JOURNAL READING

What the Radiologist Needs to Know About Urolithiasis :

Part 1 Pathogenesis, Types, Assessment, and Variant Anatomy

AYU WULANDARI
162021222

Pembimbing :
dr. Novita Elyana, SpRad

KEPANITERAAN KLINIK DEPARTEMEN

FAKULTAS KEDOKTERAN UPN VETERAN JAKARTA
RSUD AMBARAWA
2017
 SYSTEMA URINARIA
1.SYSTEMA URINARIA MASCULINA
1.1. ORGANAE URINARIAE : RENES DEXTRA ET
SINISTRA
1.2. TRACTUS URINARIUS :
1.2.1. URETER
1.2.2. VESICA URINARIA
1.2.3. URETHRA ( MASCULINA )
 URETER
CONTINUATION OF PELVIS RENALIS TO VESICA URINARIA
RENES
FORM & SIZE :
25 34 C;
:1 MM 1 CM. URETER DEXTRA SHORTER.
URETER
PARTS
1. PARS ABDOMINALIS URETERIS:

2. PARS PELVINA URETERIS

VESICA URINARIA
 VESICA URINARIA ( BLADDER )
A MUSCULO MEMBRANOUS SAC THAT FUNCTION AS RESERVOIR
URINE.
FULL : EXTEND CRANIOVENTRALLY INTO CAVUM ABDOMINALIS

FORM, SIZE & POSITION DEPEND ON ITS CONTENT.

CAPACITY : 500 CC ; 200 300 CC MICTIO
VESICA URINARIA
PARTS:
1. VERTEX VESICAE : THE TOP : APEX VESICAE:
LIG. VESICO UMBILICALE MEDIALE (URACHUS)
2. CORPUS VESICAE
3. FUNDUS VESICAE : CAUDODORSALLY,TOWARD RECTUM.
 URETHRA

1. PARS PROSTATICA URETHRAE

3 CM, WIDEST , MOST DILATABLE
NEARLY VERTICAL WITH GLD. PROSTATAE.
2. PARS MEMBRANACEA URETHRAE
THE SHORTEST, SMALLEST POSSIBILITY FOR
DILATATION, FROM APEX PROSTATAE TO
BULBUS PENIS.
3. PARS SPONGIOSA URETHRAE
LENGTH 15CM, LOCATED IN CORPUS
CAVERNOSUM URETHRAE

LENGTH : 17,5 20 CM ; ORIFICIUM URETHRA

INTERNA - ORIFICIUM URETHRA EXTERNA.
 INTRODUCTION

Urolithiasis is a common
clinical entity. Renal calculi
affect up to 6% of all
American women and 12% of
all American men during their
lifetimes. Overall, the
prevalence is increasing and is
higher in developed countries.

AJR : What the Radiologist Needs to Know About Urolithiasis

TYPES OF RENAL CALCULI
CALCIUM

MAGNESIUM
AMMONIUM
PHOSPATE
TYPES OF
RENAL
CALCULI
MEDICATION
& URIC ACID
METABOLITES

CYSTINE

AJR : What the Radiologist Needs to Know About Urolithiasis

CHARACTERISTICS OF DIFFERENT TYPES OF URINARY TRACT CALCULI

COMPOSITION (%) IMAGING PEARL CAUSATIVE FACTOR

Calcium 70-80 Wide range of densities and gross Numerous, including primary
morphologies hyperparathyroidism, chronic
diarrhea, and distal renal tubular
acidosis
Magnesium 15-20 Staghorn calculus refers to a struvite Infection
ammonium calculus involving the renal pelvis and
phosphate extending into at least two calyces
(struvite)
Uric acid 5-10 Pure uric acid stones are radiolucent on Gout, small-bowel disease, and
radiography high body mass index
Cystine 1-3 May contain low-attenuation foci Cystinuria
(voids)

Medications & 1 Indinavir can be radiolucent even on CT Prolonged or excessive use of some
their medications
metabolites

AJR : What the Radiologist Needs to Know About Urolithiasis

 CLINICAL ASSASEMENT
SYMPTOMS
Colic pain
Renal pelvic or proximal ureteral
obstruction flank pain
Lower ureteral obstruction pain
radiating to the testicle or labium.
Stones at the ureterovesical
junction urgency and
suprapubic discomfort
Nausea and vomiting may be
present.
Gross or microscopic hematuria
can be associated with renal or
ureteral stones
AJR : What the Radiologist Needs to Know About Urolithiasis
LABORATORY EXAM :
Blood and urine renal function
and hematologic status.
Electrolyte, blood urea nitrogen,
and creatinine levels reflect
renal and metabolic status.
WBC count may be elevated
response to infection or stress
Hemoglobin level can be
depressed some cases of
chronic calculus disease.
Urinalysis detects hematuria
and pyuria and includes urine pH,
which can help guide
management.
IMAGING OF
UROLITHIASIS
 RADIOGRAPHY
For decades, the kidney-ureter-bladder
radiograph was the initial examination of
choice in the evaluation of acute onset of flank
pain.

Unfortunately, radiography has been found to

be only about 60% sensitive overall in the
detection of urolithiasis because bowel
contents, overlying soft tissues, gas, and
osseous structures may obscure small
radiopaque calculi.

AJR : What the Radiologist Needs to Know About Urolithiasis

 EXCRETORY UROGRAPHY
Excretory urography allows increased
delineation of renal anatomy compared with
the kidney-ureter-bladder radiograph and may
reveal the presence of a calculus causing
obstruction.

Unfortunately, these calculi can also be

obscured by contrast material.

Urinary obstruction may cause significant delay

in the excretion of contrast agent, thus
increasing the study time.

AJR : What the Radiologist Needs to Know About Urolithiasis

 ULTRASOUND
Ultrasound is advantageous in the setting of the pediatric patient, pregnant
patient, or a patient with recurrent bouts of urolithiasis , because ultrasound does
not use ionizing radiation.

Ultrasound can also reveal secondary effects, such as obstruction, superimposed

infection, or abscess formation.

The direct visualization of ureteral calculi can be also difficult with ultrasound
because of overlying bowel gas and the relative depth of the ureter within the
pelvis. Ultrasound visualization may be further complicated in obese patients by
large amounts of intervening fat

AJR : What the Radiologist Needs to Know About Urolithiasis

 MRI
ADVANTAGES DISADVANTAGES
MR urography is an excellent Unfortunately, as with
modality for the delineation of nearly any calcified
secondary effects of
urolithiasis such as infection or structure on MRI, the actual
obstruction calculus is often not well
Like ultrasound, MRI does not visualized
use ionizing radiation and can
be of value alone or in
combination with radiography
in the evaluation of the
pediatric, pregnant, or serially
imaged patient

AJR : What the Radiologist Needs to Know About Urolithiasis

 CT
ADVANTAGES DISADVANTAGES
CT, both unenhanced and A significant drawback is
contrast enhanced, has quickly
become the modality of choice that CT utilizes ionizing
in the evaluation of suspected radiation.
urolithiasis
CT can measure stone
attenuation, evaluate
secondary effects of
obstruction, delineate
surgically relevant anatomy,
and detect other potential
sources of pain or pathologic
abnormality

AJR : What the Radiologist Needs to Know About Urolithiasis

 MODALITIES IN THE EVALUATION OF UROLITHIASIS
MODALITY ADVANTAGES
Radiography Relatively low radiation dose with
respect to CT; 90% of calculi are
radiopaque
Excretory Some delineation of renal and
urography collecting system anatomy
Ultrasound Lack of ionizing radiation;
intermediate sensitivity for
detection of renal calculi and
hydronephrosis
MR urography Nonionizing radiation; imaging of
secondary effects of urolithiasis
and other genitourinary
abnormalities, including
malignancy
Unenhanced CT Delineation of urinary tract and
nongenitourinary anatomy; rapid
acquisition and interpretation;
highlights procedurally relevant
anatomy
DISADVANTAGES
Only 60% sensitivity in detection
of urinary calculi; patients source
of pain may not be urolithiasis
Exposure to contrast agent;
length of examination; contrast
agent can obscure calculi
Operator dependent; deep
portions of ureter difficult to
image
Actual calculus difficult to
visualize
Radiation exposure especially in
the recurrent stone former,
young, or pregnant patient
PREFERRED UTILIZATION
Monitoring of calculus
burden in patients known to
have urolithiasis
CT now preferred over
excretory urography in most
settings for evaluation of
renal and collecting system
anatomy
Pregnant or pediatric
patients and recurrent stone
formers
Evaluation of urinary tract
findings other than
urolithiasis such as stricture
First-line imaging
investigation in the adult
with flank pain
COMPLEX OR VARIANT GENITOURINARY ANATOMY
A horseshoe kidney results from renal fusion and subsequent ascent failure at the
level of the inferior mesenteric artery. Collecting system drainage of a horseshoe
kidney is impaired because of malrotation and a high ureteral insertion. Up to
20% of horseshoe kidneys can present with calculi, most of which consist of
calcium oxalate

AJR : What the Radiologist Needs to Know About Urolithiasis