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Urinary tract imaging and pathology

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imaging and pathology of the urinary tract

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Urinary tract imaging and pathology

  2. 2. Anatomy of the urinary tract Pelvic calacyeal system  There are usually seven pairs of minor calyces,  Minor calyx pairs combine to form two or three major calyces,which in turn drain via their infundibula to the pelvis.  The pelvis may be intrarenal or partially or entirely extrarenal.  The hilum of the kidney lies medially, that of the left at L1 vertebral level and that of the right slightly lower at L1/L2 level, owing to the bulk of the liver above.  At the hilum, the pelvis lies posteriorly and the renal vein anteriorly with the artery in between.
  3. 3. Anatomy of the urinary tract The ureters  Each is 25-30 cm long and is described as having a pelvis and abdominal, pelvic and intravesical parts  the ureter has a diameter of about 3 mm but is narrower at the following three sites:  The junction of the pelvis and ureter.  The pelvic brim  The intravesical ureter where it runs through the muscular bladder wall.
  4. 4. Anatomy of the urinary tract
  5. 5.  1. Right upper-pole (major) calyx  2. Right middle (major) calyx  3. Right lower-pole (major) calyx  4. Left upper-pole (major) calyx  5. Left lower-pole (major) calyx  6. Minor calyx (infundibulum of)  7. Papilla  8. Infundibulum  9. Fornix  10. Bifid left renal pelvis  11. Right renal pelvis  12. Right ureter  13. Left ureter: vascular impression  14. Upper pole right kidney  15. Right psoas outline  16. Gas in body of stomach  17. Gas in transverse colon  18. Intravesical ureter
  6. 6. Anatomy of the urinary tract Bladder  This is a pyramidal muscular organ when empty. It has a triangular-shaped base posteriorly.  The ureters enter the posterolateral angles and the urethra leaves inferiorly at the narrow neck, which is surrounded by the (involuntary) internal urethral sphincter.  It has one superior and two inferolateral walls, which meet at an apex behind the pubic symphysiss.  In the female, the body of the uterus rests on its postero¬superior surface and the cervix and vagina are posterior, with the rectum behind.  In the male the neck is fused with the prostate.  The bladder is supplied via the internal iliac artery via superior and inferior vesical arteries.
  7. 7. Urinary bladder rectum prostate
  8. 8. Anatomy of the urinary tract The urethra  The male urethra runs from the internal urethral sphincter at the neck of the bladder to the external urethral orifice at the tip of the penis.  The posterior urethra comprises the prostatic and membranous urethra and the anterior part comprises the bulbous and penile urethra.  In females This is 4 cm long. It extends from the internal urethral sphincter at the bladder neck through the urogenital diaphragm to the external urethral meatus anterior to the vaginal opening.
  9. 9. 1.Balloon of catheter in navicular fossa 2. Penile urethra 3. Bulbous urethra 4. Membranous urethra 5. Impression of verumontanum in prostatic urethra 6. Filling of utricle (not usually seen) 7. Air bubbles in contrast
  10. 10. Imaging techniques of the urinary tract  kub  Ivu  Mcug  Ultrasound  Ascending urethrogram  Mri
  11. 11. Pelvicalyceal system  Duplex collecting system  Congenital ureteropelvic junction (UPJ) obstruction  Congenital megacalyces  (PYELO)Calyceal diverticulum  Renal papillary necrosis (RPN)  Pyonephrosis
  12. 12. Duplex collecting system  It is one of the most common congenital renal tract abnormalities 4- 5. It is characterised by incomplete fusion of upper and lower pole moieties resulting in complete or incomplete duplication of the collecting system  duplex collecting system - a duplex kidney draining into:  single ureter - i.e. duplex kidney's duplication pelvicalcyeal systems uniting at the pelvi-ureteric junction (PUJ)  bifid ureter (ureter fissus) - two ureters that unite before emptying into the bladder  double ureter (complete duplication) two ureters that drain separately into the bladder or genital tract
  13. 13. Duplex collecting system  Orthotopic ureter: drains lower pole and enters bladder near trigone  Ectopic ureter: drains upper pole and enters bladder inferiorly and medially (Weigert- Meyer rule); the ectopic ureter may be stenotic and obstructed
  14. 14.  Spot film taken during an IVP shows bilateral duplex kidneys.  On the left side the ureters have fused at the level of L3 vertebra  On the right side both ureters have opened into the bladder.
  15. 15.  Fluoroscopy MCU Grade 5 reflux with double excretory system on the left side. Fusion of both ureters right before the bladder (cystoscopy confirmed the presence of only 2 ostia in the bladder). Hydronephrosis.
  16. 16.  Drooping lily sign - a urographic sign of duplicated renal collecting system. It refers to the inferolateral displacement of the opacified lower pole moiety due to an obstructed (and relatively unopacified) upper pole moiety.  In duplicated collecting system it is classically the upper pole ureter that is obstructed due to a ureterocoele and the lower pole ureter that refluxes: as described by the Weigert-Meyer law.
  17. 17.  left sided duplicated collecting system with a distorted lower pole moiety from obstructed upper pole. This results in the so called drooping lilly sign.
  18. 18. Congenital ureteropelvic junction (UPJ) obstruction Most common congenital anomaly of the GU tract in neonates. 20% of obstructions are bilateral. • Intrinsic, 80%: defect in circular muscle bundle of renal pelvis • Extrinsic, 20%: renal vessels (lower pole artery or vein) The estimated incidence in pediatric population is at ~1 per 1000-2000 newborns and there is a recognised predilection towards the left side (~67% of cases) and a male predominance.
  19. 19. Congenital ureteropelvic junction (UPJ) obstruction  asymptomatic or When symptomatic, symptoms include recurrent urinary tract infections, stone formation and even a palpable flank mass. Ultrasound  will often show a dilated renal pelvis with a collapsed proximal ureter  with Doppler sonography the obstructed kidneys can show higher RI's (resistive indices). CT  May show evidence of hydronephrosis +/- calyectasis with collapsed ureters. Useful for assessing crossing vessels at the PUJ especially when surgical intervention is planned
  20. 20. Congenital ureteropelvic junction (UPJ) obstruction  Left sided hydronephrosis is seen with dilated and ballooned out left renal pelvis.  Left pelviureteric junction is markedly narrowed with probably delayed contrast excretion into left ureter.
  21. 21. Congenital ureteropelvic junction (UPJ) obstruction  Right PUJ obstruction.  Dilated renal pelvis and renal calices with normal ureter.
  22. 22. Congenital megacalyces  is an incidental finding which mimics hydronephrosis. It is a result of underdevelopment of the renal medullary pyramids with resultant enlargement of the calyces. It it more frequently seen in males.  The enlarged, floppy calyces predispose to stasis, infection and calculus formation. There is an association with congenital megaureter.  due to the lack of normal medullary pyramids, not only are the calyces enlarged but they lack the normal imprint from the papillae, thus having a flat appearance.
  23. 23. Congenital megacalyces  The renal pelvis is of normal size helping to distinguish megacalyces from hydronephrosis.  In addition to enlargement of the calyces there is often also polycalycosis (increased number of calyces); they are crowded and multifaceted with a mosaic-like appearance.
  24. 24. Congenital megacalyces  This 10-month old male had a large right kidney, thought to be due to tumour.  There are more than the usual number of calyces
  25. 25. (PYELO)Calyceal diverticulum  Outpouching of calyx into corticomedullary region.  May also arise from renal pelvis or an infundibulum.  Usually asymptomatic, but patients may develop calculi. • Type I: originates from minor calyx • Type II: originates from infundibulum • Type III: originates from renal pelvis
  26. 26. (PYELO)Calyceal diverticulum Imaging features :-  Cystic lesion connects through channel with collecting system. • If the neck is not obstructed, diverticula opacify retrograde from the collecting system on delayed IVP films. • May contain calculi or milk of calcium, 50%
  27. 27.  Calyceal diverticulum with multiple stones. a, Abdominal plain film shows multiple calculi (arrow) over the upper pole of the right kidney.  On ten-minute excretory urogram (EXU), all stones are shown to be locate in an upper pole calyceal diverticulum (arrow).
  28. 28. (PYELO)Calyceal diverticulum  On Sonography, a pyelocalyceal diverticulum appears as a cystic lesion, which is difficult to distinguish from simple renal cyst. However, the presence of mobile, echogenic and dependent layering due to milk of calcium is pathognomic of a pyelocalyceal diverticulum.
  29. 29. Renal papillary necrosis (RPN) RPN represents an ischemic coagulative necrosis involving variable amounts of pyramids and medullary papillae. RPN never extends to the renal cortex. Causes:  Ischemic necrosis • Diabetes mellitus • Chronic obstruction, calculus • Sickle cell disease • Analgesics  Necrosis due to infections • TB • Fungal
  30. 30. Renal papillary necrosis (RPN) Imaging features : • Enlargement (early) • Small collection of contrast medium extends outside the interpapillary line in partial necrosis. • Contrast may extend into central portion of papilla in “medullary type” RPN. • Eventually contrast curves around papilla from both fornices, resulting in “lobster-claw” deformity.  Sequestered, sloughed papillae cause filling defects in collecting system: “ring sign.”  • Tissue necrosis leads to blunted or clubbedcalyces.  Multiple papillae affected in 85%. Rimlike calcificationof necrotic papilla occurs.
  31. 31. Renal papillary necrosis (RPN) Classical features may appear as 4:  ball on tee  forniceal excavation  lobster claw  signet ring  sloughed papilla with clubbed caly
  32. 32. Renal papillary necrosis (RPN)  Enlarged view of the left kidney showing central papillary necrosis (top arrow), and marginal excavation (bottom arrow), the pre-cursor to the characteristic lobster claw appearance
  33. 33. Renal papillary necrosis (RPN)  Coronal image of the left kidney from a CT Urogram shows numerous irregular collections of contrast arising from the calyces, some streak-like densities and overall distortion of the normal medullary-calyceal anatomy
  34. 34. Renal papillary necrosis (RPN)
  35. 35.  Renal Papillary Necrosis Ring Sign
  36. 36. Pyonephrosis  Pyonephrosis is a term given to infection of the renal pelvic system which can then subsequently get filled with pus and is then complicated by obstruction.  The diagnosis of pyonephrosis is suspected when the clinical symptoms of fever and flank pain are combined with the radiologic evidence of obstruction to the urinary tracts 1.
  37. 37. Pyonephrosis Ultrasound: Usually shows dilatation of the pelvi-calyceal system with the following additional features:-  echogenic collecting system debris - considered the most reliable sign  fluid-fluid levels within the collecting system  incomplete (dirty) echoes of collecting system gas can be occasionally seen.
  38. 38. Pyonephrosis CT  The presence of clinical signs of infection with hydronephrosis on CT is considered a more sensitive indicator of pyonephrosis than many of the CT findings alone .  thickening of the renal pelvic wall (>2 mm)  parenchymal or perinephric inflammatory changes, dilatation and obstruction of the collecting system, higher than usual attenuation values of the fluid within the renal collecting system, and layering of contrast material above and anterior to the purulent fluid on excretory studies.
  39. 39. Pyonephrosis  There is a calculus noted in right renal pelvis causing gross hydronephrosis and parenchymal thinning.  Parenchymal thickness is less than 2 mm at places.  Pelvi-calyceal system shows fluid - debris levels with few tiny calculi. No air foci are noted.  Parenchymal flow is preserved.
  40. 40. The Ureters  Ectopic ureter.  Ureterocele.  Primary megaureter.  Obstruction of collecting system.  Ureteral injury .  Ureteral tumors.
  41. 41. Ectopic ureter  Ureter does not insert in the normal location in the trigone of the bladder.  Incidence: M:F = 1:6.  Associations • 80% have complete ureteral duplication. • 30% have a ureterocele (“cobra head” appearanceon IVP) Insertion Sites • Males: ureter inserts ectopically into the bladder> prostatic urethra > seminal vesicles, vas deferens, ejaculatory ducts. • Females: ectopic ureter commonly empties into postsphincteric urethra, vagina, tubes, perineum
  42. 42. Ectopic ureter Intravenous urography (IVU)  It can detect abnormal ureteral insertion and associated anomalies e.g. renal duplication.  In complete duplex kidney and ureter, the ectopic ureter usually drains the upper moiety and associated with ureterocele and obstruction. Voiding cystourethrogram  Usually the ectopic ureter is associated with vesico-ureteric reflux, which can detected and graded with VCUG. Ultrasound  Associations and complications such as duplex kidneys, hydronephrosis andureterocoele can be also be assessed.
  43. 43. Ectopic ureter  A child with urinary incontinence and recurrent urinary tract infection.
  44. 44. Ectopic ureter  An ectopic ureter is identified and inserted into the posterior urethra. Associated grade III vesico-ureteric reflux is also noted.
  45. 45. Ureterocele A ureterocele refers to a herniation of the distal ureter into the bladder. Two types: Simple (normal location of ureter), 25% • Almost always occurs in adults • Usually also symptomatic in children Ectopic (abnormal location of ureter), 75% • Almost always associated with duplication • Unilateral, 80% • May obstruct entire urinary tract, because of prolapse into the bladder neck causing bladder outlet obstruction.
  46. 46. Ureterocele Radiographic Features • Ureterocele causes filling defect in bladder on IVP. • Typical appearance of a cystic structure by US • Ureterocele may be distended, collapsed, or everted to represent a diverticulum. Complications: Ureteroceles may contain calculi. May be very large (bladder outlet obstruction)
  47. 47. Ureterocele
  48. 48. Megaureter Congenital megaureter is a 'basket-term' to encompass causes of an enlarged ureter which are intrinsic to the ureter, rather than as a result of a more distal abnormality; e.g. bladder, urethra. It encompasses:  obstructed primary megaureter  refluxing primary megaureter (although vesico-ureteric reflux (VUR) is a cause of primary congenital megaureter it is usually considered separately)  non-refluxing unobstructed primary megaureter
  49. 49. Obstructive primary megaureter  Obstructive primary megaureter is related to a distal adynamic segment with proximal dilatation, and is a common cause of obstructive uropathy in children It is analogous to oesophageal achalasia or colonic Hirschsprung disease although lack of ganglion cells within the wall of the ureter has not been proven to be the cause .  the ureter tapers to a short segment of normal caliber or narrowed distal ureter, usually just above the vesicoureteric junction (VUJ).  The distal ureter above this narrowed segment is most dilated (similar to achalasia).  There is associated hydronephrosis, and active peristaltic waves can be seen on ultrasound.
  50. 50. Refluxing primary megaureter  Refluxing primary megaureter is a result of an abnormal vesico-ureteric junction, which impedes the normal anti-reflux mechanisms. This can be due to a short vertical intramural segment, congenital paraureteric diverticulum, ureterocoele with or without associated duplicated collecting system etc..  vesicoureteric reflux is demonstrated
  51. 51. Non-refluxing unobstructed primary megaureter  This is thought to be the most common cause of primary megaureter in neonates, and even though the vesicoureteric junction is normal, with no evidence of reflux or obstruction the ureter is enlarged. The cause for this is unknown.  there is absent or only a minor degree of hydronephrosis. Although rare, congenital megaureter may co-exist with congenital megacalyces 1, making assessment of hydronephrosis more difficult.
  52. 52. Dilation and elongation of both ureters, left >> right. Small left kidney with pyelonephritic scarring and sloughed necrotic papillae. Single pyelonephritic scar on the right.
  53. 53.  Primary megaureter - “A 10 month child came for the workup of recurrent UTI.  Primary megaureter is diagnosed in the absence of reflux, stricture, calculus or ureterocele.”
  54. 54. Vesicoureteral reflux (VUR)  Vesicoureteric reflux (VUR) is the term for abnormal flow of urine from the bladder into the upper urinary tract and is typically a problem encountered in young children.  The incidence of UTI is 8% in females and 2% in males  Reflux from the bladder into the upper urinary tract predisposes to pyelonephritis by allowing entry of bacteria to the usually sterile upper tract.  As such the diagnosis is first suspected after a urinary tract infection in a young child.
  55. 55. Vesicoureteral reflux (VUR)  Vesicoureteric reflux is, in the majority of cases, the result of a primary maturation abnormality of the vesicoureteral junction resulting in a short distal ureteric submucosal tunne. MCUG  The primary diagnostic procedure for evaluation of vesicoureteric reflux is a voiding cystourethrogram (VCUG).  presence and grade of VUR  whether reflux occurs during micturition or during bladder filling  presence of associated anatomical anomalies ultrasound  Routine ultrasound is usually also performed (in addition to VCUG) to assess the renal parenchyma for evidence of scarring or anatomic anomalies.
  56. 56. Vesicoureteral reflux (VUR) • Grade I: reflux to ureter but not to kidney • Grade II: reflux into ureter, pelvis, and calyces without dilatations • Grade III: reflux to calyces with mild dilatation,blunted fornices • Grade IV: to calyces with moderate dilatation,obliteration of fornices • Grade V: gross dilatation, tortuous ureters.
  57. 57. Vesicoureteral reflux (VUR)  Voiding cystourethrogram demonstrates reflux into both kidneys, with dilatation of the ureters and renal collecting system. The calyxes are distended and blunted. The urethra appears normal.  This case illustrates typical bilateral grade V vesicoureteric reflux
  58. 58. Vesicoureteral reflux (VUR)  VCUG demonstrating bilateral Grade III vesicoureteral reflux
  59. 59. Vesicoureteral reflux (VUR)  Pre-void contrast filled bladder demonstrated bilateral vesico- ureteral reflux with mildly tortuous and moderately dilated ureters, with contrast reaching blunted dilated calyces. Findings are keeping with bilateral type 4 vesico-ureteral reflux.
  60. 60. Obstruction of collecting system Causes • Calculi • Tumor • Previous surgery (ligation, edema, clot)
  61. 61. Urolithiasis  refers to the presence of calculi anywhere along the course of the urinary tracts.  The lifetime incidence of renal stones is high, seen in as many as 5% of women and 12% of males.  By far the most common stone is calcium oxalate, however the exact distribution of stones depends on the population and associated metabolic abnormalities  calcium oxalate +/- calcium phosphate: ~75%  struvite (triple phosphate): 15%  pure calcium phosphate: 5-7%  uric acid: 5-8%  cystine: 1%
  62. 62. Plain film Calcium containing stones are radiopaque  calcium oxalate +/- calcium phosphate  struvite (triple phosphate) - usually opaque but variable  pure calcium phosphate Lucent stones include  uric acid  cystine  Indinavir stones  pure matrix stones
  63. 63. Ct On CT almost all stones are opaque, but vary considerably in density.  calcium oxalate +/- calcium phosphate: 400-600HU  struvite (triple phosphate): usually opaque but variable  pure calcium phosphate: 400-600HU  uric acid: 100-200HU  cystine: opaque Two radiolucent stones are worth mentioning 11:  Indinavir stones - (anti-retroviral drug) radiolucent and usually undetectable on CT 5  pure matrix stones
  64. 64. Ct  In patients with little retroperitoneal fat, distinguishing a ureteric calculus from a phlebolith can be challenging. Two signs have been found helpful 12:  comet-tail sign - favours a phlebolith  soft-tissue rim sign - favours a ureteric calculus  comet-tail sign :The sign refers to a tail of soft tissue extending from a calcification, representing the collapsed/scarred/thrombosed parent vein. When well seen it is said to have a positive predictive value of 100% 1.  The soft-tissue rim sign is used to distinguish a ureteric calculus from a phlebolith. The former appears as a calcific density with a surrounding rim of soft tissue which represents the oedematous ureteric wall. Phleboliths on the other hand usually have imperceptible walls (although up to 8% may have a soft tissue rim sign 2) but may have a comet-tail sign.
  65. 65. Ct  Findings of ureteral obstruction include  ( 1 ) mild dilatation of the pelvicalyceal system and ureter (3 mm) proximal to the stone,  ( 2 ) slight decrease in attenuation of the affected kidney caused by edema.  ( 3 ) perinephric soft tissue stranding representing edema in the perinephric and periureteral fat.
  66. 66.  Nonenhanced CT image shows an obstructing left proximal ureteral calculus with a slight soft-tissue rim around the stone (ie, rim sign)
  67. 67.  40 Male patient complaining of right renal colic with hematuria
  68. 68.  An oval shaped radiodense stone is seen at the junction between upper 2/3 and lower 1/3 of the right ureter measuring about 0.5 x 1 cm along its maximum diameters and eliciting density of about (690 HU) associated with marked dilatation of the right pelvi- calyceal system and proximal part of the right ureter.
  69. 69. IVP (30-minute delay image) of the right kidney shows a moderately hydronephrotic collecting system to the level of a proximal ureteral stone (arrow). Source: emedicine.
  70. 70.  13 minutes after infusion of contrast medium there is contrast of the right pyelon and in the bladder, but yet no contrast of the left pyelon. There is also contrast outlining the left kidney, whereas it has already cleared from the right (delayed nephrogram).
  71. 71.  Two hours after infusion you can appreciate a distension of the left ureter and a hydronephrosis of the left pyelon.  This examination demonstrates the typical IVP features of collecting system dilatation and a delayed nephrogram secondary to a distal obstructing calculus. In this case, the calculus is well seen radiographically.
  72. 72.  30 year old male right flank pain; ultrasound shows proximal hydroureter and mild hydronephrosis  Scout- apparently normal with no evidence of calculus
  73. 73.  10 min film- right sided proximal hydroureter and mild dilatation of pelvicalyceal system
  74. 74.  15 min film- findings are persistent and a filling defect is noted at the L3-L4 level
  75. 75. Ultrasound  Ultrasound is frequently the first investigation of the renal tract, and although by no means as sensitive as CT, it is often able to identify calculi. Small stones and those close to the corticomedullary junction can be difficult to reliably identify. Ultrasound compared to CT-KUB reference showed a sensitivity of only 24% in identifying calculi. Nearly three-quarters of calculi not visualised were 3mm or less in size.13. Features include 7:  echogenic foci  acoustic shadowing  twinkle artefact on color Doppler  color comet-tail artefact 9
  76. 76.  80 year old female Non specific flank pain. Limited history due patient's confusion  Right hydronephrosis
  77. 77.  Left ureteric jet present (i.e. left ureter non obstructed)  No ureteric jet on the right (suspicious, although not in itself diagnostic for ureteric obstruction)
  78. 78.  Shadowing calculus at the right VUJ  Comet tail artefact supports the presence of a calculus
  79. 79. Ureteral tumors Types Benign tumors • Epithelial: inverted papilloma, polyp, adenoma • Mesodermal: fibroma, hemangioma, myoma, lymphangioma • Fibroepithelial polyp: mobile long intraluminal mass, ureteral intussusception Malignant tumors • Epithelial: transitional cell carcinoma, SCC, adenocarcinoma • Mesodermal: sarcoma, angiosarcoma, carcinosarcoma
  80. 80. Ureteral tumors  Due to the small caliber of the ureter, tumours are more likely to obstruct the kidney at small tumour size.  Obstruction may lead to hyrdonephrosis with or without hydroureter and may also result in a non-functioning kidney or delayed nephrogram. • Bergman's coiled catheter sign: on retrograde pyelogram the catheter is typically coiled in dilated portion of ureter just distal to the lesion
  81. 81. Ureteral tumors  Smaller or polypoid tumours may be seen as filling defects, and if they cause partial long-standing obstruction may result in focal dilatation of the ureter at the site of the tumour. This may lead to the so-called goblet sign, best seen on retrograde ureterography 2.  Occasionally circumferential thickening of the ureteric wall results from diffuse infiltration an may have an apple core appearance 4. 
  82. 82. Ureteral tumors Prognosis • 50% of patients will develop bladder cancer. • 75% of tumors are unilateral. • 5% of patients with bladder cancer will develop ureteral cancer. Sites of metastatic spread of primary ureteral neoplasm: • Retroperitoneal lymph nodes, 75% • Liver, 60% • Lung, 60% • Bone, 40% • Gastrointestinal tract, 20% • Peritoneum, 20% • Other (<15%): adrenal glands, ovary, uterus
  83. 83. Ureteral tumors  CT demonstrates a very large right sided ureteric mass with trapped contrast, which almost mimics a vascular aneurysm, and proximal long standing hydronephrosis.
  84. 84. Ureteric injury  Ureteric injury is a relatively uncommon but serious event, which may result in serious complications as diagnosis is often delayed.  Ureteric injuries unreliably demonstrate macro- or micro-scopic haematuria as it may be absent in up to 25% of patients. There is a wide-range of injury:  injury to the mucosa of the ureter post lithotripsy  perforation and false passage  partial or complete ureteric transection  complete ureteric avulsion  loss of ureteric segment  ligation  dissection
  85. 85. Ureteric injury  Iatrogenic(most commonly injured after gynaecological procedures)  Traumatic Classification Ureteric injury can be classified into three types according to its site:  upper-third  upper-third and pelvico-ureteric junction (PUJ) most affected by blunt trauma 5, 7  mid-third  distal-third  most common site  often following iatrogenic injury
  86. 86. Ureteric injury Fluoroscopy  Excretory intravenous urography if CT is not available: demonstrates contrast leakage and spillage outside the course of the urinary system.  Retrograde pyelography may be performed if both excretory intravenous urographyand CT with intravenous contrast are inconclusive and there is still a high suspicion of injury 1.
  87. 87. Ureteric injury CT  CT with intravenous contrast and delayed scan with full reformatted sagittal and coronal images and 3D reconstruction. The delayed scan should be performed between 5-8 minutes after IV contrast to ensure a CT-IVU (a.k.a. excretory phase) set of images is acquired.  intra-abdominal fluid collections without other cause shown  contrast extravasation from renal hilum/PUJ (usually medially) without associated renal injury
  88. 88. Ureteric injury  Post emergency caesarean section intraperitoneal tube drainage high output.  Contrast leakage and spillage is seen in the left side of pelvis in the region of lower third left ureter denoting a left ureteric injury
  89. 89. Bladder  Bladder exstrophy.  Bladder diverticulum.  Bacterial cystitis.  Emphysematous cystitis.  Neurogenic bladder.  Bladder calculi.  Malignant bladder neoplasm.  Bladder injuries.
  90. 90. Bladder exstrophy  Bladder exstrophy (also known as ectopia vesicae) refers to a herniation of the urinary bladder through an anterior abdominal wall defect. The severity of these defects is widely variable.  The estimated incidence of bladder exstrophy is 1:10,000-50,000 live births .  It is thought to be caused by a developmental defect of the cloacal membrane which results in a subsequent eversion of the bladder mucosa. This then protrudes out like the mass like lesion. General associations  extension of the bladder defect into the urethra  cryptorchidism  bilateral inguinal herniation  OEIS complex  epispadia  vaginal duplication  clitoral cleft
  91. 91. Bladder exstrophy  Imaging findings include a soft-tissue mass extending from a large infra-umbilical anterior wall defect which may be close to the umbilical arterial exits.  The absence of a normal urinary bladder and a low-lying umbilical cord insertion may also indicate the diagnosis.  Failure of the pubic bones to meet in the midline (widened pubic symphysis). This appearance on AP plain radiograph of the pelvis has been likened to a manta ray swimming towards you (manta ray sign).
  92. 92. Bladder exstrophy  Marked widening of the pubic symphysis (manta ray appearance) consistent with bladder exstrophy for which the patient had a known history.  In terms of a cause for hip pain, there is no fracture identified but there is mild left hip degenerative disease, and mild bilateral greater tuberosity irregularity suggesting chronic gluteal tendinosis.
  93. 93. Bladder exstrophy
  94. 94. Bladder diverticulum  Bladder diverticulum are outpouchings from the bladder wall, whereby mucosa herniates through the bladder wall.  They may be solitary or multiple in nature and can very considerably in size.  Diverticulae may be congenital or acquired. A range of causes of urinary bladder diverticula are described.  Acquired diverticula are more common, usually occurring the context of a trabeculated bladder, resulting from chronic bladder outlet obstruction.
  95. 95. Bladder diverticulum  Diverticula are often an incidental finding on imaging investigations, including ultrasound, CT, MRI and IVU. They may be associated with a range of complications including:  infection  reflux  stone formation  malignancy
  96. 96. Bladder diverticulum  IVU images shows a diverticulum at the right lateral wall.  Note the elevated base of the bladder due to the enlarged prostate.
  97. 97. Bladder diverticulum  Congenital diverticulae are solitary and are most often discovered during childhood.  Acquired bladder diverticulae are the result obstruction of the bladder outlet or bladder dysfunction. They are often multiple and typically seen in older men.
  98. 98. Bacterial cystitis Acute Cystitis Pathogens: E. coli > Staphylococcus > Streptococcus > Pseudomonas Predisposing Factors • Instrumentation, trauma • Bladder outlet obstruction, neurogenic bladder • Calculus • Cystitis • Tumor Imaging Features • Mucosal thickening (cobblestone appearance) • Reduced bladder capacity • Stranding of perivesical fat
  99. 99. Emphysematous cystitis  Emphysematous cystitis refers to gas forming infection of the bladder wall. Risk factors include:  female sex: reported M:F ratio 1:2  immunocompromised state  diabetes mellitus: may be present in ~50% of cases 2  neurogenic bladder  transplant recipients  The most common causative organism is E. coli, with other organisms including Enterobacter aerogenes, Klebsiella pneumonia, Proteus mirabilis, Staphylococcus aureus,
  100. 100. Emphysematous cystitis CT  CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas.  CT is also useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel carcinoma or inflammatory disease. Ultrasound  Can demonstrate echogenic air within the bladder wall with dirty shadowing artefact.  Ultrasound will also commonly demonstrate diffuse bladder wall thickening and increased echogenicity.
  101. 101. Emphysematous cystitis
  102. 102. Neurogenic bladder  Term applied to a dysfunctional urinary bladder that results from an injury to the central or peripheral nerves that control and regulate urination.  Injury to the brain, brainstem, spinal cord or peripheral nerves from various causes including infection, trauma, malignancy or vascular insult can result in a dysfunctional bladder 3.
  103. 103. Neurogenic bladder  In a large cohort study, the mean age of neurogenic bladder patients was 62.5 years and resultant etiologies included 4:  multiple sclerosis: ~17%  Parkinson disease: ~15%  cauda equina syndrome: ~9%  paralytic syndrome: ~8%  stroke complications: ~6%
  104. 104. Neurogenic bladder  A number of classification schemes exist for neurogenic bladders, including the Lapides classification which remains popular.  sensory neurogenic bladder: posterior columns of the spinal cord or afferent tracts leading from the bladder  motor paralytic bladder: damage to motor neurons of the bladder  uninhibited neurogenic bladder: incomplete spinal cord lesions above S2 or cerebral cortex or cerebropontine axis lesions  reflex neurogenic bladder: complete spinal cord lesions above S2 - may lead to pine cone bladder  autonomous neurogenic bladder: conus or cauda equina lesions
  105. 105. Neurogenic bladder uoroscopic/IVP Sensory neurogenic bladder Inability to sense bladder fullness results in a large rounded and smooth bladder. Voiding is often preserved. Motor paralytic bladder Atonic large bladder with inability of detrusor contraction during voiding. Unhibited neurogenic bladder Rounded bladder with a trabeculated apperance to the mucosa above the trigone from detrusor contractions. On voiding large interureteric ridge is noted Reflex neurogenic bladder Results from detrusor hyperreflexia with a dyssynergic sphincter. This leads to contrast extension to the posterior urethra and an elongated pointed urthera with pseudodverticula. Autonomous neurogenic bladder Intermediate between detrusor hyperreflexia (contracted) and dysreflexia (atonic).
  106. 106. Neurogenic bladder Ultrasound  Detailed images of the bladder often demonstrate a thick wall with a small contracted or large atonic bladder.  A large post void residual is often noted.
  107. 107. Neurogenic bladder  VCUR examination demonstrate elongated distended urinary bladder with multiple urinary bladder diverticulae characteristic of neurogenic bladder.  Grade III VUR on the left side is also demonstrated.
  108. 108. Neurogenic bladder  Neurogenic bladder, typically occurs in those with sacral abnormalities at birth.  The appearances has been described as a Christmas tree of pine cone bladder.  The shape of the bladder is highly abnormality with an elongated appearance, with the dome like the top of a Christmas tree.  The associated bladder wall hypertrophy gives an outline, which mimics the decorations that adorn a Christmas tree.
  109. 109. Neurogenic bladder  A pine cone bladder or christmas tree bladder is a cystogram appearance in which the bladder is elongated and pointed with thickened trabeculated wall.  It is typically seen in severe neurogenic bladder with increased sphincter tone (detrusor sphincter dyssynergia) due to suprasacral lesions (above S2-S4) or epiconal lesions (in and around S2-S4).  It is however not pathognomonic of a neurogenic bladder and can be seen in patients with lesions anywhere along the sacral reflex arc leading to poor detrusor compliance. Occasionally it is also seen in bladder neck obstruction of a non-neurogenic cause.
  110. 110. Bladder calculi  Bladder calculi occur either from migrated renal calculi or urinary stasis. Bladder calculi can be divided into primary and secondary stones:  primary: stones form de novo in the bladder  secondary: stones are either from renal calculi which have migrated down into the bladder, or from concretions on foreign material (e.g. urinary catheters)
  111. 111. Bladder calculi associated with :-  bladder outlet obstruction  cystocoele  neurogenic bladder  foreign body. Radiographic features  Plain Film  Usually densely radio-opaque, calculi may be single or multiple and often large. Frequently lamination is observed internally, like the skin of an onion.  Ultrasound  Sonographically they are mobile, echogenic, and shadow distally.  They may be associated with bladder wall thickening due to inflammation.
  112. 112. Bladder calculi
  113. 113. Malignant bladder neoplasm Clinical Finding • Painless hematuria. Types and Underlying Causes Transitional cell carcinoma, 90% • Aniline dyes • Phenacetin • Pelvic radiation • Tobacco • Interstitial nephritis SCC, 5% • Calculi • Chronic infection, leukoplakia • Schistosomiasis Adenocarcinoma, 2% • Bladder exstrophy • Urachal remnant • Cystitis glandularis. 10% pass mucus
  114. 114. Malignant bladder neoplasm Ct :  bladder transitional cell carcinomas appear as either focal regions of thickening of the bladder wall, or as masses protruding into the bladder lumen, or in advanced cases, extending into adjacent tissues.  The masses are of soft tissue attenuation and may be encrusted with small calcifications. MRI  MRI is superior to other modalities in locally staging the tumour and is in some instances able to distinguish T1 from T2 tumours on T2 weighted image.  T1: isointense compared to muscle 4  T2: slightly hyperintense compared to muscle  T1 C+ (Gd): shows enhancement
  115. 115.  Polypoidal, enhancing filling defect arising from the left bladder wall is typical of transitional cell cancer. No obstruction to the left ureteric orifice nor invasion through the bladder wall.
  116. 116. Malignant bladder neoplasm  Mural broad-based lesion lining the left aspect of Bladder. The lesion shows internal flow on Doppler.
  117. 117. Malignant bladder neoplasm  Polypoidal irregular mural thickening of the left lateral and posterior wall of the urinary bladder which coalesce to form large fungating mass arising from left lateral wall are seen and extends through the wall to invade the perivesical fat
  118. 118. Bladder injuries Extraperitoneal bladder rupture  Extraperitoneal rupture is the most common type of bladder injury, accounting for ~85% (range 80-90%) of cases.  It is usually the result of pelvic fractures or penetrating trauma.  Cystography reveals a variable path of extravasated contrast material. Intraperitoneal bladder rupture  Occurs in approximately ~15% (range 10-20%) of major bladder injuries, and typically is the result of a direct blow to the already distended bladder.  Cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds and in the paracolic gutters.
  119. 119. Bladder injuries Classification of Bladder Injury • Type 1: Bladder contusion • Type 2: Intraperitoneal rupture • Type 3: Interstitial bladder injury • Type 4: Extraperitoneal rupture • Type 4a: Simple extraperitoneal rupture • Type 4b: Complex extraperitoneal rupture • Type 5: Combined bladder injury
  120. 120. Bladder injuries CT  Bladder rupture is one form of genitourinary tract trauma, along with renal trauma and urethral injuries.  Contrast enhanced CT is the imaging technique of choice for bladder injuries in the form of CT cystography.  This may be combined with standard CT to evauluate the upper tracts.  Standard cystography has a more limited role
  121. 121. Bladder injuries Bladder catheter balloon in the intraperitoneal space
  122. 122. Bladder injuries Postvoid film shows a flame- shaped density adjacent to lateral walls of bladder representing extra-peritoneal contrast from a bladder rupture.
  123. 123. The Urethra  Posterior urethral valves (PUVs).  Urethral injuries.  Urethral strictures.
  124. 124. Posterior urethral valves (PUVs)  Posterior urethral valves (PUV's) are the most common congenital obstructive lesion of the urethra and a common cause of obstructive uropathy in infancy.  Posterior urethral valves are congenital and only seen in male infants 2. The estimated incidence is at ~1 in 10,000-25,000 live births with a higher rate of incidence in utero.  Clinical presentation depends on the severity of obstruction. In severe obstruction the diagnosis is usually made antenatally.  The fetus will be small for gestational age and ultrasound examination will demonstrate oligohydramnios
  125. 125. Posterior urethral valves (PUVs) Associations  Posterior urethral valves are also seen in association with other congenital abnormalities including :  chromosomal abnormalities, e.g. Down syndrome 5  bowel atresia  craniospinal defects
  126. 126. Posterior urethral valves (PUVs) Ultrasound Antenatal ultrasound:  On antenatal ultrasound the appearance is that of marked distention and hypertrophy of the bladder, with or without hydronephrosis and hydroureter, and depending on the severity, oligohydramnios and renal dysplasia. Postnatal ultrasound  The bladder is typically thick-walled and trabeculated with an elongated and dilated posterior urethra (keyhole sign).  The kidneys in most cases are hydronephrotic, although it is important to note that in up to 10% of cases they appear normal 5. They may also be hyperechoic with loss of the normal corticomedullary differentiation, a manifestation of renal dysplasia 5.
  127. 127. Posterior urethral valves (PUVs) Voiding cystourethrogram  Voiding cystourethrogram (VCUG) is the best imaging technique for the diagnosis of posterior urethral valves.  The diagnosis is best made during the micturition phase in a lateral or oblique views, such that the posterior urethra can be imaged adequately . Findings include :  dilatation and elongation of the posterior urethra (equivalent of the ultrasonographic keyhole sign)  linear radiolucent band corresponding to the valve (only occasionally seen)  vesicoureteral reflux (VUR): seen in 50% of patients .  bladder trabeculation/diverticula
  128. 128. Posterior urethral valves (PUVs)  Keyhole sign Rotated image of an antenatal ultrasound of the foetal pelvis demonstrating the keyhole sign, created by the distend bladder and posterior urethra.  The keyhole sign is an ultrasonograhic sign seen in boys with posterior urethral valves. It refers to the appearance of posterior urethra which is dilated, and associated thick walled distended bladder which on ultrasound may resemble a key hole.
  129. 129. Posterior urethral valves (PUVs)  Micturating cystourethrogram reveals marked dilatation of the prostatic portion of the urethra consistent with posterior urethral valves.
  130. 130. Posterior urethral valves (PUVs) Ultrasound reveals marked bilateral hydronephrosis and hydroureter. There is dependent echogenic debris seen throughout the renal collecting system consistent with infection
  131. 131. Urethral injuries  Urethral injuries can result in long-term morbidity and most commonly result from trauma.  The male urethra is much more commonly injured than the female urethra..  Clinically :blood of the external urethral meatus or vaginal introitus may be seen but is an unreliable sign.  Male urethral injuries are divided into anterior (penile/bulbar) and posterior (membranous/prostatic) urethral injuries.
  132. 132. Urethral injuries Classification:  blunt trauma: due to shearing or straddle injuries associated with pelvic fractures (occurs in ~10%) often associated with bladder injury.  penetrating trauma: e.g. stab wounds, gunshot wounds, dog bites (more commonly affect the anterior urethra)  iatrogenic, for example urethral instrumentation, e.g. catheterisation, Foley catheter removal without balloon deflation, cystoscopy,post-surgical (e.g. surgery for benign prostatic hyperplasia)
  133. 133. Urethral injuries Fluoroscopy  Retrograde urethrography is the modality of choice.  It will demonstrate extraluminal contrast, which has extravasated from the urethra. CT  CT cystography can be performed but this is much less specific for urethral vs. bladder injury.  Other features of urethral injury include retropubic and perivesical haematoma and obscuration of the urogenital fat plane.
  134. 134. Urethral injuries  Retrograde urethrogram in a patient with pelvic fractures demonstrates contained contrast leakage at the posterior urethra (membranous portion).  Contrast does ascend into the bladder and therefore the urethral injury is incomplete.
  135. 135. Urethral injuries  there is a small amount of extravasated contrast (from prior urethrogram) within the retro-pubic space (cave of Retzius), inferior extraperitoneal pelvic cavity and tracking into the perineum/perineal muscles and adductor musculature of the left thigh
  136. 136. Urethral stricture  Clinical presentation poor urine stream Aetiology  Infection(gonococcal urethritis (more common)),  trauma  straddle injury (most common)  pelvic fractures  iatrogenic  instrumentation  prolonged catheterisation  transurethral resection of the prostate  open radical prostatectomy  urethra reconstruction (hypospadia/epispadia)  congenital  uncommon
  137. 137. Urethral stricture  Past history of chlamyida infection.  20mm stricture in the bulbous urethra. 
  138. 138. Urethral stricture  Short segment (5mm) stricture at the junction of the penile and bulbous urethra.  Filling defect related to lubricant jelly used.
  139. 139. Thank You