diagnostic imaging of urinary tract radiology department of ruijin medical college affiliated to...

DIAGNOSTIC IMAGING

OF URINARY TRACT

DIAGNOSTIC IMAGING

OF URINARY TRACT

Radiology Department of Ruijin Medical CollegeAffiliated to Shanghai Jiaotong University Medical School

骨关节系统影像学骨关节系统影像学

瑞金临床医学院瑞金临床医学院

医学影像学教研室医学影像学教研室

INTRODUCTION INTRODUCTION

Including both kidney, ureter, bladder and urethra.

Lack of natural contrast.

Need various kinds of contrast examination.

Use of CT, USG,MRI.

Including both kidney, ureter, bladder and urethra.

Lack of natural contrast.

Need various kinds of contrast examination.

Use of CT, USG,MRI.

METHODS OF EXAMINATION METHODS OF EXAMINATION

Plain Film of the Abdomen (KUB) Plain Film of the Abdomen (KUB)

Including both sides of kidney, area of

ureter and bladder.

To show contour, size, shape of the ab

ove organs and psoas muscles margin.

To demonstrate stone and calcification

of urinary tract

Including both sides of kidney, area of

ureter and bladder.

To show contour, size, shape of the ab

ove organs and psoas muscles margin.

To demonstrate stone and calcification

of urinary tract

KUB

Intravenous Urography (IVU) Intravenous Urography (IVU)

METHODS OF EXAMINATION METHODS OF EXAMINATION

Preparation: 1. sensitivity test of iodine.

2.preparation of intestinal tract

(fast 8~12h, catharsis)

Contrast medium: 1.Urografin (泛影葡胺 )

2. Iopamidol (碘必乐 )

3. Iopromide (碘普罗胺 )

Preparation: 1. sensitivity test of iodine.

2.preparation of intestinal tract

(fast 8~12h, catharsis)

Contrast medium: 1.Urografin (泛影葡胺 )

2. Iopamidol (碘必乐 )

3. Iopromide (碘普罗胺 )

Technique: 1.intravenous instillation of contrast medium

(100ml) should be over in 5~10minutes

2. films are taken at 3,5,10,15,25(KUB)

minutes

Display: 1.excretory function of kidney

2.morphology of urinary tract

Technique: 1.intravenous instillation of contrast medium

(100ml) should be over in 5~10minutes

2. films are taken at 3,5,10,15,25(KUB)

minutes

Display: 1.excretory function of kidney

2.morphology of urinary tract

Intravenous Urography (IVU) Intravenous Urography (IVU)

METHODS OF EXAMINATION METHODS OF EXAMINATION

-C +C

I.V.U.

I.V.U.

Retrograde Urography Retrograde Urography

METHODS OF EXAMINATION METHODS OF EXAMINATION

To be used when IVU has been unsatisfactory or

inconclusive.

To show the morphology of urinary tract only.

To be used when IVU has been unsatisfactory or

inconclusive.

To show the morphology of urinary tract only.

Retrograde Urography Retrograde Urography

Renal Angiography Renal Angiography

METHODS OF EXAMINATION METHODS OF EXAMINATION

abdominal aortography.

Selective renal arteriography.

abdominal aortography.

Selective renal arteriography.

Renal Angiography Renal Angiography

Renal Angiography Renal Angiography

CT CT

METHODS OF EXAMINATION METHODS OF EXAMINATION

Plain Scans Plain Scans

patient preparation :

⑴ oral contrast mediun administration for bowel and bladder filling

⑵ 1~2%, 500ml of urografin for kidney CT

⑶ 1~2%, 1000ml of urografin for bladder CT

⑷ the bladder must be fully distended

Slice thickness and intervals: 5~10mm

Scanning method: sequential CT scans

Scanning ranges: upper pole of kidney→ureter→bladder

patient preparation :

⑴ oral contrast mediun administration for bowel and bladder filling

⑵ 1~2%, 500ml of urografin for kidney CT

⑶ 1~2%, 1000ml of urografin for bladder CT

⑷ the bladder must be fully distended

Slice thickness and intervals: 5~10mm

Scanning method: sequential CT scans

Scanning ranges: upper pole of kidney→ureter→bladder

CT CT Plain Scans Plain Scans

Contrast enhanced Scans Contrast enhanced Scans CT CT

METHODS OF EXAMINATION METHODS OF EXAMINATION

Contrast medium: 60~100ml, 1.5~2.5ml/s

Intravascular administration: bolus injection

Scanning:

⑴Sequential CT scans: start at 15~20s after injection

⑵Delayed CT scans: can be performed at 5~10min. after injection to show filling the pelvis, ureter and bladder with contrast medium

Contrast medium: 60~100ml, 1.5~2.5ml/s

Intravascular administration: bolus injection

Scanning:

⑴Sequential CT scans: start at 15~20s after injection

⑵Delayed CT scans: can be performed at 5~10min. after injection to show filling the pelvis, ureter and bladder with contrast medium

Contrast enhanced Scans Contrast enhanced Scans CT CT

MRI MRI

Plain Scans:

⑴ transverse T1WI (T1-Weighted imaging) + T2WI

(T2-Weighted imaging) with SE (spin-echo sequences)

⑵ coronal T1WI with SE

Contrast enhanced scans:

⑴ contrast medium: Gd-DTPA, 0.1~0.2mmol/kg

⑵ scanning sequences: T1WI with SE

MRU (MR urography):

to demonstrate the obstruction of urinary tract

Plain Scans:

⑴ transverse T1WI (T1-Weighted imaging) + T2WI

(T2-Weighted imaging) with SE (spin-echo sequences)

⑵ coronal T1WI with SE

Contrast enhanced scans:

⑴ contrast medium: Gd-DTPA, 0.1~0.2mmol/kg

⑵ scanning sequences: T1WI with SE

MRU (MR urography):

to demonstrate the obstruction of urinary tract

METHODS OF EXAMINATION METHODS OF EXAMINATION

KUB I.V.U.R.U.

Angio CT

US

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

KUB & IVU KUB & IVU

Kidney Kidney

1. position: T11~12 to L1~2

2. size: 11~13×5~6×2~3cm (3×6×12cm)

1. position: T11~12 to L1~2

2. size: 11~13×5~6×2~3cm (3×6×12cm)

Contour: smooth

Minor calyces: 10~14

Major calyces: 2~4

Pelvis: trumpet , branch, ampulla

Contour: smooth

Minor calyces: 10~14

Major calyces: 2~4

Pelvis: trumpet , branch, ampulla

Ureter Ureter

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

KUB & IVU KUB & IVU

long: 25~30cm

width: 3~5mm

physiological narrowings: ⑴ pelvi-ureteral junction

⑵ iliac vessels

⑶ entry of bladder

long: 25~30cm

width: 3~5mm

physiological narrowings: ⑴ pelvi-ureteral junction

⑵ iliac vessels

⑶ entry of bladder

Bladder Bladder

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

KUB & IVU KUB & IVU

shape: round or oval

capacity: 200~350ml

shape: round or oval

capacity: 200~350ml

I.V.U.

CT CT

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

Plain Scans Plain Scans

Kidney ⑴ renal parenchyma: soft tissue density, 30~50Hu

⑵ pelvis: water density, 10~20Hu

⑶ renal sinus: fat density, -60~-100Hu

Uretersoft tissue density

Bladderwater density when fully distended

Kidney ⑴ renal parenchyma: soft tissue density, 30~50Hu

⑵ pelvis: water density, 10~20Hu

⑶ renal sinus: fat density, -60~-100Hu

Uretersoft tissue density

Bladderwater density when fully distended

Contrast Enhanced Scans Contrast Enhanced Scans CT CT

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

Kidney: ⑴ 1′after injection: cortical enhancement

⑵ 2′after injection: medullary enhancement

⑶ 5~10′after injection: parenchyma enhancement and filling the pelvis with contrast medium

Kidney: ⑴ 1′after injection: cortical enhancement

⑵ 2′after injection: medullary enhancement

⑶ 5~10′after injection: parenchyma enhancement and filling the pelvis with contrast medium

Contrast Enhanced Scans Contrast Enhanced Scans CT CT

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

Ureter and Bladder: ⑴ bladder wall enhanced on early scans

⑵ filling with the contrast medium on delayed scans

MRI MRI

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

Plain Scans Plain Scans

The signal intensity of renal cortex on T1WI is higher

than that of renal medulla

The signal intensity of renal cortex and medulla on T2

WI are all higher

The signal intensity of ureter and bladder are low on T

1WIand higher on T2WI

The signal intensity of renal cortex on T1WI is higher

than that of renal medulla

The signal intensity of renal cortex and medulla on T2

WI are all higher

The signal intensity of ureter and bladder are low on T

1WIand higher on T2WI

MRI MRI

NORMAL IMAGING OF URINARY TRACT NORMAL IMAGING OF URINARY TRACT

Contrast Enhanced Scans Contrast Enhanced Scans

Renal parenchyma and bladder wall show

enhancement

Renal parenchyma and bladder wall show

enhancement

CALCULUS OF URINARY TRACT CALCULUS OF URINARY TRACT

Radiopaque(calcium) in 90% of patient

Radiolucent(urate) in 10% of patient

Radiopaque(calcium) in 90% of patient

Radiolucent(urate) in 10% of patient

Renal Calculus Renal Calculus

CALCULUS OF URINARY TRACT CALCULUS OF URINARY TRACT

round, horny, morula

lie in the calyces or pelvis

hydronephrosis

CT: high density, 200~1000Hu

round, horny, morula

lie in the calyces or pelvis

hydronephrosis

CT: high density, 200~1000Hu

Ureteral calculus Ureteral calculus

CALCULUS OF URINARY TRACT CALCULUS OF URINARY TRACT

grain of rice size, jujube core shaped

long axis parallel to the ureter

often stay in the sites of narrowness

hydroureter or hydronephrosis above the stone

CT: high density, 200~1000Hu

grain of rice size, jujube core shaped

long axis parallel to the ureter

often stay in the sites of narrowness

hydroureter or hydronephrosis above the stone

CT: high density, 200~1000Hu

Ureteral calculus Ureteral calculus

Calculus of Urinary bladder Calculus of Urinary bladder

CALCULUS OF URINARY TRACT CALCULUS OF URINARY TRACT

round, oval, laminited, concentric circles shaped

CT: high density

MRI: low signal on T1WI and T2WI

round, oval, laminited, concentric circles shaped

CT: high density

MRI: low signal on T1WI and T2WI

Calculus of Urinary bladder Calculus of Urinary bladder

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

Secondary infection

Hematogenous dissemination

Secondary infection

Hematogenous dissemination

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

PathologyPathology

TB bacilli TB bacilli

renal cortex infection renal cortex infection

medullary destruction medullary destruction

caseous necrosis caseous necrosis

abscess (calcification) abscess (calcification)

pelvicalyceal destruction pelvicalyceal destruction

ureter and bladder TB ureter and bladder TB

TUBERCULOSISTUBERCULOSIS

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

Auto-resection of kidney Auto-resection of kidney

Diffused calcification of caseous foci,

or whole kidney + loss of renal function

Diffused calcification of caseous foci,

or whole kidney + loss of renal function

Auto-resection of kidney Auto-resection of kidney

Renal Tuberculosis Renal Tuberculosis

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

KUB:

⑴ normal (early stage )

⑵ calcification

KUB:

⑴ normal (early stage )

⑵ calcification

Renal Tuberculosis Renal Tuberculosis

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

IVU:

⑴ calyceal destruction

⑵ abscess and cavity formation

⑶ pyonephrosis

⑷ diffuse fibrotic contraction and calcification

⑸ auto-resection of kidney

IVU:

⑴ calyceal destruction

⑵ abscess and cavity formation

⑶ pyonephrosis

⑷ diffuse fibrotic contraction and calcification

⑸ auto-resection of kidney

Renal Tuberculosis Renal Tuberculosis

Plain CT scans:

⑴ high density (calcification)

⑵ low density areas (abscess or cavity)

⑶ CT values: 20~40Hu(abscess)

Plain CT scans:

⑴ high density (calcification)

⑵ low density areas (abscess or cavity)

⑶ CT values: 20~40Hu(abscess)

Renal Tuberculosis Renal Tuberculosis

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

Contrast-enhanced CT scans:

⑴ low density areas without enhancement.

⑵ contrast media is demonstrable within the abscess.

⑶ pelvicalyceal enlargement

Contrast-enhanced CT scans:

⑴ low density areas without enhancement.

⑵ contrast media is demonstrable within the abscess.

⑶ pelvicalyceal enlargement

Renal Tuberculosis Renal Tuberculosis

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

MRI:

⑴ low signal on T1WI

⑵ high signal on T2WI

MRI:

⑴ low signal on T1WI

⑵ high signal on T2WI

Renal Tuberculosis Renal Tuberculosis

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

TUBERCULOSIS OF URINARY TRACT TUBERCULOSIS OF URINARY TRACT

Ureteral Tuberculosis Ureteral Tuberculosis

KUB:

calcification

IVU:

⑴ stricture

⑵ shorten

⑶ beading

KUB:

calcification

IVU:

⑴ stricture

⑵ shorten

⑶ beading

TUBERCULOSIS OF URINARY BLADDER TUBERCULOSIS OF URINARY BLADDER

IVU:

Small bladder

Contracted bladder

IVU:

Small bladder

Contracted bladder

TUMORS OF URINARY TRACT TUMORS OF URINARY TRACT

Renal Carcinoma Renal Carcinoma

KUB:

⑴ kidney enlarged, local protrusion

⑵ calcification in 10% of patients

IVU:

⑴ renal contour: bulging

⑵ calyces and pelvis:

compression

narrowing

dissociation

destruction

KUB:

⑴ kidney enlarged, local protrusion

⑵ calcification in 10% of patients

IVU:

⑴ renal contour: bulging

⑵ calyces and pelvis:

compression

narrowing

dissociation

destruction

Renal Carcinoma Renal Carcinoma

Plain CT scans:

⑴ mass (20~50Hu)

⑵ calcification

⑶ the tumor may be hypodense or isodense in comparison to the surrounding structures

Plain CT scans:

⑴ mass (20~50Hu)

⑵ calcification

⑶ the tumor may be hypodense or isodense in comparison to the surrounding structures

TUMORS OF URINARY TRACT TUMORS OF URINARY TRACT

Renal Carcinoma Renal Carcinoma

Contrast-enhanced CT scans:

⑴ inhomogeneous enhancement

⑵ peripheral enhancement

⑶ non-enhanced necrotic areas in the tumor

Contrast-enhanced CT scans:

⑴ inhomogeneous enhancement

⑵ peripheral enhancement

⑶ non-enhanced necrotic areas in the tumor

TUMORS OF URINARY TRACT TUMORS OF URINARY TRACT

Renal Carcinoma Renal Carcinoma

Renal Carcinoma Renal Carcinoma

MRI:

(1) Plain scans: inhomogeneous signals on T1WI and T2WI

(2) Contrast-enhanced scans: inhomogeneous enhancement

MRI:

(1) Plain scans: inhomogeneous signals on T1WI and T2WI

(2) Contrast-enhanced scans: inhomogeneous enhancement

TUMORS OF URINARY TRACT TUMORS OF URINARY TRACT

Renal Carcinoma Renal Carcinoma

Angioleimyolipoma Angioleimyolipoma

Benign tumor of the kidney

The tumor is histologically comprised of blood vessels,

smooth muscle, and fat tissue.

The proprtions of the conponents in the tumor are vari

able

Benign tumor of the kidney

The tumor is histologically comprised of blood vessels,

smooth muscle, and fat tissue.

The proprtions of the conponents in the tumor are vari

able

KUB and IVU KUB and IVU

Angioleimyolipoma Angioleimyolipoma

kidney enlarged

pelvicalyceal compression

calcification in 20% of patients

kidney enlarged

pelvicalyceal compression

calcification in 20% of patients

CT CT

Angioleimyolipoma Angioleimyolipoma

Fatty components of the tumor:

⑴ much lower dentisy

⑵ CT values:-40to-120Hu

⑶ non-enhancement

The vascular and muscular structeres of the tumor:

enhancement

Calcification: high density

Fatty components of the tumor:

⑴ much lower dentisy

⑵ CT values:-40to-120Hu

⑶ non-enhancement

The vascular and muscular structeres of the tumor:

enhancement

Calcification: high density

MRI MRI

Angioleimyolipoma Angioleimyolipoma

Fatty components:

⑴ high signal on T1WI and T2WI

⑵ much lower signal on STIR

Other components:

inhomogeneous signal on T1WI and T2WI

Fatty components:

⑴ high signal on T1WI and T2WI

⑵ much lower signal on STIR

Other components:

inhomogeneous signal on T1WI and T2WI

Renal Pelvic Carcinoma Renal Pelvic Carcinoma

Transitional cell carcinoma (80~90%) Transitional cell carcinoma (80~90%)

KUB: normal

IVU : filling defect within the pelvis

CT: mass of renal sinus⑴

⑵ enhancement

⑶ filling defect on delayed contrast CT imaging

MRI: mass of renal sinus ⑴

⑵ enhancement

KUB: normal

IVU : filling defect within the pelvis

CT: mass of renal sinus⑴

⑵ enhancement

⑶ filling defect on delayed contrast CT imaging

MRI: mass of renal sinus ⑴

⑵ enhancement

Renal Pelvic Carcinoma Renal Pelvic Carcinoma

Carcinoma of the Urinary Bladder Carcinoma of the Urinary Bladder

Papillary carcinoma of the epithelium of the urinary tract

Mass protruding on the bladder wall

KUB: normal

IVU: filling defect within the bladder

CT and MRI:

⑴ mass in the bladder

⑵ enhancement

⑶ invasion of surrounding structures

⑷ demonstrate metastatic lymph nodes

Papillary carcinoma of the epithelium of the urinary tract

Mass protruding on the bladder wall

KUB: normal

IVU: filling defect within the bladder

CT and MRI:

⑴ mass in the bladder

⑵ enhancement

⑶ invasion of surrounding structures

⑷ demonstrate metastatic lymph nodes

Carcinoma of the Urinary Bladder Carcinoma of the Urinary Bladder

RENAL CYST RENAL CYST

Simple Renal cyst Simple Renal cyst

Single or multiple

KUB: normal or bulging contour

IVU: pelvicalyceal compression

Single or multiple

KUB: normal or bulging contour

IVU: pelvicalyceal compression

RENAL CYST RENAL CYST

Simple Renal cyst Simple Renal cyst

CT:

⑴ round clear margin homogeneous low density ⑵ ⑶ ⑷CT values: 6~18Hu nonenhancement⑹

MRI: low signal on T1WI⑴

⑵ high signal on T2WI

⑶ nonenhancement

CT:

⑴ round clear margin homogeneous low density ⑵ ⑶ ⑷CT values: 6~18Hu nonenhancement⑹

MRI: low signal on T1WI⑴

⑵ high signal on T2WI

⑶ nonenhancement

Simple Renal cyst Simple Renal cyst

Polycystic Renal Disease in Adults Polycystic Renal Disease in Adults

Genetic disease

Accompanied with polycystic hepatic disease in 30~60% of patients

KUB: enlargment of both kidney

IVU: pelvicalyceal compression, shift, dissociation-- “spider feet”

CT and MRI:

⑴ multiple cysts in various sizes

⑵ nonenhancement

Genetic disease

Accompanied with polycystic hepatic disease in 30~60% of patients

KUB: enlargment of both kidney

IVU: pelvicalyceal compression, shift, dissociation-- “spider feet”

CT and MRI:

⑴ multiple cysts in various sizes

⑵ nonenhancement

RENAL AND URETERAL DYSPLASIA RENAL AND URETERAL DYSPLASIA

Double pelvis and ureter

Solitary kidey

Horse-shoe kidney

Ectopic kidney

Double pelvis and ureter

Solitary kidey

Horse-shoe kidney

Ectopic kidney

Thank youThank you