Urinary Tract: Kidneys Leandro C. Manalaysay, M.D. Methods 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

of examination of the urinary tract plain film x-ray excretory urography ultrasonography computed tomography renal scintigraphy retrograde pyelography renal angiography percutaneous antegrade pyelography/nephrostomy voiding cystography/ cystourethrography cystography prostatic enlargement

Hydronephrosis ultrasound is imaging of first choice EXU - flattening of the calyx and blunting of the ; clubbing of the calyx;dilatation and distortion; destruction of parenchyma arteriogram - crescent sign Renal calculi originate as Randalls plaques deep in the lining of the collecting ducts in the renal papillae urinary stasis and infection are factors promoting formation of calculi opacity overlying the urinary tract excretory urography - for calculi localization and determine condition of calyceal system ultrasound, CT may be necessary to find radiolucent low-density calculi with renal or ureteral colic g delayed excretion by involved kidney dilatation of drainage structures CT stonogram using helical CT Renal calculi :Chemical composition calcium phosphate, calcium oxalate, magnesium ammonium phosphate (struvite) diammonium calcium phosphate, magnesium phosphate cystine, urate and xanthine Renal calculi: Predisposing factors matrix calculi - mucoprotein and mucopolysaccharide; Proteus infection hyperparathyroidism - hypercalcemia osteolytic metastasis, leukemia, multiple myeloma, sarcoidosis gout/ hyperuricemia; hyperoxaluria Renal cystic disease Classification simple renal cyst renal cysts with multiple renal neoplasm acquired cystic kidney disease vonHipple-Lindau disease tuberous sclerosis polycystic kidney disease autosomal dominant autosomal recessive cysts of the renal medulla medullary sponge kidney medullary cystic disease multicystic kidney cysts of the renal sinus miscellaneous cystic disease Simple renal cysts lesion is peripheral, bulges out of the kidney wall is very thin mass is quite radiolucent and sharply demarcated from renal parenchyma beak-like deformity - claw sign Acquired renal cystic disease develops during dialysis treatment large number of cysts, less than 3 cm cortical and medullary develop renal cell carcinoma in 7% complication: retroperitoneal hemorrhage Von Hipple-Lindau disease

Plain film x-ray kidneys- bean-shaped, T11 to L3 level right kidney lower than the left kidneys descends 2-3 cm in the upright position left kidney may have fetal lobulation; dromedary hump Excretory urography renal pelvis - triangular or conical, variable major and minor calyces ureters with three normal narrowings o ureteropelvic junction o bifurcation of the iliac vessels o ureterovesical junction Excretory urography bladder - transversely round or oval above the symphysis pubis rounded dome in male; flat or concave dome in females relatively larger in children Renal anomalies renal agenesis - tend to be larger; associated with congenital heart anomaly and neuromuscular deficit accompanied by small pelvic outlet, sacral agenesis, bladder hypoplasia horseshoe kidney - most common type of fusion anomaly o lower poles of kidney joined by parenchymatous mass or fibrous tissue o upper pole rarely involved o associated rotation anomaly crossed ectopy - fusion of the kidneys on the same side o lower one is ectopic; ureter crosses the midline to enter the bladder on the opposite side o lower in position o associated with rotation anomalies o associated with partial obstruction Hydronephrosis obstructive uropathy dilatation of the calyces and pelvis with potential progressive destruction of renal parenchyma pyelectasis, caliectasis, ureterectasis, hydroureter Non-obstructive hydronephrosis diabetes insipidus - large volume of hypotonic urine UTI - segmental or generalized dilatation, with poor or reversed peristalsis intra-abdominal inflammatory disease overhydration Obstructive Uropathy tumors calculi strictures radiation therapy operative procedures

autosomal dominant phakomatosis retinal angiomatosis, CNS hemangioblastomas, pheochromocytoma multiple simple renal cysts; one third have renal cell carcinomas

Autosomal recessive PKD grossly elongated, dilated collecting ducts throughout the renal parenchyma both kidneys symmetrically and uniformly enlarged associated hepatic cysts Autosomal dominant PKD spherical fluid-filled cysts, 1-3 cm in size throughout may have curvilinear wall or intrarenal punctate calcifications knobby appearance of kidney surface kidneys are greatly enlarged associated hepatic cysts; also in the pancreas, spleen, lungs and ovaries associated with 10% rupture of berry aneurysm of the arteries at the base of the brain Renal cell carcinoma hypernephroma, adenocarcinoma men > women; 40-60 years weight loss, flank pain, palpable mass, hematuria metastasize to lungs, liver, lymph nodes, renal vein and inferior vena cava kidneys enlarged, may be irregular may have calcification - irregularly scattered or curvilinear renal displacement, tilting of axis Renal cyst versus carcinoma Bosniak classification o Type 1 - simple renal cyst o Type 2 - minimally complicated cyst; increased attenuation values, thin calcifications, thin septation o Type 3 - with thick septation or chunky calcifications, uniform thick wall or nonenhancing nodules o Type 4 - thick walls, enhancing components and solid enhancing nodules Bosniak classification o Type 1 = no chance of malignancy o Type 2 = may have chance of malignancy o Type 3 = 57% probability of malignancy o Type 4 = 100% malignant Renal cell carcinoma solid, with or without cystic component tumor enhancement on contrast infusion areas of necrosis or hemorrhage do not enhance perihilar lymphadenopathy, direct tumor invasion of adjacent organs Wilms tumor nephroblastoma most common abdominal neoplasm in infancy and childhood arise from embryonic renal tissue tends to become very large arise within the first 5 years of life usually unilateral (95%) abdominal mass, hematuria, pain occasionally may contain calcification x-ray - large intrarenal tumor with distortion of calyces and pelvis impaired renal function ultrasound - homogeneous echogenic renal mass CT show no vessel encasement

Neuroblastoma versus Wilms tumor present at birth contains calcification in 50% of cases less calyceal distortion, arising adjacent to the kidney and displaces it vessel encasement and retrocrural adenopathy are seen on CT

Lymphoma Non-Hodgkins lymphoma > Hodgkins lymphoma renal enlargement; distortion or elongation of the pelvocalyceal system solitary or multiple tumor nodules perirenal masses that may engulf or displace the kidney multiplicity of nodules suggest lymphoma retroperitoneal adenopathy CT used to evaluate course and response to therapy Leukemia common in children with acute leukemia cortical involvement bilateral renal enlargement stretching and elongation of the calyces and pelvis irregularity of the renal outline Benign tumors of the ureter papilloma - most common benign ureteral tumor o premalignant? , considered Grade I malignancy by other pathologists o filling defect within the ureter fibroepithelial polyp o core of fibrous tissue covered by a layer of transitional epithelium o long, branched, smooth, intraluminal structure; may be multiple Benign tumors of the ureter fibrolipoma leiomyoma endometriosis Malignant tumor of the ureter transitional cell tumor o usually the papillary form o tend to be multiple; multicentric o obstruction, hydronephrosis o Bergmans sign - coiling of the catheter tip on RGP at the site where the mass impedes its upward progress