[DIAGNOSTIC IMAGING] Module No.

[URINARY SYSTEM RADIOLOGY (Renal masses and Congenital Anomalies)]

2
m
[Dr. Micheal Thomas Mesina] 06 DECEMBER 2016
RENAL CORTICAL PHASE
Outline
- Corticomedullary phase
I. Solid Renal Neoplasms
II. Cystic Renal Masses - 25-70 sec after contrast
A. Simple administration
B. Complicated - Smaller lesions
C. Complex  Homogeneous
III. Congenital Anomalies of the Kidney, Ureter, and Bladder enhancement
A. Kidney
- Larger lesions
1. Renal agenesis (Single kidney)
2. Horseshoe kidney  Variable
3. Crossed fused ectopia enhancement
4. Supernumerary kidneys (necrosis)
B. Ureter - Renal involvement
1. Ureteral duplication
2. Bifid renal pelvis  Renal involvement: renal vein and IVC (worse prognosis)
3. Ureteropelvic junction obstruction  Small lesions: < 3cm
C. Bladder
1. Exstrophy
2. Urachal Remnant Diseases
RENAL PARENCHYMAL PHASE

LEGEND
Lecture Powerpoint, Audio, Textbook, 2018 Trans - Nephrogenic phase
- 80 – 180 sec
I. SOLID RENAL NEOPLASM - Most sensitive phase

 Renal cell carcinoma (RCC)

 Transitional cell carcinoma (TCC)
 Angiomyolipoma (AML)
 Oncocytoma
 Lymphoma
 Metastasis
EXCRETORY PHASE
RENAL CELL CARCINOMA (RCC)

 Most common renal mass - Less worth

 It is more common in men (3:1) - For assessing collecting
 50 to 70 years old system anatomy
 Bilateral in 2% of cases.
 Surgical resection provides the only chance for cure.
 Any solid renal mass should be considered suspect
for RCC!
 Accounts for 85%
CONTRAST PHASES
CLASSIC CLINICAL TRIAD

 Hematuria
 Flank pain
 Palpable Mass
 Only 10-15% of the patients presents with these.

IMAGING FINDINGS

 Multidetector CT scan with and without contrast

 Can diagnose and stage at the same time

NON-CONTRAST PHASE

- Soft tissue density

- Irregularity of the borders

A. Contrast-enhanced CT scan reveals a lobulated tumor (T) in the

right kidney (RK).
 Septations (arrowheads) are evident between low-attenuation
cystic areas.
 A focal calcification (long black arrow) is also present.
 The right renal vein (black arrow) and the inferior vena cava
(IVC) are free of tumor thrombus.

B. US image in a different patient shows a multicystic mass (between

open arrows) arising from the lateral aspect of the left kidney (LK;
between closed arrows).

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

 The thin septations were lined by clear cells, which is typical STELLATE PATTERN
of renal cell carcinoma.

ANGIOMYOLIPOMA

 Uncommon renal neoplasms

 composed of varying amounts of fat, smooth muscle, and
abnormal blood vessels lacking elastic tissue.
 Most are solitary unilateral tumors
 Middle-aged women
o The rest - Tuberous sclerosis.
 Thin -walled vessels
o prone to hemorrhage, which may be massive.
 Large solitary lesions are usually surgically removed.
 May be as large as 20 cm
SPOKE WHEEL CONFIGURATION
 Usually incidental finding.
IMAGING FINDINGS

LYMPHOMA

 Rare
 Commonly involved by metastatic lymphoma or by direct
invasion.
 MOC: Multidetector CT scan o Hodgkin lymphoma
 Involves the cortex  CT
 Macroscopic fat o homogenous, round, poorly enhancing
 HU of fat (-20)  Extensive retroperitoneal adenopathy favors the diagnosis.

METASTASIS

 Frequent site of hematogenous metastases.

 Detected late in the course of malignancy.
 Appear as multiple, bilateral, small, irregular.
 Lung, breast, and colon carcinoma and melanoma.

CYSTIC RENAL MASSES

 Simple cyst
 Complicated cyst
 Hyperechoic  Renal abscess
 Located in the cortex  Cystic renal diseases
 May exhibit acoustic shadowing o Autosomal dominant polycystic disease
o Autosomal recessive polycystic disease
ONCOCYTOMA o Tubular sclerosis
o Von Hippel-Lindau
o Medullary sponge kidney
 Rare renal lesion
 Composed of eosinophilic cells (oncocytes)
 Difficult to distinguish from RCC SIMPLE RENAL CYST
 Average size: 5 – 8 cm
 Large tumors  Most common type of renal mass.
o stellate central scar  Older than age 55.
 Angiography:  Large cysts (>4 cm)
o Spoke wheel configuration of radiating vessels. o Obstruction, pain, hematuria, or hypertension.
 US, CT, and MRI.
 Multiple and bilateral

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

CRITERIA: ULTRASOUND BOSNIAK CLASSIFICATION

Bosniak developed a classification system for cystic masses that helps

to categorize these problematic lesions.

COMPLEX RENAL CYST

 Round or oval anechoic mass.
 Increased through transmission.
 Sharply defined far wall.
 Thin or imperceptible cyst wall.

CRITERIA: CT SCAN

- Sharp margination with the

renal parenchyma.

- No perceptible wall.

- Homogeneous attenuation
near water density (-10 to
+10 H) AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE
(ADPKD)

 Hereditary
CRITERIA: MRI  Renal parenchyma is progressively replaced by multiple
non-communicating cysts of varying size.
 Commonly complicated by internal hemorrhage.
 30 and 50 years old
 Associated findings:
o Increased incidence of aneurysm
o Cysts elsewhere: liver, pancreas and spleen.
 Large kidneys with multiple cysts
 May have calcifications

 Homogeneous, sharply defined, round or oval mass.

CONGENITAL ANOMALIES OF THE KUB (KIDNEYS,
 Homogeneous low signal intensity on T1WIs.
URETHERS, BLADDER)
 Homogeneous high signal intensity similar to that of T2WIs.
 Renal agenesis (Single kidney)
 Horseshoe kidney
COMPLICATED RENAL CYST  Crossed fused ectopia
 Supernumerary kidneys
 Complicated by hemorrhage and infection.
RENAL ANGENESIS (SINGLE KIDNEY)
 Resulting change in imaging characteristics may make
 Associated genital tract anomalies in the female.
differentiation from cystic renal tumors difficult!
 Ipsilateral adrenal agenesis is found in 10% of cases.
 Adrenal gland may appear enlarged.
 Compensatory hypertrophy of the opposite kidney is
usually evident.

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

HORSESHOE KIDNEY: ULTRASOUND

SUPERNUMERARY KIDNEYS
 Rare anomaly.
 Anomalous kidney is small and rudimentary.
 Demonstration of separate pelvis, ureter and blood
supply is essential for diagnosis.
 Intravenous pyelogram demonstrates pelvis and ureter.
 Aortography demonstrates separate blood supply and is
confirmatory.
 CT scan, MRI and ultrasound.
 Less or non-invasive methods.
HORSESHOE KIDNEY: CT

(1) Left: Intravenous pyelogram - demonstrates pelvis and ureter (2)

Right: Multi-planar reconstruction

HORSESHOE KIDNEY

 Most common type of fusion anomaly

 Lower poles of kidneys are joined by a fibrous or
parenchymal band. HORSESHOE KIDNEY: RENAL ANGIOGRAM
 Kidneys are malrotated
o Renal pelvis directed more anteriorly
o Lower pole calyces are directed medially
 Low in position
 Renal arteries: multiple and ectopic in position

HORSESHOE KIDNEY: INTRAVENOUS PYELOGRAM (IVP)

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

 Angiography shows these kidneys supplied by multiple

arteries and the isthmus usually supplied by
anomalous branches of common iliac artery of one or
both sides.

HORSESHOE KIDNEY: NUCLEAR MEDICINE

PANCAKE KIDNEY (DISK KIDNEY)

 Both upper and lower poles are fused
 Calyces are directed posteriorly
 Lies in or near midline
 Low in position
 May be sacral
 Ureters enter bladder normally

 Complications
o UPJ obstruction
o Renal stones
o Wilm’s tumor in children
o Susceptibility to trauma

CROSS-FUSED ECTOPIA
 May present as an abdominal mass.
 Aberrant renal arteries
 Ureters insert in their normal location in the bladder
trigone
 Mass – because kidneys are on both sides

 Ectopic kidneys have aberrant blood supply

 Failure of rotation

 A variation in which both upper and lower poles are fused,

failure of rotation
 Calyces are directed posteriorly
 Renal mass lies in or near midline

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

 Is low in position- may be sacral

 Ureters enter bladder normally
 Ectopic kidneys have aberrant blood supply

 Lower in position than normal

 Pelvic or sacral region
 Failure to visualize a renal shadow should arouse suspicion
as agenesis is rare
 CT, IVP, Radionuclide scanning and retrograde pyelography
can be used for detection

 Plain x-ray
o Pelvic mass
 Its ureter is only long enough to connect renal pelvis to
bladder
 Nephroptosis
o Downward displacement and more mobility of
kidney than usual
 Intrathoracic kidney
o Projecting into the posterior thorax from below the
diaphragm  In complete ureteral duplication, the ureter draining the
 Usually unilateral upper pole passes through the bladder wall to insert
inferior and medial to the normally placed ureter that
drains the lower pole.
 Upper pole ureter – obstructed because of ectopic
insertion
 Lower - inserts in or near the normal location in the
bladder trigone and is subject to reflux because of
distortion in its passage through the bladder wall by
ectopic ureteroceole

 A mass in the right side of the chest, identified on a

radiograph (Panel A, arrows). He reported no
pulmonary problems and no history of chest trauma.  Excretory urography shows complete ureteral
Physical examination was unremarkable. Reformatted duplication on the right.
coronal (Panel B) and sagittal (Panel C) computed
tomographic scans show the right kidney (large
arrows) and part of the liver protruding above the
diaphragm (small arrows) and into the posteromedial
aspect of the right hemithorax through the foramen of
Bochdalek.

ANOMALIES OF THE URETER

 Ureteral duplication
 Bifid renal pelvis
 Ureteropelvic junction obstruction
 2 % of the population

URETERAL DUPLICATION
 6x more common than bilateral duplication

WEIGERT-MEYER RULE  Excretory urography in an adult patient with bilateral

 Upper pole ureter – prone to obstruction complete ureteral duplication.
 Lower pole ureter – prone to vesicoureteral reflux

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

DROOPING LILY SIGN  May go undiagnosed until adulthood.

 Hydronephrosis and parenchymal atrophy
o Severity of obstruction
 Bilateral in 30% but not symmetric
 Ureter is not dilated
 Majority of the cases
o Cause is unknown!
 Aberrant renal vessel causes obstruction

 IVP of a patient with a right sided duplicated collecting

system. The upper moiety is obstructed, and non-
functioning. It displaces the lower pole moiety
inferiorly, mimicking the appearance of a drooping
lily.
 Complications
o Urinary tract infection
o Vesicoureteral reflux
o Ureteroplevic junction obstruction

BIFID RENAL PELVIS

 10 % of the population
 Most common congenital variation of the
ureter
 Anomaly with no pathological consequences
separate pelvices draining the upper and lower
poles and joins at the ureteropelvic junction

 Marked dilatation of the renal collecting system,

degree of dilatation indicates chronic, likely congenital
process. The proximal ureter shows normal caliber,
indicating obstruction at the level of the UPJ

 IVP shows dilatation

of the renal calyces
and pelvis without
excretion of contrast
into the ureter

 Anomaly with no pathological consequences separate

pelvices draining the upper and lower poles and joins
at the ureteropelvic junction

URETEROPELVIC JUNCTION OBSTRUCTION

 Most common congenital anomaly of the urinary
tract

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

ANOMALIES OF THE URINARY BLADDER URACHUS

 Exstrophy
 Urachal remnant disease

EXSTROPHY
 Absence of lower anterior abdominal wall
 Diagnosis is based on observation
 Radiography used to study kidneys and ureters
o Dilatation of distal ureter
 Wide separation of pubic bones anteriorly at the
symphysis
o Wide diastasis
 Bladder is open, its mucosa is continuous with the skin
 Epispadia
 “Square shaped pelvis”

PATENT URACHUS
 Persistent communication between the bladder and
the umbilicus
 Urine leak
 Discovered in neonatal period
 Most common (50%)

 The predominant abnormality on this radiograph is

wide separation of the symphysis pubis.
 Exstrophy of the bladder results from failure of midline
closure of the lower abdominal wall and anterior wall.

URACHAL REMNANT DISEASES

 Discovered in asymptomatic adult patients during CT
scan or ultrasound examination
 Urachus
o Vestigial remnant of the urogenital sinus and
allantois
o Tubular structure that extends from the
bladder dome to the umbilicus along the
anterior abdominal wall.
 Diseases
o Patent urachus
o Umbilical-urachal sinus
o Vesicourachal diverticulum
o Urachal cyst

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[DIAGNOSTIC IMAGING] [URINARY SYSTEM RADIOLOGY] Module 5, Lecture 2

UMBILICAL URACHAL SINUS

 Blind ended dilatation of the urachus
 May cause persistent umbilical discharge
 15 %

A. demonstrate a small, anterosuperior outpouching (arrow)

representing a urachal diverticulum arising from the apex of
the bladder
B. Sagittal US image shows a localized hypoechoic outpouching
(arrow) communicating with the uppermost portion of the
bladder (bl), thereby helping confirm the CT findings.

URACHAL CYST
 Urachus closed at both ends but remains patent in the
middle

 Sagittal US image shows a hypoechoic tubular

structure (arrows) extending from the umbilicus (umb)
(cursors) just beneath the anterior abdominal wall. The
caudal end of this tubular structure is obliterated.

VESICOURACHAL DIVERTICULUM
 Outpouching of the bladder in the anterior midline
location of the urachus.
 5%

 Collection of fluid localized at the midline of the

anterior abdominal wall between the umbilicus
and pubis
REFERENCES
Batch 2018 Transcription
PowerPoint Lecture

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