film reading session

1. Film Reading Session
Urinary System
-BHANUPRIYA SINGH

2. Case 1
•Upper abdominal discomfort, vague constitutional
symptoms and reduced renal function in Elderly Female
PLAIN X- RAY

3. PRE AND POST CONTRAST CT

4. •X-raydemonstrates a large right sided branched calculus which
appears fragmented
•Pre- and post-contrast enhanced axial CT scans
through the kidneys show a staghorn calculous in an enlarged right
kidney (image on left, white arrow) which enhances slightly (image on
right) revealing low attenuation deposits (red arrow). There is
inflammatory stranding surrounding the right kidney
•Features are consistent with xanthogranulomatous pyelonephritis and
pre-existing staghorn calculus. It has tumor-like behavior and can
spread to involve and/or destroy adjacent organs
•Urolithiasis is common and can occur at any site along the
genitourinary tract.
•Numerous factors determine the management of renal tract stones,
with site and size being the two most important determinents.
•Prepartory imaging is an important part of the diagnostic and
management process

5. Imaging Findings
On ultrasound
Enlarged kidney which maintains reniform shape
Loss of corticomedullary differentiation
Multiple hypoechoic abscesses, granulomas or
dilated calyces
Loss of renal cortical tissue
Calculi do not usually shadow
CT is modality of choice
Heterogeneous, non-enhancing mass
Hydronephrotic kidney
Destruction of the normal renal parenchyma
Stones, of staghorn size, occur in 80% of cases
May also demonstrate small calcifications
Extrarenal extension

6. CASE-2
68-year-old woman with PAINLESS HEMATURIA. CT urography done.
Axial Non Enhanced CT scan. Axial Nephrogenic phase CT scan

7. Axial Excretory Phase CT Scan Axial Excretory Phase CT Scan :Bone
Window.

8. Coronal Maximum Intensity Projection Image

9. TCC of Renal Pelvis.
•a: mass in right renal pelvis.Mass is slightly hyperattenuating relative
to urine and renal parenchyma.
•b: mass has characteristic early enhancement,which is less than that of
surrounding renal parenchyma.
•c: mass within renal pelvis with surrounding excreted contrast medium
•d: Axial Excretory Phase CT Scan :Bone Window shows lesion clearly
•e:Coronal MIP showing tumor in Excretory Urography format
•f: same as ‘e’ showing lesion more clearly.
Maximum Intensity Projection (MIP) consists of projecting the voxel with the highest
attenuation value on every view throughout the volume onto a 2D image

10. CT Urography: consists of multi-phasic helical CT protocol.
•A PRE-ENHANCEMENT SCAN is initially prformed from upper pole of
kidney to lower edge of symphysis pubis: To Exclude URINARY TRACT
CALCULI.
•A LATE-ARTERIAL , EARLY CORTICO-MEDULLARY PHASE scan of kidney
and lower pelvis 15-25 seconds after contrast infusion,allows evaluation
of VASCULAR ABNORMALITIES.
•A NEPHROGENIC PHASE scan of kidney, 80-140sec after contrast
material infusion allows assesment of RENAL PARENCHYMA.
•A EXCRETORY PHASE Scan from upper pole of kidney to symphysis
pubis,4-8min after contrast material infusion allows assesment of
UROTHELIUM

12. Case-3
k/c/o
Rheumatic
Heart
Disease with
Sudden
onset of
flank pain
and
Hematuria

13. Renal Infarction : wedge-shaped non-enhancing lesion in the right kidney with no perinephric
inflammatory stranding
•Thrombotic disease usually affects larger vessels
Includes main renal artery
Patients with thrombotic disease usually present with hypertension or renal insufficiency
Usually results from atherosclerosis
But, blunt abdominal trauma may cause intimal tears with subsequent dissection and
thrombosis
•Emboli can affect vessels of various sizes depending on the size of the emboli
Renal artery emboli usually come from cardiac source
Embolic disease usually produces acute symptoms
Sudden onset of flank pain
Lobar Renal Infarction
Early signs
Focal attenuation of collecting system
Tissue swelling
Focally absent nephrogram
Triangular with base at cortex
Late signs
Normal or small kidney(s)
Focally atrophied parenchyma with normal interpapillary line
Cortical atrophy and irregular scarring are seen as late sequelae

14. CT signs:
Subtle renal infarcts are best demonstrated on CT
Appear as wedge-shaped, cortically based, hypodense areas
Triangular in shape with widest part at the cortex (base of infarct)
Non-perfused area corresponding to vascular division
Renal swelling may also be seen
Cortical rim sign
Entire kidney is nonenhancing except for the outer 24 mm of cortex, which are
perfused by capsular branches
USG signs:
Focally increased echogenicity
Color flow Doppler aids in diagnosis of renal artery thrombosis
There is absence of an intrarenal arterial signal
Tardus parvus waveform is seen if incomplete occlusion or collateral supply
Nuclear medicine
Nuclear imaging shows a photopenic area corresponding to the region of ischemia or
infarction
Renal Infarction

15. CASE-4
50 Y/ Male
k/c/o Ureteric obstruction secondary to a pelvic tumour
Identify the procedure.

17. IMAGES SHOW :-
1. Contrast injection through an 18 gauge needle confirms lower pole
calyx puncture.
2. Guidewire inserted through the needle.
3. 9Fr dilator inserted over the guidewire after removing the needle
4. 8Fr pigtail drain inserted over guidewire. Contrast injection confirms
satisfactory nephrostomy drain postion.
Percutaneous nephrostomy is a technique in which
percutaneous access to the kidney is achieved under radiological
guidance. The access is then often maintained with the use of an
indwelling catheter

18. CASE-5
Recurrent UTI in a 83/M Caucasian

19. Single bladder calculus
Chronic large bladder calculus with concentric rings
•solid build-ups of crystals made from minerals and proteins found in
urine.
•Bladder diverticulum, enlarged prostate, neurogenic bladder and
urinary tract infection can cause an individual to have a greater chance
of developing a bladder stones.
•Abdominal and pelvic CT: This is the most rapid scanning method for locating
a stone. This procedure can provide detailed images of the kidneys, ureters,
bladder and urethra, identify a stone and reveal whether it is blocking urinary
flow.
•Intravenous pyelogram (IVP): This is an x-ray examination of the kidneys,
ureters and urinary bladder that uses iodinated contrast material injected into
veins.
•Abdominal and Pelvic ultrasound: These exams provide pictures of the kidneys
and bladder and can identify blockage of urinary flow and help identify stones

20. Case-6
Retrograde
Pyelogram

21. CT Scan

22. •Retrograde pyelogram of right ureter demonstrates displacement of
the ureter which passes
medial to the pedicle ft the level of L4. The ureter is slightly dilated
proximal to this point and returns to a
normal position distal to its retrocaval placement.
•CT scan below the level of the kidneys demonstrates a more medial
retrocaval placement of the right ureter.

23. Case-7
19yr old Male with bladder issues from childhood
Fluoroscopy: AP

24. 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.

25. Case-8
40 year old male suffering from sickle cell anemia

26. Papillary Necrosis: Necrosis and sloughing of papillary tissue.
•a: 8 min. excretory urogram showing multiple small collections of
contrast material in papillary region adjacent to calices
•b: Excretory phase CT scan obtained within 1.25mm section thickness
through upper kidney showing small contrast filled papillary cavaties
adjascent to calices bilaterally
•c: small para-caliceal contrast material collectionsin papillary regions
These papillary defects may eventually become peripherally calcified.
Sloughed papillae appear as filling defects in the collecting system and ureters at urography
and excretory phase enhanced CT.

27. CASE-9 62 year old UNCONTROLLED hypertensive

28. Malignant pheochromocytoma in a 62-year-old man.
(a) Contrast-enhanced CT scan shows a complex left adrenal mass (solid arrows)
representing a malignant pheochromocytoma with hepatic metastases (open arrow)
and portocaval adenopathy.
(b) Pelvic CT scan shows sacral and left iliac bone metastases (arrow). Metastatic
spread is the only reliable criterion for differentiating a benign from a malignant
pheochromocytoma.

30. Case- 10

31. Simple ureterocele. Cystic dilation of intra-vesical segment of ureter.
(a) IVU image shows the typical cobra head appearance at the end of
both ureters (arrowheads). bladder.
(b) IVU image shows the contrast material–filled bladder, with a negative filling defect
(arrowheads) that represents a ureterocele.
(c) Transverse US image of the bladder(B) demonstrates a sonolucent cystic structure
with an echogenic wall (U ) that projects into the bladder, a finding that represents a
simple ureterocele.
•It represents dilatation of intra-vesical segment of ureter.
•May be associated with single or duplex ureter.
•CONGENITAL DEFECT is obstruction of meatus & URETEROCELE is simply
HYPERPLASTIC RESPONSE to this obstruction.
•OUTER WALL: Bladder Epithelium
•INNER WALL: Ureteral Epithelium
•With connective tissue and muscle fibre in between
•It may be small(1cm),or fill entire bladder and prolapse through urethra
•May be associated with uretral duplication.