1

(Topic module)
(The urinary tract imaging)
( 501)

1.
2.
3.
4.
1.
2.
2.1 Plain KUB
2.2 Intravenous pyeography
2.3 Retrograde pyelography
2.4 Cystography and voiding cystourethrography
2.5 Urethrography
2.6 Ultrasound
2.7 Computed tomography

2.8

magnetic resonance imaging, renogram,

renal angiography

3.
3.1
(congenital anomaly)
3.2
(urinary tract obstruction)
3.3
(cystic and solid renal mass)
3.4
(urinary tract infection)
3.5
(trauma of the KUB system)
4. Problem-oriented approach
5.

1.
2.

power point

3.
4.

1.
2.
3.
4.

1.

120
120
90

2.

NORMAL ANATOMY OF THE URINARY TRACT

Kidneys ( )
-

(position)

retroperitoneal space

T12

L3

(axis)
psoas
upper pole
lower pole
long axis
20
(shape)
(bean-shaped)
dorsolateral
ventromedial
medial
(size)
10-16 cm.
4 cm.
3-4 lumbar vertebral bodies
1.5 cm.
3
renal capsule, renal parenchyma
renal sinus

renal hilum
6 cm.

1
diagram
renal
capsule
Gerotas capsule,
adipose capsule, fibrous capsule
(
)

Renal capsule capsule

3
1) Gerotas capsule capsule
space
2) Adipose capsule
3) Fibrous capsule capsule
Renal parenchyma
cortex

perirenal

medulla

perinephric

1) Renal cortex
glomeruli
proximal & distal convoluted tubule
cortex
1.5-2 cm.
cortex
renal pyramid
columns of Bertin
2) Renal medulla
8-16 pyramids
descending & ascending
tubules
collecting ducts
(base)
pyramid
renal cortex
(apex)
pyramid
renal papilla
distal collecting ducts
minor calyx
Renal sinus
L2-L3 vertebral body
renal pelvis, renal artery & vein, fat, sympathetic nerve fibers
lymphatic channels

diagram
renal cortex

renal

medulla

Renal calyces
2-4 major calyces
4-6 minor
calyces
infundibulum
minor calyx
papilla (cup-shaped)
fornix
Renal pelvis drain
major calyces renal pelvis
ureteropelvic junction (UPJ) renal pelvis
renal sinus
intrarenal pelvis
renal pelvis
renal sinus
extrarenal pelvis
Renal artery and vein
Renal artery
aorta
L1
right renal artery
left renal artery
branches
inferior adrenal
renal capsular artery
renal artery
3

branches
renal sinus
renal pyramid
interlobar artery
base
pyramid
arcuate artery
interlobular artery
Venous drainage
artery
5-6 major venous branches
vein
drain
IVC
L1
Ureter (
)
-

renal pelvis

paravertebral area

psoas
-

30-34 cm.

2-8 mm.
pelvic inlet
common iliac artery bifurcation
bony
landmark
medial sacroiliac joint
ischial spine
urinary bladder
posterolateral aspect lateral margin
bladder trigone
renal collecting system
ureter
peristalsis
smooth muscle
ureteral wall
(physiologic narrowing) 3
1) Superior isthmus
2) Medial isthmus
3) Inferior isthmus
Bladder (

ureteropelvic junction (UPJ)

iliac vessels
ureterovesical junction (UVJ)
)

pubic bone
peritoneum
detrusor muscle

transitional cell
3

apex

bladder neck
(internal sphincter)

trigone

trigone
bladder neck
bladder neck

renal

oval shape

Urethra (
-

400-500 ml
full bladder

)
bladder outlet

perineum
4 cm.
bladder neck
urethral meatus
20 cm.
posterior urethra
anterior urethra
Posterior urethra
bladder neck
urogenital diaphragm
Prostatic part
3.5 cm.
prostatic urethra
verumontanum
ejaculatory ducts
Membranous part
1 cm.
urogenital diaphragm
Anterior urethra
inferior side
urogenital diaphragm
external
meatus
Bulbous part
carvernous portion
Penile part
pendulous urethra
penoscrotal junction
external
urethral meatus
fossa navicularis

A
3A

3B

diagram
(

1.

(flank pain)

2.
,
3.
4.
5.

(painless hematuria)
(renal mass)
benign
renal cell carcinoma
(urinary retention)
,

malignant

renal cyst, hydronephrosis

bladder outlet obstruction

,
,

RADIOGRAPHIC INVESTIGATIONS OF THE URINARY TRACT

Plain film
Plain film KUB (kidney-ureter-bladder)
(
KUB
1. Soft tissue shadow

pubic symphysis)

psoas,

film
,

[1] right kidney

[2] left kidney
[3] right psoas muscle
[4] left psoas muscle
[5] urinary bladder
[6] liver
[7] spleen
4

KUB

(position)

retroperitoneum

medial

(shape)
(axis)
(size)

T12-L3

Long axis
10-16 cm.
lumbar vertebral bodies

psoas muscle
6 cm.

4 cm.

3-4
1.5 cm.

10

renal cortex
(cortical thickness)

1.5-2 cm.

(outline)
2. Abnormal calcification
gallstone, appendicolith, costochondral calcification,
atherosclerosis, prostatic calculi, calcified uterine fibroid
calcification

,
, phlebolith,

A
5A 5B
paravertebral region

KUB diagram
transverse process

abnormal calcification left

L4
left ureteric calculi

A
6A

6B
pelvic cavity

KUB

diagram
prostate gland

multiple small calcifications

prostatic calcification

11

7A 7B
3. Free
sidesairof pelvicfree
cavityfluid

- Free air

KUB

diagram
seminal vesicles

abnormal calcifications at both

seminal vesicle calcification

gas forming infection

emphysematous pyelonephritis
emphysematous cystitis
penetrating trauma

8
KUB abnormal
striated gas within left renal parenchyma
large perirenal gas collection extending
into retroperitoneum
emphysematous pyelonephritis

- Free fluid
psoas
4. Bony structure
spina bifida
(bony metastasis)

osteolytic

osteoblastic

lesion
-

Intravenous pyelography (IVP)

intravenous urography (IVU)

excretory urography

12

medium)

series
film
peripheral vein

(water soluble iodine-containing contrast

glomeruli
urinary tract
anatomy

function
IVP
1. Standard IVP:
full bladder
2. Double dose IVP:
100 ml
excretory function

50 ml
1-3, 5, 10, 30
post voiding
urinary tract trauma
15

4-8
content
adverse effect
opacification

bowel

cardiovascular
collecting system

cardiopulmonary support

diabetes mellitus, myeloma, hyperuricemia, sickle cell disease

standard IVP
Scout film
void
1-3
nephrogram
2
-

film
glomeruli

underlying
known renal disease

renal cortex

differential diagnosis

Hydronephrosis
Renal mass
cyst
Compensatory hyperplasia
absent
non-function

solid

Renal hypoplasia
Scarring
post-infection
Reduced renal blood supply
artery stenosis

renal

13

Renal hyperplasia

end-stage
renal disease

polycystic kidney disease

minor calyx
major calyx
pelvocalyceal
5
system
excretion
pelvocalyceal system
proximal ureter
nephrogram film
film 1-3
o Normal calyx
(cup-shaped)
calyx
clubbed shape
hydronephrosis
o Normal excretion
density
pelvocalyceal system
filling defect
renal stone, tumor, blood clot
o
nephrogram
(dense nephrogram
persistent nephrogram)
obstruction

diagram

normal findings

IVP

scout film, 3

10
(peristalsis)
obstruction, vesicoureteric reflux
neurogenic bladder
o ureter dilate
obstruction
bladder
urethra
o
dilatation
ureter
obstruction
, blood clot,
stricture
bladder tumor
ureteric orifice
30
full bladder
,
filling defect
vesical stone,
tumor, blood clot, prostatic enlargement
renal function
renal nephrogram
pelvocalyceal system
film

14

Post-void
bladder

mucosal pattern
oblique view

10A-F
normal IVP
scout
film, at 3, 5, 15 , full bladder post void
smooth indentation at superior margin of
urinary bladder
uterine impression

urinary

delayed film

15

3
-

Prostate enlargement
Urethral obstruction
Flaccid neurogenic bladder

4
-

differential diagnosis

differential diagnosis

filling defect
Bladder filling defect
-

Chronic obstruction
Chronic cystitis
Neurogenic bladder
IVP

1.
2.

Non-opaque stone
Prostate enlargement
Blood clot
Tumor
IVP

1.

renal
parenchyma

(urothelium)
3.

Spastic neurogenic bladder

Bladder tuberculosis
Schistosomiasis
Pelvic irradiation
post surgery

2.

16

IVP

IVP
1.
2.
3.
4.

1.
colicky

IVP
5. Uroepithelial tumor
transitional
cell carcinoma
6.
ultrasound
renogram

steroid
antihistamine
2.

Retrograde pyelography (RP)

urologist cannulate ureteric orifice
cystoscope
catheter
(
)
distal ureter
renal pelvis
pelvocalyceal system
renal excretion
contrast agent
abnormal filling defect
urothelial tumor
tissue biopsy
setting

11
retrograde
pyelogram
tip of catheter
right urteric orifice
(
)
normal opacification of right ureter and
right pelvocalyceal system

RP

RP

17

1.

pelvocalyceal system
IVP
2. Kidney excretion
pelvocalyceal system
IVP
3. Unexplained hematuria IVP
cystoscope

1.

1.
2.

Cystography

oblique

lateral views

300-400 mL
anteroposterior (AP),

(Foleys catheter)
void

12
cystogram
AP view tip of Foleys catheter
urinary bladder (
)
contrast filling
within bladder (
)

1.
2.

1.
mucosa
(cystitis)

3.
4.

diverticulum

low-pressure vesicoureteral

1.
2.

18

reflux

vesical fistula

Voiding cystourethrography (VCUG)

300-500 mL
fluoroscopy
45

AP view

1.

urethra

1.
vesicoureteral reflux
posterior urethral valve obstruction

2.
3.

urinary incontinence

1.
2.

Urethrography
2
retrograde
1) Retrograde urethrography Foley catheter
(12-14 French)
urethral meatus
balloon
fossa navicularis
inflate balloon
saline
1-2 mL
Foley
50 mL
supine oblique position
dynamic
fluoroscopy

antegrade urethrography

13
technique for
retrograde urethrography

19

cystostomy tube

14A 14B
and posterior urethra

2) Antegrade

normal retrograde urethrogram contrast filled anterior

refilled of contrast into the urinary bladder

voiding urethrography
VCUG

1.

1.

urethral meatus
anterior pelvic fracture
hematuria
2.
urethral stricture
urethral anomaly
hypospadia

1.
2.

Ultrasound of the urinary system

Routine ultrasound
1) Kidney
-

ultrasound
intercostal scanning

(probe)
anterior, posterior

subcostal
lateral approach

20

supine

decubitus

prone position

probe

- Renal sonography
renal parenchymal lesion, hydronephrosis,
pelvocalyceal system, renal hilum, peri
pararenal spaces
- Normal renal sonogram
liver
spleen

echogenicity

renal cortex
slightly hypoechoic
renal echo
liver parenchyma
parenchymal disease
renal medulla
triangular-shaped, hypoechoic structures
renal cortex
renal sinus
medullary pyramids
(hyperechoic)
renal sinus complex
renal
artery, vein, pelvis
renal sinus fat
hydronephrosis
renal sinus
fat
dilated pelvocalyceal system
anechoic

15A
normal sonogram
longitudinal view right kidney renal cortex
slightly hypoechoic
liver parenchyma
renal sinus
hyperechoic,
15B
renal cortex
renal capsule
lateral margin renal
pyramid (
)

2) Ureter
-

ultrasound
hydroureter

3) Urinary bladder

21

ultrasound

full bladder

urine
anechoic
(thickened or trabeculated)
full bladder

full bladder
acoustic window
ultrasound

ultrasound
1.
2.
3.
4.

1.
2.
3.
ultrasound

1.
2.
3.
4.
Doppler ultrasound
parenchymal perfusion
bladder

hydronephrosis
renal abscess

perinephric abscess
renal artery stenosis,
normal flow
urine urinary

Computer tomography of the urinary system

Gerotas capsule, fat capsule, renal
parenchyma, renal sinus
1) Kidney
CT scan
renal protocol
- Precontrast phase
attenuation
30-50 HU
urolithiasis, acute hematoma, baseline density

phase
(density)
parenchyma
renal mass

22

- Corticomedullary phase (30-60 seconds after contrast injection)

corticomedullary junction
renal cortex
medulla
phase
venous anatomy
pathology
renal vein thrombosis
- Nephrographic
parenchymal phase (60-100 seconds after contrast injection)
renal medulla
cortex
medulla
enhancement
phase
renal parenchymal lesion, renal mass
- Excretory
delayed phase (180-300 seconds after contrast injection)
pelvocalyceal system
2) Ureter
excretory phase
psoas

16A-C
normal CT scan
renal protocol
corticomedullary, nephrographic and
excretory phases

3) Urinary bladder

23

precontrast phase
excretory phase
density)

bladder

(low density)
(high

CT KUB
renal anomaly, trauma, tumor, infection
hydronephrosis
CT

abscess, hydronephrosis

CT scan

CT scan
1.

1.
2.

2.
3.

IVP
CT scan
(renal mass)

1.
2.

ultrasound
tumor extension

staging
3.
4.
5.
6.

renal artery
(CT for renal stone)

Magnetic resonance imaging (MRI)

CT scan
Gerotas capsule, fat capsule, renal parenchyma, renal sinus, collecting system
MRI
1.
2.

MRI
1.

(axial, coronal, sagittal)

24

3.

(Gadolinium)
CT scan
renal artery

4.

2.

3.
4.

calcification

Renogram

renogram
1.

renogram
renal

function

1.
2.

1.
2.

renogram
renal artery

Renal angiography
abdominal aorta

renal artery

(catheter)
renal artery

femoral artery

25

1.

renal artery stenosis

atherosclerotic change
fibromuscular
dysplasia

PATHOLOGY OF THE URINARY TRACT

1.
2.
3.
4.

Congenital abnormalities and normal variants

Urinary tract obstruction
Cystic
solid renal mass
Infection
acute and chronic pyelonephritis, renal and perinephric abscess,
tuberculosis
5. Trauma of the KUB system

Congenital renal abnormalities and variants

1. Persistent fetal lobulation
lobar anatomy
4-5
incomplete fusion of embryonic renal lobules
lobulation
(indentation)
renal surface
renal pyramids
normal variant
pathologic
scarring
pyelonephritic scar
renal infarcts
17
diagram
ultrasound longitudinal
view of right kidney
indentation between renal

26

2. Dromedary hump
IVP
ultrasound
normal renal pyramids

(splenic impression)
hump
18
diagram
ultrasound longitudinal view of left
kidney
focal bulge on lateral
border of left kidney
echotexture
renal cortex

3. Hypertrophic column of Bertin

normal variation
unresorbed polar parenchyma of
one or both of two subkidneys that fuse to form a normal kidney
junctional
parenchyma
normal cortical tissue
medullary pyramids
renal sinus
superior
middle third
distortion
pelvocalyceal system
19
diagram ultrasound
longitudinal view of left kidney
a welldefined, mass-liked lesion located at
interpolar region (
),
echogenicity
renal cortex
, lesion
indentation
renal sinus
splitting sinus

4. Anomalies of number
4.1. Renal agenesis
4.2. Renal dysplasia

ureteric bud
collecting system

27

4.3. Renal hypoplasia

calyces
acquired conditions
chronic iscehemia, reflux nephropathy, long-standing obstruction
4.4. Supernumerary kidneys
ureteric bud

19A 19B
diagram renal agenesis
supernumerary kidneys

5. Anomalies of position
5.1. Malrotation
junction (UPJ)

vertical axis

ureteropelvic

anterior

20
IVP
UPJ
proximal ureter left kidney
anterolateral aspect
malrotation of left kidney

5.2. Renal ectopia

L2
pelvic kidney
, hydronephrosis,

(vesicoureteric reflux),

28

20

diagram
IVP
right kidney
right-sided pelvic cavity
right pelvic kidney

6. Anomalies of form
6.1. Crossed fused ectopia

midline

21
IVP
ectopy

6.2. Horseshoe kidney

isthmus

diagram
left-to-right cross renal

renal anomaly
aorta

medial
inferior vena cava

lower pole
inferior mesenteric

29

artery (IMA)

UPJ obstruction, ureteral duplication,

,

obstruction,
Wilms tumor

7. Double collecting system

UPJ
blunt abdominal injury

21A-C
diagram, IVP axial CT
scan
abnormal axis of both kidneys lower
poles medial
upper poles
CT scan
aorta IMA
parenchymal
isthmus
both lower poles

pelvocalyceal system
duplex kidneys
duplication
complete
incomplete duplication
complete duplication
Weigert-Meyer Rule
upper renal moiety
inferomedial
ectopic ureterocele
ureterovesicle obstruction
lower renal moiety
(VUR)

22A
diagram
complete double collecting
system
ureter upper
moiety
bladder
inferomedial
(c)
ureter
lower moiety
bladder trigone (b), 22B
IVP 10
complete double collecting
system right kidney

30

8. Ureteroceles

submucosal portion
simple ureterocele

ectopic
8.1. Ectopic ureterocele
system
ectopic ureteral insertion
hydronephrosis
hydronephrosis

distal ureter
ipsilateral complete double collecting

upper moiety
non-function
moiety

23A

23B
diagram
IVP
left duplex collecting system
focal dilatation at distal ureter
drain
upper moiety left kidney
ectopic ureterocele

8.2. Simple

orthotopic ureterocele
duplication
cobra head deformity
urinary bladder
trigone
ureterocele

ectopic ureterocele
IVP
lucent rim

distal ureter
bladder mucosa

24A
diagram
simple ureterocele,
24B
IVP
focal
dilatation at bilateral distal
ureters (cobra head
deformity)

9. Polycystic kidneys
autosomal dominant polycystic kidney (ADPKD)
most common cystic kidney disease
autosomal recessive polycystic kidney (ARPKD)

31

9.1. ADPKD
20-40
80

, ,
,
(vavular heart disease)
coarctation aorta

ultrasound, CT scan

berry aneurysm

MRI

25A-C
diagram, ultrasonogram axial CT scan
multiple varying in size of cystic lesions at both kidneys
ADPKD

9.2. ARPKD

lesion

pulmonary hypoplasia
(periportal fibrosis)
ultrasound
I
corticomedullary differentiation
cystic
ultrasound

Urinary tract obstruction

1. Acute obstruction
2. Intermittent obstruction
artery
3. Chronic obstruction

aberrant renal

32

double collecting system

structure
minor calyx
UPJ

infundibulum
focal caliectasis,

major calyx
pelvocalyceal system

hydronephrosis
system

pelvocalyceal

lumen

distal nephron, renal papilla

calyx
cupped shape (
)
clubbed shape (
)
14
proximal nephron
3
renal
parenchyma
clubbed shape calyx
dilated pelvocalyceal system

obstruction,
1. Plain KUB
90
2. Ultrasound
system

urinary system ,
obstruction

obstruction,

plain film
(anechoic)

pelvocalyceal
hydronephrosis

33

hydroureter
26
ultrasound of right kidney
moderate dilatation of pelvocalyceal system
anechoic lesion
renal sinus
central hyperechoic region
moderate hydronephrosis

3. IVP
3.1.

(localized obstruction)
structure
(hydronephrosis, hydroureter)
structure

3.2.
3.2.1.
(intraluminal)
,
(intramural)
(extraluminal)
3.2.2.
- Mechanical obstruction
(urolithesis),
,
(stricture)
(fibrosis),
, posterior urethral valve
- Non-mechanical obstruction
congenital UPJ obstruction, vesicoureteric reflux
neurogenic bladder
3.3. Renal function

pelvocalyceal system
function

collecting system
delayed dense nephrogram
delayed excretory
non-functioning kidney

34

diagram IVP
acute right UPJ obstruction
delayed dense nephrogram
delayed excretion

27
IVP 3 5
deleyed dense nephrogram
right urinary tract obstruction

diagram

IVP

delayed nephrogram of right kidney IVP 3

delayed excretion IVP 5
acute

chronic obstruction

non-function

right kidney

Signs of ureteral obstruction in IVP

1. Increased dense nephrogram
2. Delayed excretion
3. Dilated renal collection system (hydronephrosis) and dilated ureter (hydroureter)
4. Generalized renal enlargement
5. High grade obstruction

rupture calyx

contrast extravasation

35

Mechanical obstruction
1. Urolithiasis (stone)
renal colic, hematuria, pyuria
2
plain radiograph
radiopaque stone
90
calcium oxalate, calcium phosphate
cystine stones
plain radiograph
non-opaque stone
uric acid, xanthine, struvite, matrix
Indinavir stones
radiopaque calculus
radiolucent calculus
1) Plain KUB
calcification

plain KUB
non-opaque stone

non-contrast CT scan
IVP
ultrasound

opaque stone
plain KUB
urinary tract

:
horseshoe kidney
transverse process
IVP

sacrum
Density:

90

plain KUB (radiopaque)

Size & shape:

(staghorn stone)

Axis:
Mobility:

ectopic kidney

pelvocalyceal system

Compare with previous imaging:

36

28A-C plain film KUB

left UPJ stone, left staghorn stone

abnormal calcification
UVJ stone
small bladder stone
phlebolithes
ureter
UVJ

vesical stone

pelvic cavity
distal ureteric stone,
phlebolithes
calcification
vein
typical
(central lucency)
distal
UVJ
29
1.

2.

ureterovesicle junction (UVJ)

SI joint

symphysis
spine

pubic
ischial
UVJ

calcification
central lucency
phlebolith
calcification
pelvic vein

30
IVP post-void multiple small roundshaped calcifications within pelvic cavity
calcifications
central lucencies
UVJ
calcifications
phlebolithes at both sides of pelvic cavity

37

2) IVP
IVP
delayed and persistent nephrogram
renal pelvis

IVP
radiopaque stone
radiolucent stone, blood clot, stricture

3) Ultrasound
ultrasound
ultrasound
(hyperechoic lesion)
shadowing)

(posterior acoustic

31
ultrasound longitudinal view of
right kidney abnormal hyperechoic lesion
with posterior acoustic shadowing
UPJ
mild dilatation of pelvocalyceal
system
right UPJ stone with
obstruction

4) Non-contrast CT scan
calcium content
calcification
KUB tract

38

hydronephrosis
2
CT scan with renal stone protocol
contrast media
urinary tract stone
dilatation
stone
ureter

hydroureter

CT scan
CT

acute frank pain

proximal
obstruction

32
axial CT scan abnormal
calcification at right UPJ
markedly
dilatation of right pelvocalyceal system
renal cortical thinning
right
UPJ stone with chronic obstruction and
severe right hydronephrosis

5) MRI
tumor

calcium
intramural defect

MRI

2. Tumors

urothelial lining
urinary tract
urothelial tumor
lumen (intrinsic obstruction)
2.1. Urothelial tumor
renal pelvis
calyx IVP
filling defect
2.2. Urothelial tumor
filling
retrograde
antegrade pyelography
2.3. Urothelial tumor
UVJ
distal
ureter
IVP, CT
ultrasound
(cystoscope)
33
diagram IVP
irregular filling defect at left renal
pelvis
urothelial
carcinoma

39

(extrinsic compression)
retroperitoneum
pelvic cavity
lymph node metastasis, gynecologic
malignancy, prostate gland
rectosigmoid carcinoma
3. Stricture or fibrosis
tuberculosis or schistosomiasis,
,
4. Clotted blood
IVP

filling defect
urokinase

5. Obstruction of the bladder outflow tract

bladder outflow tract
bilateral hydronephrosis
hydroureter
trabeculation
residual urine
bladder outflow tract
5.1.
benign prostatic hypertrophy (BPH)
bladder tumor (
), vesical stone, ureterocele
urethral stricture
trauma, infection, post operation
detrusor sphincter dyssynergy
5.2.
- Posterior urethral valve
), ectopic ureterocele (
),
bladder neck obstruction
urethral stricture
Signs of bladder outlet obstruction in IVP
1. Distended bladder with incomplete emptying
2. Increased bladder pressure
3.

prostate enlargement
dilated ureters

post voiding film

bladder trabeculation

residual urine

diverticulum

smooth filling defect at base of bladder,

reflux

40

34
diagram
radiographic findings
bladder outlet obstruction BPH
tumor

Non-mechanical obstruction
1. Congenital UPJ obstruction
UPJ

urinary bladder,

chronic

(peristalsis)
calices

pelvis

UPJ
functional obstruction
2. Vesicoureteric reflux (VUR)
UVJ
system
voiding cystourethrography
2.1. Primary
congenital VUR
2.2. Secondary VUR
duplication of ureter
ureterocele,
neurogenic bladder
infravesical obstruction
VUR
-Grade 1
-Grade 2

5 grade
collecting system

dilatation

pelvocalyceal

chronic cystitis,

41

-Grade 3
-Grade 4
-Grade 5
4

calyceal blunting
calyceal blunting
calyceal blunting
5 VUR

35
grade

forniceal angles
hydroureter
50
forniceal angles
papillary impression
hydroureter

diagram

grade

classification of VUR
grade 1-5

3. Neurogenic bladder
cerebral cortex
detrusor muscle
- Spastic neurogenic bladder
central neural lesion
bladder hyper-reflex
(frequency)
(urgency
and urge incontinence)
bladder trabeculation, pine-tree shaped bladder
small urine capacity
- Flaccid neurogenic bladder
detrusor muscle
overdistended
flaccid bladder
smooth bladder wall
large urine capacity

36
diagram
neurogenic bladder

radiographi findings

spastic

flaccid

42

Renal mass
2

(cyst)

(solid mass)

1. IVP
major
carcinoma)
CT scan
2. Ultrasound
cystic
3. CT
solid cystic lesion

minor calyces
IVP

cyst
tumor, abscess

solid mass
complicated benign cyst
pelvocalyceal system
(density)

(renal cell
ultrasound
solid

Cysts and cystic renal lesions

1. Simple renal cyst
(retention of dilated tubules)
(obstructed calyceal diverticula)
-

Plain KUB
IVP
system
simple cyst
parapelvic cyst
Ultrasound
(anechoic)
distal acoustic enhancement
CT scan
low density
(0-20 HU)

pelvocalyceal
renal sinus

enhance

37 IVP
well-defined roundshaped radiolucent
mass at lower pole
of right kidney

43

38 Ultrasound
welldefined, round-shaped,
anechoic lesion with posterior
acoustic enhancement at upper
pole of right kidney
simple renal cyst
39 Axial CT scan
well-defined, round-shaped,
hypodense lesion without
contrast enhancement at right
kidney
simple renal
cyst

2. Complicated cyst
complicated cyst
(1)
(thickened cyst wall)
(2)
(irregular outline)
(3)
(septation)
(4)
(calcified wall)
malignancy
benign
(5) CT attenuation
infection
hemorrhage
(6)
CT scan
MRI enhancement
complicated cyst ultrasound
CT scan
3-6

44

40

diagram, ultrasound

Solid renal mass

(1)
(2)
(3)
benign
(4)
malignant
Solid renal masses
1. Benign tumors

malignant
staging

CT scan

complicated renal cysts

45

Angiomyolipoma (AML)
40-60
sclerosis
AML
ultrasound
lipid
- CT scan
MRI

41
kidney

ultrasound
CT scan

Benign tumor
2. Malignant tumors

lipid

tuberous
4
(spontaneous bleeding)
(well-defined echogenic nodule)
fat

well-defined, hyperechoic nodule at upper pole of right

fat density lesion
renal angiomyolipoma

adenoma, hemangioma, lipoma oncocytoma

renal cell carcinoma, lymphoma, metastasis

Wilms tumor

Renal cell carcinoma

Von Hipple-Lindau disease
CT scan
MRI
IVP
space occupying lesion
calcification
(distort renal outline)
Ultrasound

MRI

echo
10 echo
ultrasound

echo
CT scan

46

CT scan

calcification
necrosis
perirenal fat space, Gerota fascia
aorta
distant metastasis

fascia

42 axial CT scan nephrographicphase image

ill-defined, large,
heterogeneous enhancing mass in the
left kidney with perinephric infiltration
(arrow)
RCC

Metastasis
CT scan
MRI

solid soft tissue tumor

Lymphoma

enhancement

non-Hodgkin lymphoma

Hodgkins disease
(primary lesion)

3
1.
(infiltrative lesion)
2.

(multiple bilateral masses)

47

3.
hilum
perirenal of infiltrating hilar mass)

(direct invasion form

3-4

Wilms tumor

necrosis, hemorrhage
calcification

normal variants
hydronephrosis

renal abscess, subcapsular hematoma

post trauma,
fetal lobulation, dromedary hump, enlarged column of bertin

cyst, complex cyst, hydronephrosis

mass
CT scan
MRI

ultrasound
solid mass

complex cyst
staging

simple
solid

Urinary tract infection

1.

(Lower urinary tract infection)

-

2.
3.

(urethritis)
(cystitis)
(prostatitis)
(Upper urinary tract infection)
(ureteritis)
(pyelitis)

pyelonephritis

48

(renal abscess)
(pyonephrosis)
(perinephric abscess)
Urinary obstruction

benign prostatic hypertrophy, calculi

Vesicoureteric reflux
Pregnancy
Diabetes mellitus
Immunodeficiency
Instrumentation
E. coli
Klebsiella, Enterobacter, Neisseria

gram negative organism

Proteus,
Tricomonas vaginalis
sterile pyuria
sterile pyuria
tuberculosis, fungus, interstitial nephritis
glomerulonephritis
imaging
medical disease
surgical cases
pyonephrosis,
renal abscess, infected renal cyst, perinephric abscess
ultrasound

1. Pyelonephritis
gram negative bacilli

1.
2.
3.

Escherichia coli

complication)
4.
(
underlying pathology)
5.
neurogenic bladder

49

6.

immunocompromised host
abscess
emphysematous pyelonephritis

IVP

Ultrasound

acute pyelonephritis

calyceal system

echogenicity
renal cortex

CT scan
decreased density)
striated nephrogram

(patchy

underlying pathology
obstruction,
vesicoureteric reflux,
rule out complication
renal or perinephric abscess,
emphysematous pyelonephritis, chronic change
renal scarring
underlying condition
DM, immunocompromised host

2. Chronic atrophic pyelonephritis

end stage
vesicoureteric reflux
parenchymal scar
hypertrophy
renal parenchyma
scar
ultrasound
gram negative bacteria
3. Emphysematous pyelonephritis
underlying DM
urinary tract obstruction

Plain film gas collecting system /

renal parenchyma
air
extend
Gerota fascia (high mortality)
CT scan
smooth renal enlargement, impaired renal
function, thickening perirenal fascia
extension

50

4. Renal abscess
liquefaction
anaerobe
spread)

lobar nephronia
nephritis
acute pyelonephritis

gram negative bacilli

(hematogenous
Staphylococcus aureus
ultrasound
CT scan
heterogeneous

cystic change
5. Perinephric abcess
perinephric space
perinephric abscess
E. coli,
Enterobacteria, P. mirabilus, S. aureus
psoas
plain KUB,
IVP
ultrasound
CT scan
fluid collection

6. Pyonephrosis
pyonephrosis
, stricture

renal pelvis

gas

calyces

obstruction
post operative stricture

- IVP:
function)
- Ultrasound: echo collecting system
(debris)
pelvocalyceal system
pyonephrosis
hydornephrosis
- CT scan: dilated collecting system

septicemia

(loss of renal

urine-debris level
perinephric

renal abscess

51

7. Tuberculosis
25
,

,
2
(1)
renal parenchymal infection
focal
generalized abscess,
granulation
calcification
advanced case
autonephrectomy
small
calcified kidney (2)
ureter
collecting system
stricture, hydronephrosis
hydroureter
-

: Plain KUB
calcified granuloma
irregular
calyx
infundibulum
hydrocalices
autoamputation
: irregular fibrosis
peristalsis
:

IVP
fibrosis

Trauma of the KUB system

1. Renal trauma
90

, localized ileus

blunt trauma
penetrating injury
plain KUB
transverse process
T12-L3 ,
psoas
, scoliosis
ultrasound

hematoma
hematoma
vital sign stable
hematoma
ultrasound
vital sign stable
collecting system

hyperechoic content
CT scan
IVP

52

CT scan
corticomedullary phase, nephrographic phase
excretory phase

CT

KUB

single shot IVP

vital sign unstable

bolus contrast media

collecting system
film KUB

1. Blunt abdominal trauma

- Gross hematuria
- Microscopic hematuria
-

sign

shock ( systolic pressure < 90 mmHg)

,

- Deceleration injury
-

50 cell/HPF

2. Penetrating injury
- Any degree of hematuria
- Hemodynamically unstable

1.
- Renal contusion
- Renal laceration
collecting system
shattered kidney
- Subcapsular hematoma
- Perinephric hematoma

(parenchymal and capsule injury)

renal capsule
renal capsule

15

53

2.
- Urinary extravasation
- Ureteropelvic junction injury

sudden deceleration
UPJ

medial
3.
- Renal infarction
- Thrombosis

Category
1
Minor injury

2
Major injury

segmental artery
main renal artery

4 grade
Description
Renal contusion
Intrarenal and subcapsular hematoma
Minor laceration, limited perinephric hematoma without extension to
the collecting system
Small subsegmental cortical infarction
Major laceration through cortex to the medulla or collecting system
with/without urine extravasation

54

Segmental renal infarction

3
Catastrophic
injury
4

Multiple renal lacerations

Vascular injury involving the renal pedicle
Ureteropelvic junction injury (avulsion, laceration)

The American Association of Surgeons in Trauma (AAST)

5 grade
Grade
1

3
4

Injury description
Hematuria with normal imaging studies
Contusions
Nonexpanding subcapsular hematomas
Nonexpanding perinephric hematomas confined to the
retroperitoneum
Superficial cortical lacerations (<1 cm)
Lacerations > 1 cm depth without extension into the collecting system
or urinary extravasation
Lacerations extending through collecting system
Injuries to main renal a/v with contained hemorrhage
Segmental infarctions without associated laceration
Shattered or devascularized kidney
UPJ avulsions
Complete laceration or thrombus of the main renal a/v

55

Radiologic

AAST

1
Minor injury

2
Major injury

3
Catastrophic
injury

2
3

Management
Minor injuries No follow up imaging
- Contusions
- Subcapsular hematoma
- Laceration without collecting system involvement
- Small subsegmental infarction
Lacerations F/U CT at 36-72 hours to monitor extravasation from
collecting system
Urinomas from urine extravasation percutaneous drainage
Renal artey thrombosis or segmental artery injury angiography where
stenting or embolization is feasible
Renal pedicle injury or severly damaged and shattered kidney surgical
management

2. Ureteric trauma
penetrating injury
(contrast extravasation)

blunt trauma
urinoma

56

IVP

urinoma

Ultrasound

CT scan
urinoma
Retrograde pyelography
extravasation

renal pelvis
fluid collection

echo

obstruction

3. Bladder trauma
blunt abdominal trauma
60%
penetrating injury
cystography

CT cystography

1. Absolute indication
- Gross hematuria with pelvic fracture
2. Relative indications
- Gross hematuria without pelvic fracture
- Microscopic hematuria with pelvic fracture
- Isolated microscopic hematuria
3. Imaging recommended
- Suprapubic pain
- Voiding difficulties

1) Bladder contusion

density

5 type
partial tear

teardrop shape bladder

submucosa,

contrast

57

2) Intraperitoneal bladder rupture

blunt trauma, stab wound, invasive procedure
dome of bladder
cystography
peritoneal cavity, paracolic
gutters
urine ascites
3) Interstitial bladder injury
intramural
serosa
contrast media
4) Extraperitoneal bladder rupture
anterior pelvic-ring fracture
base of bladder
anterolateral
cystography
perivesicular
space
extraperitoneal space urogenital diaphragm
perineum, thigh and scrotal sac
conservative with catheter drainage
5) Combined rupture
intraperitoneal
extraperitoneal injury
contrast media
4. Urethral injury
major pelvic trauma
2
1)

anterior pelvic arch

posterior urethra
2) Straddle injury
urethral meatus
out urethral injury
partial tear

complete tear

Urethrography

extravasation

anterior urethra
pelvic trauma
urethrogram
cystogram

rule

58

Textbook
Diagnostic imaging, Chap 7, Urinary tract, Peter Armstrong, Martin L wastie, Blackwell
scientific publications 1992 Oxford London, pp. 221-261
Electronic books or website
Learning radiology.com (GU: Basic intravenous urography, Evaluation of flank pain with
CT, Unenhanced helical CT in the patients with acute flank pain , the stone search)