X RAY KUB 2

X RAY KUB 2

1. X-RAY: KUB
Dept of Urology
Govt Royapettah Hospital and Kilpauk 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. HISTORY
Discovered by William Roentgen in December 1895.


 In July 11, 1896 a renal stone was diagnosed using X ray by
Dr. John MacIntyre in Glasgow.
3 Dept of Urology, GRH and KMC, Chennai.

4. PHYSICS
•Super-heating of a bare tungsten wire – the tungsten cathode

•Emission of electrons

•Electrons impact on to a separate tungsten plate (the anode) enclosed within a
vacuumed tube.

•With the sudden deceleration of the electrons, and further interaction at an
atomic level

•Energy is released in the form of an electromagnetic wave of a very short
wavelength (approximately 1nm.) – an X-ray.

4 Dept of Urology, GRH and KMC, Chennai.

5. PHYSICS
•When directed at the human body, this ray will travel through human
tissues, but along the way it will be partly absorbed by these tissues

•This absorption (generally referred to as attenuation) is proportionate
to the tissues’ atomic number, density and thickness.

•Thus the exiting portion of the ray carries information about the
consistency of the tissue that it has just traversed.

5 Dept of Urology, GRH and KMC, Chennai.

6. PHYSICS
Prior to exposure, three variables need to be determined :
•mA determines the current that flows through the filament, thus the
number of electrons produced.
•Exposure time determines the time for which x-rays are produced.
•kVp determines the potential difference between the cathode and
anode, and hence the “power” of the beam.
6 Dept of Urology, GRH and KMC, Chennai.

7. PHYSICS
•mA and exposure time are often considered together as mAs
(milliampere second) which has the overall effect of making the
image darker or lighter.
•An inappropriate mAs will result in either an overexposed or underexposed
film.
•Increasing the kVp will increase the penetrating power of the x-rays
and decrease the contrast of the final image.
7 Dept of Urology, GRH and KMC, Chennai.

8. CONVENTIONAL RADIOGRAPHY
•Abdominal plain radiography
•Intravenous excretory urography
•Retrograde pyelography
•Loopography
•Retrograde urethrography
•Cystography
8 Dept of Urology, GRH and KMC, Chennai.

9. PLAIN ABDOMINAL RADIOGRAPHY
•The plain abdominal radiograph is a conventional radiography study,
which is intended to display the KUB.
•The plain abdominal radiograph may be employed
•(1) as a primary study
•(2) as a scout film in anticipation of contrast media
9 Dept of Urology, GRH and KMC, Chennai.

10. PLAIN ABDOMINAL RADIOGRAPHY- SYNONYMS
•X- Ray KUB
•Scout film
•Plain Film
•Preliminary Radiograph
10 Dept of Urology, GRH and KMC, Chennai.

11. TECHNIQUE
•Obtained with the patient in the supine position
•Using an anterior to posterior exposure.
•The study typically includes that portion of the anatomy from the
level of the diaphragm to the inferior pubic symphysis
•Standard plate size 14”-17”
11 Dept of Urology, GRH and KMC, Chennai.

12. TECHNIQUE
•It may occasionally be necessary to make two exposures to cover
the desired anatomic field.
12 Dept of Urology, GRH and KMC, Chennai.

13. TECHNIQUE
•Oblique films- Obtained to clarify the position of structures in
relation to the urinary tract.






•Upright films- If small bowel obstruction or free peritoneal air is
suspected.
13 Dept of Urology, GRH and KMC, Chennai.

14. INDICATIONS
1.Preliminary film in anticipation of contrast administration
2.Assessment of the presence of residual contrast from a previous
imaging procedure
3.Pre- and post-treatment assessment of renal calculus disease
4.Assessment of the position of drains and stents

14 Dept of Urology, GRH and KMC, Chennai.

15. INDICATIONS
5. Assessing the suitability of a patient for ESWL because the ability to
identify the stone on fluoroscopy is critical to targeting
6. To determine whether bowel preparation is adequate before
contrast study
7. To determine whether a contraindication to abdominal compression
exists.

15 Dept of Urology, GRH and KMC, Chennai.

16. ANATOMICAL LANDMARKS
•Organ Outlines
•Major Muscles
•Properitoneal fat
•Perivesical fat plane
•Stomach and Bowel gas

16 Dept of Urology, GRH and KMC, Chennai.

17. ANATOMICAL LANDMARKS- ORGAN OUTLINES
•Kidneys, Liver, Spleen, Urinary bladder can be identified.
•Organ outlines are visible because of the contrasting radiolucent
mesenteric or retroperitoneal fat that surrounds the organs.
•Difficulties- Numerous superimposed radiodensities and
radiolucencies from gas filled bowel- obscure anatomical detail
provided by contrasting fat.


17 Dept of Urology, GRH and KMC, Chennai.

18. RADIOGRAPHIC ANATOMY OF KIDNEY
•In well prepared plain KUB radiograph,
•renal shape
•Margins
•Dimensions
•location
•Both kidney shadows are clearly visible and can be assessed with
regard to their position and morphology.
•Radiopacities, calcifications, and radiolucencies could be identified
18 Dept of Urology, GRH and KMC, Chennai.

19. RADIOGRAPHIC ANATOMY OF KIDNEY
19 Dept of Urology, GRH and KMC, Chennai.

20. •PSOAS MUSCLE
•Well outlined by fat
•Visualised B/L in healthy patient
•Failure to clearly observed in upto 20% of healthy people.
•Disappearance- imply presence of fluid in compartment adjacent to muscle
•INTERNAL OBTURATOR MUSCLE
•In pelvis- forms the lateral wall of the pelvic fossa
ANATOMICAL LANDMARKS- MUSCLE OUTLINES
20 Dept of Urology, GRH and KMC, Chennai.

21. ANATOMICAL LANDMARKS- MUSCLE OUTLINES
21 Dept of Urology, GRH and KMC, Chennai.

22. ANATOMICAL LANDMARKS- MUSCLE OUTLINES
22 Dept of Urology, GRH and KMC, Chennai.

23. •Also known as “Flank fat stripe”
•It is the continuation of the posterior paranephric space.
•It is sandwiched between transversalis fascia and the parietal
peritoneum.
•Its medial interface marks the lateral extent of the peritoneal cavity

ANATOMICAL LANDMARKS- PROPERITONEAL FAT
23 Dept of Urology, GRH and KMC, Chennai.

24. •The top of the bladder, particularly when bladder is empty
•Outlined by a radiolucent strip of perivesical fat
ANATOMICAL LANDMARKS- PERIVESICAL FAT LINE
24 Dept of Urology, GRH and KMC, Chennai.

25. •Supine – fluid in fundus, gas in antrum
•Fluid filled fundus may mimic a L. Upper quad mass
•Presence of mass excluded by prone position.
•Chilaiditi syndrome
ANATOMICAL LANDMARKS- STOMACH, BOWEL GAS
25 Dept of Urology, GRH and KMC, Chennai.

26. ANATOMICAL LANDMARKS- STOMACH, BOWEL GAS
26 Dept of Urology, GRH and KMC, Chennai.

27. X- RAY KUB: DISORDERS
1.Acute Conditions
2.Unusual gas collections
3.Calcifications
4.Foreign Material
5.Soft tissue masses
6.Skeletal disorders

27 Dept of Urology, GRH and KMC, Chennai.

28. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Renal colic
•Intestinal Obstruction
•Ileus
•Abdominal fluid
•Abscess
•Intramural Gas

28 Dept of Urology, GRH and KMC, Chennai.

29. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Intestinal Obstruction
•After dividing and reanastomosing bowel during constructioin of conduit, diversion.
•Adhesions


29 Dept of Urology, GRH and KMC, Chennai.

30. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Ileus
•Ureteric colic
•Renal inflammatory disease- Colon cut off sign

30 Dept of Urology, GRH and KMC, Chennai.

31. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Abdominal fluid

•Retroperitoneal fluid- Obliteration of Psoas outline
•Fluid localised in the perinephric space obliterates the renal outline and the fat
•A fluid filled paranephric space contrasts the fat within perinephric space- renal
halo sign

31 Dept of Urology, GRH and KMC, Chennai.

32. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Abdominal fluid
•Fluid localised in the perinephric space obliterates the renal outline and the fat

32 Dept of Urology, GRH and KMC, Chennai.

33. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Abdominal fluid
•A fluid filled paranephric space contrasts the fat within perinephric space- renal
halo sign

33 Dept of Urology, GRH and KMC, Chennai.

34. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Abscess

34 Dept of Urology, GRH and KMC, Chennai.

35. X- RAY KUB: ACUTE ABDOMINAL DISORDERS
•Intramural Gas

35 Dept of Urology, GRH and KMC, Chennai.

36. X- RAY KUB: UNUSUAL GAS COLLECTION
•Ureterosigmoidostomy

36 Dept of Urology, GRH and KMC, Chennai.

37. X- RAY KUB: CALCIFICATIONS
•Vascular calcifications
•Intraluminal calcifications
•Parenchymal and intramural calcifications
•Extraurinary
•Urinary
•Calcifications in Muscles, Ligaments and Cartilage
•Intraperitoneal calcifications
•Calcified haematomas and abscesses

37 Dept of Urology, GRH and KMC, Chennai.

38. X- RAY KUB: CALCIFICATIONS
•Vascular calcifications
•Intrarenal branches of renal artery
•Dorsal penile artery
•Renal artery aneurysm calcification
•Phleboliths

38 Dept of Urology, GRH and KMC, Chennai.

39. X- RAY KUB: CALCIFICATIONS
•Intraluminal calcifications
•Urolthiasis
•others

39 Dept of Urology, GRH and KMC, Chennai.

40. RENAL CALCULUS- X-RAY KUB
•While up to 90% of urinary tract calculi are radiopaque
•50% of urinary tract stones may not be detected on conventional
abdominal radiographs, due to overlying bowel gas and stool, as well
as overlying bones (ribs, lumbar spine, iliac bones, and sacrum).
•The lateral tips of the transverse processes can be especially
confusing because their cortical margin may mimic a ureteral stone.
40 Dept of Urology, GRH and KMC, Chennai.

41. RENAL CALCULUS- X-RAY KUB
•Calcium oxalate and phosphate, magnesium ammonium phosphate,
and cystine stones are generally well seen on plain abdominal
radiographs
•Calcium oxalate monohydrate stones are the most radiopaque
•Cystine stones are often only faintly opaque.
•Uric acid stones are insufficiently radiopaque to be seen on an
abdominal radiograph and account for the majority of radiolucent
stones.
•Xanthene, matrix, and metabolic stones are also radiolucent.
41 Dept of Urology, GRH and KMC, Chennai.

42. RENAL CALCULUS- X-RAY KUB
42 Dept of Urology, GRH and KMC, Chennai.

43. RENAL CALCULUS- X-RAY KUB
43 Dept of Urology, GRH and KMC, Chennai.

44. RENAL CALCULUS- X-RAY KUB
44 Dept of Urology, GRH and KMC, Chennai.

45. RENAL CALCULUS- X-RAY KUB
45 Dept of Urology, GRH and KMC, Chennai.

46. •Ureter is situated just lateral to the tips of the transverse processes of the
lumbar vertebrae
•Three segments of the ureter:
•Proximal portion extending from its origin down to the upper border of the sacroiliac
joint
•Middle portion lying over the sacroiliac joint
•Distal portion remaining segment from the lower border of that joint to its entrance
into the bladder
•In a standard lateral view, the ureter stays behind the anterior margin of
the vertebral bodies until the level of L4. After this, the ureter lies anterior
to the vertebral body by approximately one-fourth the width of the
vertebral body
RADIOGRAPHIC ANATOMY OF URETER
46 Dept of Urology, GRH and KMC, Chennai.

47. RADIOGRAPHIC ANATOMY OF URETER
47 Dept of Urology, GRH and KMC, Chennai.

48. •Tips of the transverse processes
•Crosses in front of the sacroiliac
joint
•Swings out to the ischial spine
•Passes medially to the bladder.
RADIOGRAPHIC ANATOMY OF URETER
48 Dept of Urology, GRH and KMC, Chennai.

49. •Size and shape varies according
to the volume of urine


•Highlighted by perivesical fat
URINARY BLADDER IN X-RAY KUB
49 Dept of Urology, GRH and KMC, Chennai.

50. BLADDER CALCULUS IN X-RAY KUB
•Stones are usually solitary
•Ammonium acid urate, calcium oxalate, uric acid, and calcium
phosphate are the most common components
•Range from densely radiopaque stones to faintly radiopaque stones
depending on the composition.
•May have variety of shapes



50 Dept of Urology, GRH and KMC, Chennai.

51. BLADDER CALCULUS IN X-RAY KUB
51 Dept of Urology, GRH and KMC, Chennai.

52. X- RAY KUB: CALCIFICATIONS
•Parenchymal and intramural calcifications
•Adrenal cyst, Carcinoma
•Renal- Carcinoma, TB, Transplant rejection
•Bladder wall calcification
•Vas deference and seminal vesicle calcification

52 Dept of Urology, GRH and KMC, Chennai.

53. X- RAY KUB: CALCIFICATIONS
•Parenchymal and intramural calcifications
•Adrenal cyst, Carcinoma
53 Dept of Urology, GRH and KMC, Chennai.

54. X- RAY KUB: CALCIFICATIONS
•Parenchymal and intramural calcifications
•Renal- Carcinoma, TB, Transplant rejection

54 Dept of Urology, GRH and KMC, Chennai.

55. X-RAY KUB IN GUTB
•Calcification seen in more than 50% of patients.
•Initial renal lesions may appear as faint punctate calcifications within the
parenchyma.
•As TB progresses- show globular calcifications that correspond to a
tubercular mass.
•Papillary necrosis appears as triangular ringlike calcifications in the
collecting system.
•With fibrotic autonephrectomy- shows a small, shrunken, calcified
“cement” or “putty” kidney, in which calcific rims outline the individual
renal lobes; this lobar pattern is pathognomonic for end-stage renal TB.
55 Dept of Urology, GRH and KMC, Chennai.

56. X-RAY KUB IN GUTB
56 Dept of Urology, GRH and KMC, Chennai.

57. X- RAY KUB: CALCIFICATIONS
•Parenchymal and intramural calcifications
•Bladder wall calcification- Schistosomiasis, Alkaline encrusting cystitis

57 Dept of Urology, GRH and KMC, Chennai.

58. X- RAY KUB: CALCIFICATIONS
•Parenchymal and intramural calcifications
•Vas deference and seminal vesicle calcification

58 Dept of Urology, GRH and KMC, Chennai.

59. •Gall stones

EXTRA GU CALCIFICATIONS IN X-RAY KUB
59 Dept of Urology, GRH and KMC, Chennai.

60. •Splenic calcification

EXTRA GU CALCIFICATIONS IN X-RAY KUB
60 Dept of Urology, GRH and KMC, Chennai.

61. •Pancreatic calcification

EXTRA GU CALCIFICATIONS IN X-RAY KUB
61 Dept of Urology, GRH and KMC, Chennai.

62. •Hepatic calcification

EXTRA GU CALCIFICATIONS IN X-RAY KUB
62 Dept of Urology, GRH and KMC, Chennai.

63. X- RAY KUB: CALCIFICATIONS
•Calcifications in Muscles, Ligaments and Cartilage

63 Dept of Urology, GRH and KMC, Chennai.

64. X- RAY KUB: CALCIFICATIONS
•Calcified haematomas and abscesses

64 Dept of Urology, GRH and KMC, Chennai.

65. X- RAY KUB: FOREIGN MATERIAL
•.

65 Dept of Urology, GRH and KMC, Chennai.

66. X- RAY KUB: SOFT TISSUE MASSES
•Most soft tissue mass- water density, difficult to identify
•Mass can be only detected if contrasted by fat or air

66 Dept of Urology, GRH and KMC, Chennai.

67. X- RAY KUB: SKELETAL DISORDERS
•Osteoblastic Metastasis
•Osteolytic Metastasis
•Bladder Exstrophy- Epispadias complex
•Postoperative Changes

67 Dept of Urology, GRH and KMC, Chennai.

68. X- RAY KUB: SKELETAL DISORDERS
•Osteoblastic Metastasis

68 Dept of Urology, GRH and KMC, Chennai.

69. X- RAY KUB: SKELETAL DISORDERS
•Osteolytic Metastasis

69 Dept of Urology, GRH and KMC, Chennai.

70. X- RAY KUB: SKELETAL DISORDERS
•Bladder Exstrophy- Epispadias complex

70 Dept of Urology, GRH and KMC, Chennai.

71. X- RAY KUB: SKELETAL DISORDERS
•Postoperative Changes

71 Dept of Urology, GRH and KMC, Chennai.

72. LIMITATIONS OF X-RAY KUB
•Overlying stool and bowel gas may obscure small calculi
•Stones may be obscured by other structures such as bones or ribs
•Calcifications in pelvic veins or vascular structures may be confused
with Ureteric calculi.
•Stones that are poorly calcified or composed of uric acid may be
radiolucent.
•Plain radiography has a very limited role in evaluating soft tissue
abnormalities of the urinary tract.
72 Dept of Urology, GRH and KMC, Chennai.

73. LIMITATIONS OF X-RAY KUB
•Right ureteral calculus (arrow) overlying the sacrum is difficult to
visualize on the plain film. (B) The right posterior oblique study fails to
confirm the location of the ureteral calculus. (C) CT confirms this 6-
mm calculus in the right ureter at the level of the third sacral
segment.
73 Dept of Urology, GRH and KMC, Chennai.

74. BIBLIOGRAPHY
•Clinical Urolography, Second Edition; Pollack, McClennan.
•Campbell, Walsh, Wein Urology- 12
th
edition.
•Images in Urology Diagnosis and Management; Simon Bott, Uday
Patel, Bob Djavan, Peter Carroll.
•Genitourinary Radiology, Sixth edition; Dunnick, Newhouse.
74 Dept of Urology, GRH and KMC, Chennai.

75. THANK YOU
75 Dept of Urology, GRH and KMC, Chennai.