SURGERY POSTING

1. Mujaahid Amin
Aiman Shaifuzain
Rajhmuniran Kandasamy

2.  Anatomy of genitourinary tract
 Urolithiasis
 Pyelonephritis
 Pyonephrosis
 Hydronephrosis
 Cystitis
 Bladder diverticulum
 Bladder cancer
 Prostate imaging

6. Purpose of the KUB Radiography
 To determine the size, shape, and position of the kidneys
and bladder
 To detect obvious abnormalities of the urinary system, such
as kidney stones
 To help differentiate between urologic and gastrointestinal
diseases, which both produce abdominal pain
 To locate a foreign object (e.g. that has been swallowed)
 To detect air or fluid in the space surrounding the abdominal
organs (peritoneal space)

7.  Patient’s particular
- Name of patient, RN, Date and Name of Hospital
 Radiograph
- Type of examination : plain radiograph
- Part of examination : KUB
- View of projection : AP
- Body position : supine
- Left / Right marker

8.  Centering
 Region of interest of the pt should be well centered on the film
 Rotation
 Distance between the spinous process and pedicle
 Exposure
 Good exposure gives the differentiation between bones, soft tissue, fat planes and gas.
Also bone trabeculae are visualized
 Correct position and good exposure film demonstrate kidney shadows and psoas
outline provided no or minimal bowel shadow.
 Collimation
 Upper – lower liver portion (upper poles of the kidney must be well included)
 Lower – symphysis (urinary bladder base must be included)
 Side to side – abdominal wall and its soft tissue of no interest and they are excluded.
Therefore, it is satisfactory if lateral margins of the kidneys are well included. This
aiming to get only the necessary structures ( region of interest)

9. Kidney length should not be
less than three vertebral body
lengths, and no more than four
vertebral body lengths
L3 has the longest transverse process
Good exposure?
Look at vertebral
column
• Unable to see –
poor exposure
• Only bone -
overexposure

10. Kidneys
 Visualized due to surrounding perirenal fat,
surrounding kidney
 Length of kidney is estimated
approximates to 3 and half of vertebral
body height ~ 12-14 cm
 Position & orientation : lying over the
psoas muscle and lying obliquely with the
head more medially orientated

11. Ureters
 Not visualized normally. Only in IVU study it
is visualized.
 Normally it travels along the tips of the
transverse processes of the vertebral
bodies in the abdomen. When it enters the
pelvis it crosses the sacro-iliac joint to
bladder.
This frontal x-ray from an intravenous pyelogram (IVP),
obtained 10 minutes after the intravenous injection of
iodinated contrast, shows a normal appearance of the
kidneys, ureters and bladder

12. Urinary bladder
 Is visualized when it is full (opaque).
 Surrounding bowel gas is radiolucent
causing contrast. Also rounded shape
and displacement of the bowel gas give
the impression of the bladder.

13. Psoas muscle
 Visualized due to fat underlying fascia.
 In normal individual, either one or both
sides can be visualized. It is still normal if
one side is not visualized.
Bones
 Must be reviewed for other possible
associated or incidental findings.
 Ribs, lumbar vertebrae, sacrum, coccyx,
pelvis, proximal femur

16.  Size of the kidney,
 Thickness of its cortex
 Presence and degree of hydronephrosis
 Intrarenal masses - smooth walled and fluid filled (simple cysts) or solid and complex
(possible tumours).
 Stones produce a bright ultrasonic reflection and cast an acoustic shadow
 The volume of urine in the bladder before and after micturition can be calculated, and
even tiny filling defects within it detected.
 Ultrasound scanning provides broadly similar anatomical information to an intravenous
urogram but without the risks

18. R
Sagittal /Longitudinal Transverse
•Size
•Shape
•Parenchyma
•Hydronephrosis
Normal kidney size – Male 10-14cm, female 9-13cm

19. L
Sagittal/Longitudinal Transverse
•Size
•Shape
•Parenchyma
•Hydronephrosis

20. Renal pelvis is filled with urine and is echo free
with posterior enhancement behind renal pelvis.
Posterior shadowing :
A blackish area @ shadow
under a very dense
structure
(bone/stone/calcification)
because sound cannot
travel past it
Posterior enhancement :
A whitish area under lesser
dense structure (water/pus)
because sound can move
freely (dispersed)

22.  Intravenous urography (IVU), also referred to as intravenous pyelography
(IVP) or excretory urography (EU), is a radiographic study of the renal
parenchyma, pelvicalyceal system, ureters and the urinary bladder. This
exam has been largely replaced by CT urography.

23.  These are organic chemicals to which iodine atoms are attached to absorb
X-rays.
 When injected, it is filtered from the blood by the glomeruli and does not
undergo tubular absorption.
 Rapidly passes through the renal parenchyma into the urine, which it
renders radio-opaque.
• Normal IVU showing the
outline of both kidneys
with the collecting system
and upper ureters
highlighted by the
contrast medium.

26.  CT is particularly useful to assess structures in the retroperitoneum.
 In renal carcinoma it will show:
• the size and site of the tumour and the degree of invasion of
adjacent tissue
• the presence of enlarged lymph nodes at the renal hilum;
• invasion of the renal vein and vena cava.
 CT is of crucial importance in the initial staging and follow-up of men with
testicular cancer, in whom the presence of retroperitoneal lymph node masses is
a feature of advanced disease.
 It has also been used to stage bladder and prostate cancer, but its value is less
clear cut in these diseases.
 Non-contrast CT is also used routinely in the diagnosis of urinary calculi.

29.  Refers to the presence of stones in the kidney(s).
 Presented with sudden onset of severe pain
originating in the flank and radiate to the back.
 May associated with hematuria, nausea and
vomiting.
 CT of the abdomen and pelvis without contrast
performed using low-radiation-dose scanning
protocols is the preferred exam for most adults
with suspected nephrolithiasis.

30.  Diagnose 90% of radio-opaque stones.
 Differential diagnoses of opacities on KUB:
I. Phleboliths
II. Calcified mesenteric lymph nodes
III. Ossified tip of 12th rib
Radioopaque stones (90%)
•Calcium containing stones
•Cysteine stone (faintly)
Radiolucent stones (10%)
•Uric acid stone

31. Phleboliths are calcifications within venous structure.
Common in the pelvis where they may mimic ureteric calculi.
Appear as focal calcifications, often with radiolucent centers.

33.  Echogenic rim
 Posterior acoustic shadowing

36. Definition :
Bacterial infection of the renal pelvis and parenchyma
Clinical Features :
 Rapid onset of high fever
 Flank pain
 Costovertebral angle tenderness (i.e. positive Murphy
kidney punch).
 Less specific or non-urinary symptoms and signs may
also be present, which may lead to clinical confusion.
Laboratory Findings :
 White cells and bacteria are usually present in the urine
 Blood tests reveal the expected changes:
leukocytosis and increased C-reactive protein(CRP)
or erythrocyte sedimentation rate (ESR).
 In severe cases, sepsis may be present.
Diagnosis :
• Diagnosed based on clinical symptoms and
laboratory data without imaging examinations
• When imaging is warranted, CT is the modality of
choice for evaluating acute bacterial nephritis.
• It provides comprehensive anatomic and physiologic
information that accurately characterizes both intra-
and extrarenal pathologic conditions.
• After administration of contrast material, acute
bacterial nephritis most commonly manifests as one
or more wedge-shaped areas or streaky zones of
lesser enhancement that extend from the papilla to
the renal cortex.

37.  This is a clinical diagnosis – imaging is rarely required during
uncomplicated adult disease
 It can however be useful if diagnosis is in doubt or to exclude
obstruction or abscess development.
Ultrasound
Ultrasound is insensitive to the changes of acute pyelonephritis,
with most patients having 'normal' scans. Abnormalities are
identified in only ~25% of cases.
 Possible features include:
 particulate matter/debris in the collecting system
 reduced areas of cortical vascularity by using power
Doppler
 gas bubbles (emphysematous pyelonephritis)
 abnormal echogenicity of the renal parenchyma
 focal/segmental hypoechoic regions (in edema) or
hyperechoic regions (in hemorrhage)
 mass-like change
 Ultrasound is, however, useful in assessing for local
complications such as hydronephrosis, renal
abscess formation, renal infarction, perinephric collections,
and thus may guide management.
CT
CT is a sensitive modality for evaluation of the renal tract, able to
assess for renal calculi, gas, perfusion defects, collections and
obstruction.
There is usually no need for a three or four phase CT IVP (CT
urography). A single 45-90 second post-contrast scan usually
suffices, although clinical acumen may be necessary to choose
the best contrast phase.
Non-contrast CT
• often the kidneys appear normal
• affected parts of the kidney may appear edematous, i.e.
swollen and of lower attenuation
• renal calculi or gas within the collecting system may be
evident
Post-contrast CT
• one or more focal wedge-like regions will appear
swollen and demonstrate reduced enhancement
compared with the normal portions of the kidney
• the periphery of the cortex is also affected, helpful in
distinguishing acute pyelonephritis from a renal infarct
(which tends to spare the periphery; the so-called 'rim
sign')
• if imaged during the excretory phase, a striated
nephrogram may also be visible
• If for some reason the kidney is imaged again within 3-6
hours, persistent enhancement of the affected regions

39. (7) Unenhanced CT scan shows asymmetric enlargement and absence of the pyramids of the
right kidney (ct. the preserved pyramids [arrow] in the normal left kidney).
Loss of the renal pyramids is a nonspecific marker for edema, which is more typically seen in
obstruction related to calculi.
(8) Unenhanced CT scan demonstrates multiple, scattered, round and oval hyperattenuation foci
within the left kidney, findings indicative of hemorrhagic acute bacterial pyelonephritis.

40. Definition :
 Term given to an infection of the kidney with pus
in the upper collecting system which can
progress to obstruction.
 Pyonephrosis may be suspected when the
clinical symptoms of fever and flank pain are
combined with the radiologic evidence of urinary
tract obstruction. Debris in the upper collecting
system on imaging raises even more suspicion.
Clinical Features :
 Urinary tract obstruction
 Flank pain
 Fever
 Others – weight loss, dull pain
Diagnosis : Is based on the clinical findings and
imaging studies

41.  Ultrasound
 Ultrasound usually shows dilatation of the
pelvicalyceal system with the following additional
features:
 echogenic debris in the collecting system:
considered the most reliable sign
 fluid-fluid levels within the collecting system
 incomplete ("dirty") shadows of gas in the
collecting system may occasionally be seen
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.
features of obstruction :
• 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
• gas-fluid levels in the intrarenal collecting
system
• layering of contrast material above / anterior to
the purulent fluid on excretory studies
A caveat to CT evaluation is that it is often difficult
to distinguish simple hydronephrosis from
pyonephrosis by fluid attenuation measurements.

42. (a) US image shows a dilated collecting system that is nearly completely filled with
echogenic debris (arrow) secondary to pyonephrosis.
(b) Fluid – fluid level in dilated callices

43. Definition :
 Dilatation of the urinary collecting system of
the kidney (the calyces, the infundibula, and
the pelvis)
Clinical Features :
 Pain - from bladder distension, secondary
infection, or obstructing stones or masses.
Hydronephrosis alone is almost always
asymptomatic
 Change in urine output
 Hypertension
 Hematuria
 Increased serum creatinine
Laboratory Findings :
• Urinalysis is used to assess for signs of
infection. Pyuria suggests the presence of
infection.
• Microscopic hematuria may indicate the
presence of a stone or tumor.
• Complete blood cell count may reveal
leukocytosis, which may indicate acute
infection.
• Serum chemistry studies can reveal an
elevation of BUN and creatinine levels, which
may be the result of bilateral hydronephrosis
and hydroureter
Diagnosis :The diagnosis of urinary tract
obstruction is done via imagings

44.  The hallmark of urinary obstruction is dilatation of
the collecting system in one or both kidneys. This
is readily apparent on sonograms because the
hypoechoic fluid displaces the echogenic sinus fat
 On CT, the urine has greater attenuation than the
sinus fat but only slightly less than the renal
parenchyma.
 On contrast-enhanced scans, the parenchyma is
considerably brighter than the urinary space until
the excretory phase, when contrast fills the
collecting system . Usually, the minor and major
calyces and the renal pelvis are dilated, but dilation
of the minor calyces may not be apparent early.
• In addition to the collecting system, it is
important to evaluate the parenchyma since
cortical thinning often indicates chronic
obstruction

45. (a) The minor and major calyces and the renal pelvis are dilated
(b) Central pocket of anechoic region – water
(c) There is no cortical thinning
(d) This is a posterior enhancement showing that there are pus/fluid collection within the pelvis

46.  Dilated anechoic calyces with
increased posterior transmission
of sound.
 Hyperechoic fat delineating
dilated calyces.
 Cortex is normal with similar
echo pattern of liver.

47.  A. Grade 1 (mild)
 dilatation of the renal pelvis without
dilatation of the calyces
 B. Grade 2 (mild)
 dilatation of the renal pelvis and
calyces
 C. Grade 3 (moderate)
 moderate dilatation of the renal pelvis
and calyces
 D. Grade 4 (severe)
 gross dilatation of the renal pelvis and
calyces, which appear ballooned

48. 1. On contrast-enhanced scans, the parenchyma is considerably brighter than the urinary space
2. Showing dilated calyces, pelvis, and proximal ureter on the right side.
3. There is almost complete cortical thinning

49.  Transverse (A) and coronal reconstruction
(B) from a contrast-enhanced scan
(corticomedullary phase) showing, grossly
larger left kidney with dilated calyces,
pelvis, and proximal ureter.

51.  Infection of bladder that give rise to
symptoms of frequency, urgency,
suprapubic discomfort, dysuria, and cloudy
offensive urine
 Predisposing cause :
- bladder outflow obstruction
- calculus, foreign body, neoplasm
- dilated ureters in pregnancy or VUR that causes
incomplete emptying of upper tract
 Ascending infection from urethra is
commonest route
- From bowel  vulva reach urethra
- Urethral instrumentation  urinary infection
• Other route : descending from kidney
(tuberculosis), hematogenous spread,
lymphogenous and from adjoinng sructures
(vagina, fallopian tube or gut)
• Common organism : Escherichia coli , Proteus
mirabilis, Staphylococcus epidermidis,
Streptococcus faecalis
• Diagnosis : history, physical examination
• Investigations : mid stream urine collection
(microscopy and culture)

52. BLADDER ULTRASOUND
The urinary bladder is distended showing
abnormal irregular wall thickening. The
mural thickness is approximately 7 mm

53. 1)Differential diagnosis for bladder wall thickening depends on whether the
bladder is adequately distended. The bladder wall may be thickened if:
 >3 mm when distended
 >5 mm when nondistended
2)Diffuse bladder wall thickening Ddx
 bladder outlet obstruction
 neurogenic bladder
 infectious cystitis
 cystitis from radiation or chemotherapy
 3) Focal bladder wall thickening can be transitional cell carcinoma, blood
clot

54. Plain radiography is noninvasive and is good for
diagnosing renal and bladder calculi and bladder
calcification, as occur in some forms of chronic
cystitis
Plain radiograph in a 63-year-old patient
with poorly controlled type 2 diabetes
mellitus shows emphysematous cystitis.

55. intravenous urography in a 62-year-old man with recurrent urinary tract infections
shows multiple opaque bladder calculi (left). Note calculi in the right kidney. Right:
Image obtained 20 minutes after the administration of contrast material shows a left
hydronephrosis, hydroureter, bladder trabeculation secondary to bladder outlet
obstruction, and bladder calculi.

56.  Normal intravesical pressure during voiding is
about 35-50 cmH2O. However, Pressure as
great as 150 cmH2O may be reached by
hypertrophied bladder endeavouring to force
urine past an obstruction.
 This pressure causes the lining between the
inner layer of hypertrophied muscle to protrude,
forming multiple saccules.
 If one or more saccules is forced through whole
thickness of bladder wall -> Diverticulum

57. PATHOLOGY
 Usually mouth of diverticulum is
situated above and to the outer
side of one ureteric orrifice
 Size varies from 2 to 5cm but may
be larger
 Large diverticulum enlarges
downwards and may obstruct
ureter
COMPLICATIONS
• recurrent urinary infection
• Bladder stone
• Neoplasm
• Hydronephrosis and
hydroureter
DIAGNOSIS
Diverticula are usually
discovered incidentally on:
cystoscopy or
ultrasonography
Also can do cystogram

60. BLADDER & PROSTATE

61. CT ANATOMY

63. MRI ANATOMY

65. BLADDER

66. Bladder Carcinoma
• Primary bladder cancer : 95 % originate from
transitional epithelium
• Secondary bladder cancer : arise from sigmoid,
rectum, prostate, uterus, ovaries.
• Classic clinical presentation is painless, gross
hematuria, age >50 years old, chemical and radiation
exposure
• Diagnosis
– Cystoscopy and biopsy
– Gold standard for diagnosis
• Urinary cytology
• Imaging
– CT scan – contrast and non contrast
– MRI scan
– IVU (intravenous urogram)
– Ultrasound

67. BASIS OF IMAGING IN BLADDER CA

68. ULTRASOUND
A sessile or pedunculated mixed
echogenicity mass projecting
into bladder lumen

73. CT

74. MRI BLADDER CANCER

75. • Help to reveal cancer growth that is overlooked or difficult to
characterise by conventional CT, X-RAY or MRI.

76. PROSTATE

78. Plain Radiograph
• Cannot be used to demonstrate
localized disease in the prostate
• They are generally only needed in
the first line evaluation of
metastatic disease. (most skeletal
metastases from prostate cancer –
about 85% are osteoblastic and
are visible as an area of abnormal
tracer activity on a radionuclide
bone scan.
• Imaging with skeletal radiographs
can help distinguish metastatic
areas from degenerative disease.
X ray of the pelvis shows
prostatic calcification with
areas of sclerosis in the pelvis
and proximal femur on both
sides

79. CT Scan
• Has little value in demonstrating
intraprostatic pathology and in local
staging
• However it may be helpful in detecting
metastatic disease (such as LN
involvement or bone metastases)
• It also helpful in detecting invasive
progression of prostate carcinoma
• Nodal staging is indicated in
– pt with a PSA value of 20 ng/ml or
higher
– Clinical stage T2b or higher
– Gleason score of 7 or higher

80. Ultrasound Prostate
• Approach of ultrasound can be divided into :
– TRUS (Transrectal Ultrasound)
– TRAS (Transabdominal Ultrasound)
• Objective of Prostate Ultrasound
– Size of gland
– Overall echotexture
– Focal lesion
– Seminal vesicles
– Vasa deferentia
– Ejaculatory ducts
– Periprostatic fat

81. 1) Prostate Volume
• Size of glands :
– Sagittal image
– Transverse image
• V : (0.52) x L x W x H
• Weight = Volume
• Normal : 7-16 grams
• Volume < 30 ml (NORMAL)

83. 2) Echotexture of prostate
• Outer gland :
– Iso-hyper echoic
• Inner gland :
– Hypoechoic
Hyperechoic : (white on screen)
Hypoechoic : (gray on screen)
Anechoic : (black on screen)
Isoechoic : (same relatively)

86. MRI Anatomy of prostate
• The best anatomic detail is on T2WI.
• Below an example of a prostate with minimal BPH (<30 mL entire gland).
• From superior to inferior, the gland is commonly divided into 3 levels
(approximate thirds)
 Base (incudes parts of peripheral zone, central zone and transition zone)
 Mid Gland (includes mostly peripheral and transition zones)
 Apex (includes mostly peripheral zone, some transition zone)
Sagitt
al
Coro
nal

87. BPH

88. Approach to Benign Prostate Hyperplasia
• Benign prostatic hyperplasia is due to a combination of stromal and
glandular hyperplasia, predominantly of the transition zone (as
opposed to prostate cancer which typically originates in the
peripheral zone).
• Androgens (DHT and testosterone) are necessary for the
development of BPH, but are not the direct cause for the hyperplasia.
• C/P : asymptomatic or with lower urinary tract symptoms (LUTS)
• Clinically use International Prostate Symptom Score (IPSS) for plan of
Mx
• P/E : DRE -> enlarged prostate
• Markers : Prostate Specific Antigen (PSA) : elevated but non-specific

89. BASIS OF IMAGING IN BPH /BENIGN
• benign processes such as BPH and prostatitis require little
investigation.
• TRUS can provide high-resolution images of the prostate and real-
time guidance for intervention such as biopsy, aspiration, and
drainage, without the use of radiation.
• (MRI) accurately delineates the internal prostatic anatomy but is
not routinely used for the investigation of benign prostate
lesions owing to its high cost and relatively limited availability.
• Relative to these modalities, radiography and computed tomography
(CT) have limited roles in the evaluation of most prostate processes.

90. Ultrasound in BPH
• Ultrasound has become the standard first
line investigation after the urologist's finger.
– there is an increase in volume of the prostate
with a calculated volume exceeding 30 mL (width
x height x length x 0.52)
– the central gland is enlarged, and is hypoechoic
or of mixed echogenicity
– calcification may be seen both within the
enlarged gland as well as in the pseudocapsule
(representing compressed peripheral zone)
– post-micturition residual volume is typically
elevated
– associated bladder wall hypertrophy and
trabeculation due to chronically elevated filling
pressures
Ultrasound of the bladder and
prostate demonstrates and
enlarged prostate (consistent with
benign prostatic hypertrophy)
resulting in a high post micturition
volume

91. MRI of Prostate (BPH)
Coronal image of a normal
prostate. Note the
hyperintensity of the CZ
compared to the PZ.
Peripher
al zone
Central
zone
Magnetic resonance imaging T2-
weighted axial image of the
prostate, showing normal prostate
anatomy.

92. Prostate Hyperplasia
BPH less commonly
occurs
outside of the
transition zone.
• Small BPH nodule
at R base at the
central/peripheral
zone border
• Benign prostate hyperplasia (BPH) typically arises in
the transition zone, distorts zonal anatomy, and can
get very large (over 200 mL).
• BPH has glandular components (T2 light) as well as
stromal components (T2 dark), usually with multiple
encapsulated appearing nodules.
BPH commonly extends
into the urinary bladder
(UB), frequently referred
to as the “median lobe,”
worth mentioning as
there can be treatment
implications
UB

93. PROSTATE CA

94. Approach to Prostate Cancer
• Prostatic carcinoma ranks as the most common
malignant tumor in men and the second most
common cause of cancer-related deaths in men.
• Prostatic adenocarcinoma is by far the most common
histological type
• C/P : LUTS symptoms, hematuria, back pain
• Clinically use International Prostate Symptom Score
(IPSS) to assess symptoms severity.
• Pathophysiology :
– 95% prostatic adenocarcinoma
– spread
• local invasion
• lymphatic spread
• haematogenous spread
– bone (90%)
– use Gleason score

95. Approach to Prostate Cancer
• Investigations :
– assisted prostatic biopsy (ultrasound/MRI)
– local and whole-body staging
• Role of imaging :
– assist in a successful biopsy
(ultrasound/MRI)
– MRI for local staging, e.g. is there
extracapsular spread?
– whole-body staging (Bone Scan/CT Scan)

96. BASIS OF IMAGING IN PROSTATE CA

97. Ultrasound in Prostate Cancer
• a hypoechoic region in the periphery of the gland
• ultrasound-guided transrectal biopsy

98. CT Scan
• Not accurate at detecting in situ
prostate cancer.
• Scans of the abdomen and pelvis are
commonly obtained before the onset of
radiation therapy to identify bony
landmarks for planning.
• In advanced disease, CT scan is the test
of choice to detect enlarged pelvic and
retroperitoneal lymph nodes,
hydronephrosis and osteoblastic
metastases

99. CT SCAN PROSTATE CA

101. MRI in Prostate CA
• The primary indication for MRI of the prostate is in the
evaluation of prostate cancer after an ultrasound guided
prostate biopsy has confirmed cancer in order to
determine if there is extracapsular extension
• MRI is also being used to detect and localize cancer when
the PSA is persistently elevated, but routine TRUS biopsy is
negative.
• MRI-guided prostate biopsy is also being used, particularly
in those cases where TRUS biopsy is negative but clinical
and PSA suspicion remains high
• Following radical prostatectomy, patients with elevated
PSA should also be examined using MRI.
• Often a PI-RADS score is given to assess the probability of
the lesion being malignant.

102. Axial view sagittal
view
Ill-defined hypointense lesions in the peripheral zone of
the prostate gland. This appearance is suggestive of
prostate carcinoma.

103. T2 hypointense
nodule at the base of
the left prostate side
lobe extending
beyond the capsule.
Involvement of left
seminal bladder can't
be excluded.
Disseminated
osteoblastic skeletal
metastases.
https://radiopaedia.org/c
ases/t3-prostate-cancer-
on-mri