Urinary system

Methods of investigationMethods of investigation

X-rayX-ray

• Plain abdominal radiographs • Urogram

– Excretory urography (intravenous pyelography, IVP)

– Retrograde urography– Cystography & urethrography – Abdominal aortography & Selective renal

arteriography

Plain abdominal radiographs Plain abdominal radiographs (KUB)(KUB)

• Bowel preparation• A full-length film including:

– Th11 to bladder base– The prostatic urethra (in the male)

• Investigation :– calcification – The position, shape, size of the kidneys

Normal KUBNormal KUB

Excretory urographyExcretory urography

• Purpose: – Showing the anatomical shape of renal

pelvis, ureter, bladder– An indication of renal function

• Method:– Normal dosage– Double dosage

• Dosage:300 mg-600mg I kg−1 body weight

Normal IVPNormal IVP• To know the principle and applications of IVP• To observe the pelvicaliceal system, the renal calices and

the ureter

Retrograde urographyRetrograde urography

• Applications: In the patients whom excretion urography is failure

• Contraindications: the lower urinary tract infection

• Method: Cystoscopic-guided catheterize into the selected ureter

• Contrast media: 10-25% Iodinated contrast media 5-10ml, the dosage can be increase when hydronephrosis presents.

BilateralBilateral retrograde retrograde urographyurography• To observe the

pelvicaliceal system, the renal calices and the ureter

Air retrograde urographyAir retrograde urography

• To know the applications and method of air retrograde urography

• To observe the pelvicaliceal system and the ureter after injected negative contrast medium

CystographyCystography

• Applications: Bladder mass, Diverticulum, compression of adjacent organ

• Method: Antegrade and Retrograde• Contrast media: 3-5% Iodinated contrast

media 100-200ml, air, or both of them (Double contrast cystography)

Normal cystographyNormal cystography

• Upper: normal Iodinated contrast media cystography

• Lower: air cystography

UrethrographyUrethrography

• Applications: Stenosis of Urethra

• Method: Antegrade and Retrograde

• Contrast Media: 15-25% Iodinated contrast media

Normal antegrade urethrography, a oblique view and a A-P view

Abdominal aortography & Abdominal aortography & Selective renal arteriographySelective renal arteriography

• Method: Digital Subtraction angiography

• Applications: Renovascular disease, tumor disease (combine with interventional therapy)

Normal abdominal aortographyNormal abdominal aortography

• Showing the bilateral renal arteries (red arrow)

Stenosis of the left renal artery Stenosis of the left renal artery (green arrow)(green arrow)

Selective renal digital Selective renal digital subtraction arteriographysubtraction arteriography

CTCT

MRMR

UltrasoundUltrasound

Image observing and Image observing and analysis (X-ray)analysis (X-ray)

Normal Normal Plain Plain abdominal abdominal

radiographs (KUB)radiographs (KUB)

• Kidney– From the superior line of

Th12 to the inferior line of L3– The right kidney is usually

located more inferiorly than the left.

– Size: 5-6 ×12-13cm– The axis of kidney: 15-25

degree– The movement of kidney is

less than the height of one vertebra.

KidneyKidney

• Renal parenchyma– Cortex– Medulla (Pyramides renales)

• Collecting cave– Calyces– Pelvis

• IVP:– 1-2min nephrographic phase– 2-3min calyces and pelvis begin to

be shown– 15-30min calyces and pelvis are

been shown well. (pyelographic phase)

• Different form of pelvis renales– A normal form– B branch form (without pelvis)– C ampullae form (without calyx major)

• Normal pelvis and calyces– Observe the position, shape, borderline and

density of them

• Ampullae form– The pelves is directly

connected with minor calyces

– The shape of pelves are full

• Branch form– The major calyces are

directly connected with ureter, without pelvis

RefluxReflux

A. tubular reflux

B. sinus reflux

C. intravenous reflux

D. Lymphatic reflux

• Tubular reflux: it is like sector in the upper pole of left kidney

Reflux: tubular reflux (red arrow), sinus reflux (blue arrow), Lymphatic reflux (black arrow)

tubular reflux and sinus reflux

Lymphatic reflux

UreterUreter

• 25cm long

• 3 physiological narrowings

• Peristalsis

Dual Dual retrograde retrograde

pyelographypyelography

Anatomical detail of the pelvicaliceal system is demonstrated.

Normal Cystography Normal Cystography (fill with (fill with Iodinated contrast media (left) and air (right))Iodinated contrast media (left) and air (right))

The normal Capacity of bladder is about 250ml.The normal Capacity of bladder is about 250ml.

The size and shape of bladder is determined on filling.The size and shape of bladder is determined on filling.

UrethraUrethra

• The male urethra is divided into two parts: the anterior and the posterior urethra.

• It has 2 curvature and 3 physiological narrowing.

Normal male urethraNormal male urethra (AP and Oblique position)(AP and Oblique position)

Normal Normal female female urethraurethra

Disease DiagnosisDisease Diagnosis

Calculus disease Calculus disease • Urinary calculus can occur in every part of

urinary tract.• Plain abdominal radiograph is the first

choice.• Calculi are divided into negative

(radiolucent) and positive stones.• Calculi in different part of urinary track

have different form.• Urinary calculi should be distinguished

with biliary calculus, calcification of lymph nodes, Intestinal contents and phlebolith .

Renal TuberculosisRenal Tuberculosis

• Renal tuberculosis results from hematogenous dissemination from a distant site, usually in the lung or bone.

• Characteristics of renal tuberculosis:– Parenchymal calcification– Parenchymal scar– Papillary necrosis– Infundibular strictures– Nonfunction (autonephrectomy)

• Ureter Tuberculosis: presents strictures and calcification.

• Tuberculous cystitis: presents contracted and irregular and reflux

Renal TuberculosisRenal Tuberculosis• A:

Infundibular strictures

• B: Papillary necrosis

• C: autonephrectomy

Renal TumerRenal Tumer• Renal carcinoma

– Twice as common among men than women

– The incidence peaks in the fifth to seventh decade

– Usually in one kidney– Painless gross hematuria– Internist’s tumer

Renal carcinomaRenal carcinoma

• renal cell carcinoma may cause displacement, compression, distortion, stretching, invasion, or amputation of calices and infundibula.

CT findingCT finding

• May have calcification• Heterogeneous mass• Diffuse margin with normal

parenchyma• Enhances with intravascular contrast

media

MR findingMR finding

• MRI can be used to detect and stage renal cell carcinoma.

• The signal characteristics of renal carcinoma are variable– isointense or hypointense compared to the

renal cortex on T1 sequences– slightly hyperintense on T2-weighted

sequences.

• Contrast: Heterogeneous enhancement occurs immediately, decreasing on delayed images.

Bladder TumorsBladder Tumors

• Transitional cell carcinoma

– X-ray finding:

• Filling defect (Iodinated contrast media )

• Soft tissue mass (air)

Urinary obstruction Urinary obstruction

• Cause: calculus, tumor, inflammation, reflux, etc.

• Classification:– Grade I: the most minimal dilatation appreciable,

characterized by slight blunting of the caliceal fornices.

– Grade II: obvious blunting of the caliceal fornices and enlargement of the calices, but the intruding shadows of the papillae, although flattened, are still easily seen.

– Grade III: caliceal ballooning

Congenital AnormaliesCongenital Anormalies

Benign Prostatic HypertrophyBenign Prostatic Hypertrophy

• X-ray finding:– BPH elevates and indents the bladder

base

– Stricture of prostatic urethra

– Obstructive cystitis