URINARY TRACT RADIOLOGY

Modalities
1. Simple radiology
2. Intravenous urography
3. Retrograde pyelography
4. Antegrade pyelography
5. Renal angiography
6. Cystography, cysto-urethrography and dynamic bladder studies
7. Urethrography
8. Cyst puncture
9. Ultrasound
10. Computed tomography
11. Isotope imaging and renography
1. Plain X-rays
? Good-quality films will often show the renal outlines quite clearly, and
gross enlargement of the kidney by hydronephrosis or tumour may be readily reco
gnised
? Similarly, gross shrinkage of the kidney from chronic pyelonephritis or
from renal ischaemia may be diagnosed.
? Calcification in the renal areas is most commonly due to renal calculi i
n the calices or renal pelvis.
? Nephrocalcinosis or calcification within the renal substance, is much le
ss common, and is seen in such rare conditions as hyperparathyroidism, renal tub
ular acidosis, and medullary sponge kidney.
? Calcification may also be observed in the kidney in renal tuberculosis,
and occasionally in renal tumours.
? Plain X-rays will also demonstrate opaque calculi in the ureter and in t
he bladder
? Calcification in the bladder wall and ureter is seen in schistosomiasis.
? Very rarely calcification may be detected in bladder tumours due to encr
ustations on the surface of a tumour,
2. Intravenous urography (IVU)
Introduction:
? The IVU, also known as excretory urography (EU) , or intravenous pyelogr
aphy (IVP), can demonstrate a wide variety of urinary tract lesions, is simple t
o perform, and is well tolerated by most patients.
? Provided that the kidney is functioning and the blood urea is not too hi
gh intravenous urography will demonstrate most lesions affecting the (normal ana
tomy of the renal drainage system)
Procedure:
? Following a preliminary plain film of the abdomen, additional radiograph
s are taken at timed intervals after the intravenous injection of iodine-contain
ing contrast medium. Normal kidneys promptly excrete contrast agents, almost ent
irely by glomerular filtration.
? The usual dose of the injection recommended for patients 14 years of age
and older and of average weight for rapid IV administration is 30-60 mL given o
ver 30-90 seconds.
? When nephrograms and/or rapid sequential urograms are desired, the dose
should be injected over 15-30 seconds.
? Radiographs of the urinary tract are usually taken at 5- to 10-minute in
tervals for 20-30 minutes after the infusion is started in patients with normal
renal function.
? In patients with impaired renal function, visualization is usually delay
ed and radiographs are taken as necessary.
1. Renal parenchyma including the renal cortex: 1 minute following rapid in
jection of contrast media
2. Prompt excretion: 5 minutes
3. Calyces and pelves: 10 minutes after bolus injection of contrast media.
4. Ureters: 15 minutes after bolus injection of contrast media.
5. Bladder: 30 minutes after rapid IV injection of the drug in patients wit
h normal renal function.
Indications:
? An IVU can demonstrate anatomy (size, shape, and position) and can semiq
uantitatively evaluate renal function
1. Congenital anomalies
? Congenital anomalies, such as double pelves and ureters, or duplex and h
orse-shoe kidneys, can be diagnosed with certainty.
? Polycystic kidneys can also be identified unless renal failure has super
vened.
? In a typical case both kidneys are enlarged, and there are multiple caly
ceal deformities
2. Urinary tract obstruction:
? Excretion urography is used to evaluate abnormalities of the urinary tra
ct (e.g. to determine the site of urinary tract obstruction)
? Hydronephrosis may be demonstrated and the site of obstruction will be s
hown
3. Infections

? In chronic pyelonephritis of the renal cortex and dilatation of the caly

ces can be recognised.
? Calyceal excavation due to tuberculosis can also be identified on intrav
enous urography, as can the characteristic small pericalyceal cysts of medullary
sponge kidney.
4. Calculus
? Opaque or suspected non-opaque renal calculi may be further investigated
by intravenous urography.
? The relationship of an opaque renal calculus or of a suspected renal cal
culus to the ureter, pelvis or calyces is clearly demonstrated
? Non-opaque calculi are shown as filling defects which may be obstructing
the renal drainage system and causing hydroureter and hydronephrosis proximal t
o the level of the obstruction.
? The bladder is also well shown at intravenous urography.
5. Tumours
? Bladder tumours whether papillomatous or carcinomatous can be demonstrat
ed though such tumours may be better visualised by cystography.
? Local distortion of the renal calyces by a kidney mass is often seen on
urography
? In many of these cases it is impossible to differentiate between hyperne
phroma and a simple cyst from the pyelogram.
? CT will differentiate renal tumour from cyst.
? If a cyst is demonstrated the diagnosis can be confirmed by percutaneous
cyst puncture, and the cyst can then be emptied by aspiration.
6. Prostatic lesions
? Prostatic lesions with bladder-neck obstruction are often assessed by in
travenous urography.
? The enlarged prostate may show as a large rounded filling defect at the
neck of the bladder.
? The bladder itself may show trabeculation and thickening of its wall and
there may also be evidence of back pressure on the kidneys.
7. Diverticula
? Diverticula of the bladder, which are more frequent in the elderly patie
nt with bladder-neck obstruction, can also be seen.
? In prostatic problems it is vital to obtain a film of-the bladder after
micturition, as the amount of residual urine gives a good index of the degree of
obstruction.
8. Hypertension
? Hypertension of possible renal origin is also investigated by intravenou
s urography in the first instance.
? This will demonstrate unilateral or bilateral hydronephrosis and will di
rect attention to the unilateral non-functioning kidney or to polycystic kidneys
.
? Intravenous urography may also show a characteristic pattern in hyperten
sive patients in whom the cause is unilateral ischaemia of a kidney.
? In these patients, in whom the usual causative lesion is an atheromatous
plaque stenosing the main renal artery the ischemic kidney is small and shows i
ncreased density of contrast in the pelvis and calyces as the examination procee
ds.
? This is because there is a greater percentage of water resorption on the
affected side than on the normal side.
3. Retrograde pyelography
? Retrograde pyelography is performed after cystoscopy and the insertion o
f a radio-opaque ureteric catheter by the surgeon
? A small quantity of sterile contrast medium is injected up the catheter
to outline the renal tract and appropriate films are taken.
? Retrograde pyelography is still sometimes used to confirm or disprove th
e relationship of a suspected small calculus to the ureter.
? It is also sometimes used to help dislodge a ureteric calculus and oil it
down the ureter.
? In squamous cell carcinoma/transitional cell carcinoma marked irregular
filling defects involving calices, pelvis, and proximal ureter may be seen
4. Antegrade pyelography (percutaneous nephrostomy)
? Percutaneous antegrade pyelography is a useful method of demonstrating t
he renal calyces, pelvis and ureter in cases of suspected urinary tract obstruct
ion where the intravenous method has been unsuccessful or inconclusive.
? Unlike retrograde urography it does not require GA and it has a lower in
cidence of urinary tract infection.
? It is also useful in infant and children where cystoscopy is difficult o
r impossible.
? A dilated renal calyx is punctured percutaneously from the lumbar region
using a fine needle, and contrast medium is injected.
? The technique can also be used to insert a catheter and provide temporar
y drainage.
? The catheter tract can also be used for a percutaneous approach to renal
calculi and for stent insertions.
5. Renal angiography
? An opaque catheter is passed percutaneously into the aorta and its presh
aped tip screened into the renal artery origin with the aid of an image intensif
ier.
? The whole renal circulation can be beautifully demonstrated using only a
small quantity of low-concentration contrast medium.
? The typical hypernephroma shows excessive vascularity with pathological
vessels throughout the tumour area
? The typical cyst appears as a large rounded defect in the angiogram.
? The method was highly accurate in differentiating between tumours and cy
sts though occasionally a non-vascular tumour was encountered which gave rise to
difficulty.
? Renal angiography has also been widely used for the embolisation of vasc
ular tumours and for the investigation of renal hypertension.
? A small proportion of patients with hypertension are suffering from rena
l ischaemia with secondary hypertension.
? The usual cause is an atheromatous narrowing of the origin of a renal ar
tery
? Other less common causes of renal artery stenosis include a peculiar con
dition occurring mainly in female patients and termed fibromuscular hyperplasia
of the renal artery
? Renal artery stenosis shown by angiograhy can now be treated by percutan
eous dilatation with a Gruntzig balloon catheter
6. Cystography
? Cystography is performed after passage of a catheter to the bladder and
injection of contrast medium.
? The method is useful for outlining tumours of the bladder when intraveno
us urography has been unsuccessful or equivocal.
? Ultrasound can also be used to demonstrate bladder tumours and CT enable
s such tumours to be assessed and staged.
? Vesico-ureteric reflux is present in a high proportion of patients with
chronic pyelonephritis, and that it may be an important etiological factor.
? Reflux is best demonstrated by performing a micturating cystogram though
it may occur spontaneously when the bladder is well filled
? As the patient micturates, reflux up the ureters may be seen as the blad
der contracts.
7. Cysto-urethrography
? This examination is used for the investigation of bladder obstruction in
males, the various forms of bladder-neck disturbance seen in postpartum females
, and other disorders of the peripheral control of micturition.
? The technique is to fill the bladder via a catheter which is then remove
d.
? The act of micturition is observed on the screen and films of the bladde
r-neck and urethra taken during micturition.
? Vesico-ureteric reflux may be observed during this procedure and is an i
mportant finding.
? The procedure is performed with the aid of an image intensifier.
? This has the added advantage that it is possible to take a cine film of
the act of micturition.
? This can then be played back and details observed at leisure.
? Dynamic bladder studies are indicated in more complicated bladder proble
ms with incontinence, frequency, disorders of storage function and voiding, neur
opathic bladder and postoperative disturbed function.
? Various physiological measurements are superimposed upon a video image o
f the bladder and urethra during filling and voiding.
? These measurements are the abdominal and bladder pressures (recorded by
rectal and bladder transducers respectively), the detrusor or intrinsic bladder
pressure (the recorded bladder pressure minus the abdominal pressure) and the ur
ine flow rate.
? Analysis of these synchronous recordings permits improved evaluation of
the mechanisms of the bladder dysfunction.
8. Urethrography
? Urethrography in the male is usually performed by injection of a viscous
contrast medium which provides excellent contrast throughout the urethra.
? The contrast medium is injected after insertion of a tight-fitting nozzl
e into the meatus and the whole of the urethra is outlined.
? Obstruction by a stricture can then be localised, and in the case of pro
static problems the prostatic urethra can be carefully studied.
9. Cyst puncture
? Renal cysts can be punctured percutaneously from the lumbar region.
? This is best done under ultrasound control when the point of puncture an
d the depth and size of the cyst can be assessed.
? The straw-coloured fluid they contain is aspirated.
? Once the cyst is entered it can be outlined by injecting a small quantit
y of contrast medium.
? This will show the size of the cyst and the contrast can be used to conf
irm that most or all of the fluid has been aspirated.
10. Vasography
? Vasoseminal vesiculography is most often used in the investigation of ma
le sterility.
? The radiopaque contrast medium is introduced into the ductal system by d
irect injection into an ejaculatory duct following panendoscopy or, more commonl
y, by injection into the vas deferens after it has been surgically exposed throu
gh a small incision in the scrotal neck.
12. Ultrasonography
? Ultrasound is commonly used for the evaluation of the kidney, urinary bl
adder, prostate, testis, and penis.
? Ultrasound is useful for assessing renal size and growth
? Renal ultrasound is useful in detection and characterization of renal ma
sses.
? Ultrasound provides an effective method of distinguishing benign cortica
l cysts from potentially malignant solid renal lesions.
? The differential diagnosis for echogenic renal masses includes renal sto
nes, angiomyolipomas, renal cell carcinomas, and, less commonly, abscesses and h
ematomas
? Doppler sonography is useful for the evaluation of renal vessels, vascul
arity of renal masses, and complications following renal transplant.
? It can detect renal vein thrombosis, renal artery stenosis, and ureteral
obstruction prior to the development of hydronephrosis, arteriovenous fistulas,
and pseudoaneurysms.
? Perinephric fluid collections following renal transplantation, extracorp
oreal shock wave lithotripsy, or acute obstructions are reliably detected by ult
rasound.
? Applications of bladder sonography include assessment of bladder volume
and bladder wall thickness and detection of bladder calculi and tumors
? Normal intratesticular arterial blood flow is consistently detected with
power or color Doppler.
? Sonography is highly accurate in differentiating intratesticular from ex
tratesticular disease and in the detection of intratesticular pathology.
? Ultrasound is commonly used to evaluate acute conditions of the scrotum.
? It can distinguish between inflammatory processes, inguinal hernias, and
acute testicular torsion.
? In addition, epididymitis not responding to antibiotics within 2 weeks s
hould be investigated further with scrotal ultrasonography.
13. Computed tomography scanning
? Renal CT is most commonly used in the evaluation of acute flank pain, he
maturia, renal infection (search for abscess), and renal trauma, and in the char
acterization and staging of renal neoplasm
? CT evaluation of renal anatomy and pathology generally requires intraven
ous injection of iodinated contrast media; noncontrast scans are needed, however
, when renal or perirenal calcification, hemorrhage, or urine extravasation is s
uspected, since scans obtained after the administration of contrast media may ma
sk these abnormalities.
? Also, precontrast and postcontrast scans are required to determine wheth
er a mass is solid or cystic.
? In the evaluation of the urinary bladder, CT is used primarily in stagin
g bladder tumors and in diagnosing bladder rupture following trauma.
? Performing CT after filling the bladder with dilute contrast medium (CT
cystography) improves the sensitivity of this modality for detecting tumors and
bladder rupture.
? For prostate diseases, CT is used for detection of lymphadenopathy and t
o delineate prostatic abscesses.
? CT is used for detection of the abdominal location of suspected undescen
ded testes, for staging of testicular tumors, and in the search for nodal or dis
tant metastasis.
? Helical CT without oral or intravenous contrast is the preferred imaging
modality for patients with renal colic or suspected urolithiasis
14. Magnetic resonance imaging
? MRI has been applied in imaging the kidney, retroperitoneum, urinary bla
dder, prostate, testis, and penis.
? Applications for MR in renal imaging include demonstration of congenital
anomalies, diagnosis of renal vein thrombosis, and staging of renal cell carcin
oma.
? MR angiography, which does not require intravenous contrast media, is us
eful in evaluating renal transplant vessels, renal vein tumor or thrombosis, and
renal artery stenosis.
? MRI is used primarily to stage bladder tumors and to differentiate betwe
en benign bladder wall hypertrophy and infiltrating malignant neoplasm.
? In imaging the prostate gland, MRI is principally used to stage patients
with prostate cancer
The adrenals
? Calcification in the adrenals also occurs, though rarely, in certain tum
ours, and has been recorded in carcinoma, neuroblastoma and phaeochromocytoma.
? Large adrenal tumours can be shown by simple X-ray or by IVU with nephro
tomography.
? They can also be shown by ultrasound or CT.
? Small adrenal tumours present a more difficult problem and are not readi
ly shown by simple X-ray, nephrotomography or ultrasound.
? They can however be demonstrated by a good quality CT examination which
is now the primary examination of choice,
? In Cushing s syndrome it is unusual to demonstrate a localised tumour of t
he adrenals and most cases show bilateral hyperplasia of the glands.
? Radiology in Cushing s syndrome will demonstrate osteoporosis of the skele
ton and often shows pathological fractures in ribs and vertebrae.
? These are often painless and unsuspected.
? Phaeochromocytoma in the classical case presents with paroxysmal hyperte
nsion.
? The diagnosis is confirmed by biochemical studies, but CT will be necess
ary for localisation.
? These tumours were at one time demonstrated by angiography, particularly
selective renal and adrenal angiography.
? In Conn s syndrome small adenomas may be present.
? CT is the best technique for demonstrating these small tumours which can
be identified even when 1 cm or less in diameter
? Isotope scanning provides an alternative method of diagnosing these smal
l adrenal tumours
? With improvements in CT the invasive methods of diagnosing small adrenal
tumours have now been superseded.
? CT is now the method of choice where high resolution CT machines are ava
ilable