80micro meter

USES
Measure total wall thickness
Diagnosis and staging of tumors

104 Dept of Urology, GRH and KMC, Chennai.

105. POWER MODE DOPPLER ULTRASOUND
Doppler imaging – difficult to image small vessels in organ, peripheral
vascular system [low doppler shift, low numbers of scatterers ]
Power mode – used to imaging of smaller vessels on the basis of
quantity of blood present in that area
Power map contains only one colour scale

Advantages
able to detect slower flow
detect neovascularity [ prostatic ca]


105 Dept of Urology, GRH and KMC, Chennai.

106. Color-Doppler ultrasonography of the renal
artery
Renal artery (A) is displayed in red [blood flow
toward the transducer]
Renal vein (V) is displayed in blue [blood flow
away from the transducer]
Power-mode Doppler imaging reveals
intrarenal blood flow. does not provide any
information about velocity or the direction of
blood flow
106 Dept of Urology, GRH and KMC, Chennai.

107. power-mode Doppler ultrasonogram bladder reveals a
urine jet from the orifice of the ureter 107 Dept of Urology, GRH and KMC, Chennai.

108. Color Doppler TRUS and power Doppler
108 Dept of Urology, GRH and KMC, Chennai.

109. CONTRAST ENHANCED ULTRASOUND

Current Doppler modalities are not able to identify the microvessels of
tumors [10 to 15 μm]
Intravenous microbubble ultrasound contrast agents
0.01-0.1ml/kg
Doppler imaging to amplify flow signals within the microvasculature of
tumors, allowing selective visualization of malignant foci
Advantages
It has increased diagnostic accuracy
accurate localization of the sites of cancer.

109 Dept of Urology, GRH and KMC, Chennai.

110. Unenhanced color (A) TRUS and power
Doppler (B) TRUS fail to detect evidence of
an underlying malignancy.
After contrast agent, demonstrate an
area of increased flow in the left mid gland
110 Dept of Urology, GRH and KMC, Chennai.

111. SONOGRAPHIC ELASTOGRAPHY

superior to color Doppler imaging in the identification of
malignant areas in the prostate

This technique employs sonographic imaging of the prostate at
baseline and under varying degrees of compression
Through computerized calculations, differences in displacement
between ultrasonic images from baseline and during
compression may be visualized and regions with decreased
tissue elasticity may be tagged as suggestive of malignancy

111 Dept of Urology, GRH and KMC, Chennai.

112. Elastography demonstrates an area of
decreased compliance in the right base
consistent with an underlying malignancy
112 Dept of Urology, GRH and KMC, Chennai.

113. USG guided intervention

Biopsy:
renal
renal sol –fnac
prostate
transplant allograft
Aspiration:
renal cyst(only if symptomatic)
perinephric collection
prostatic abscess
post operative collection
scrotal cyst
urinoma

Nephrostomy

Lithotripsy

113 Dept of Urology, GRH and KMC, Chennai.

114. Limitations
Obesity, intestinal gas, and physical deformity may be impediments to
complete renal evaluation.
Renal ultrasonography has poor sensitivity for renal masses less than 2 cm
There is a lack of specificity for renal tumor type except for
angiomyolipoma.
 benign vs malignanat
Failure to scan both kidneys simultaneously
Mistaking prominent renal pyramids for hydronephrosis
Mistaking prominent pyramids for cysts
Confusing normal renal arteries for the ureter
114 Dept of Urology, GRH and KMC, Chennai.

115. Thank you
115 Dept of Urology, GRH and KMC, Chennai.