Imaging of the Genitourinary Tract

Blok 17
Keluhan dan penyakit berkaitan dengan
sistem uropoetik
Semester V

Mashuri, dr.,Sp.Rad.,M.Kes
Department of Radiology
Faculty of Medicine
University of Lambung
Mangkurat/
Ulin Hospital

Imaging Modalities
Conventional non contrast
Plain X-Ray

Conventional with contrast

Intravenous pyelography
Antegrade pyelography
Retrograde Pyelography
Retrgograde Cystography
Retrograde Urethrography
Cystourethrography
Bipolar cystourethrography
Voiding Cystourethrography
Retrograde cystourehtrography

 Non-conventional
Ultrasound
Computed Tomography Scan
Digital Substraction Angiography (DSA)
Nuclear Medicine (Scintigraphy)
Magnetic Resonance Imaging (MRI)

Kidneys

Position of kidneys:
R: L1-L3
L: T12-L3

Long axis of the kidneys is directed downward and outward, parallel to the
lateral border of the psoas muscles

Ureter

Urinary Bladder

Urethra

Plain Photo Abdomen (KUB)

or BNO
Indication:

Renal opaque calculi,

Preparation for IVU
Check placement of
catheters/stents/drains/foreign bodies

Contraindication: none
Technique: supine position

Plain photo abdomen

KUB
All exposures at end
of expiration for any
urinary system study
The Last 2 Ribs
All Lumber And Sacral
Vertebrae
Psoas Muscles
Symphysis Pubis

Plain X-ray film

Renal shadow
Gastrointestinal tract shadow
Calcification or radiopaque shadow
Psoas shadow
Bone

IVU (dulu IVP)

1.
2.
3.
4.
5.

Suspected congenital anomaly

Renal Tumor
Renal colic
Persistent urinary tract infection
Renal Trauma

Indications

Preparation

After midnight: Nil Per Os (puasa + 8 hours)

Bowel cleansing
Clear liquid diet
Dont talk to much and smoking
Empty bladder
Free from contrast agent hypersensitivity

Contrast Agent and Adverse Reactions

Complications

Crucial not to leave pt alone for first

5 minutes after injection!

1 . Immediate
Minor: Nausea, vomiting, arm pain, and headach
Sever allergic: Erythema, urticaria, facial or glottic
edema.
Treatment: antihistamines, steroids and/or epinephrine.
Chemotoxic or idiosyncratic reactions: (most serious)
Include: convulsions, pulmonary edema, cardiovascular
collapse, thrombosis, cardiac arrest. 1 of every 7,500
The mortality rate for contrast administration, 1:100,000
2. Delayed
Nephrotoxicity: Patients with diabetic nephropathy,
creatinine levels are >3 mg/dl. This nephrotoxicity is
usually reversible.

IVU procedure
1.
2.
3.
4.
5.
6.

Preliminary (Plain photo)

Immediate
5 minute
Abdominal compression
Release
Post micturation

Should ideally be tailored to answer the

clinical question

Preliminary Film (Foto I)

Precontrast KUB
radiograph.

To demonstrate
opacities that may lie
within the urinary tract.
To check abdominal
preparation, positioning
and exposure factor.
Additional radiographexpiration or oblique of
the renal areas to
determine the position
of any opacities lie
within the urinary tract.

(All exposures at end

of expiration for any
urinary system study)

Immediate film (Foto II)

1-3 min post contrast radiograph
collimated to the kidneys.
To demonstrate the nephrogram phase.
The renal parenchyma opacified by the
contrast in the renal tubules.

5 minute film (Foto III)

5 min post contrast KUB radiograph.
To determine if excretion is symmetrical or
a further dose of contrast is required if the
opacification is poor.

Abdominal compression is then applied if

no contraindication.

Abdominal compression
Contraindications:
Evidence of obstruction on 5 minute image
Abdominal mass
Abdominal aortic aneurysm
Recent abdominal surgery
Severe abdominal pain
Suspected urinary tract trauma

Compression Film (Foto IV)

A 15 min post contrast
collimated to the kidneys.
To demonstrate
distended collecting
systems and proximal
ureters.
- effectively produces
partial ureteric
obstruction
- Improved calyceal detail
and more reliable ureteric
opacification upon release
of compression.

Release film (Foto V-VII)

A 30 min post contrast KUB radiograph
following release of compression.
To demonstrate the entire urinary tract
particularly the lower ureters.
Additional radiograph - prone or upright
KUB when the lower ureters are not seen
adequately.

Post Micturation Film (Foto VIII)

Post micturation KUB radiograph.
To demonstrate complete bladder
empting and any hold-up of contrast in
the collecting system.
Persistence dilatation on post void image
suggest obstruction and decompression
indicates physiologic distension.

 Preliminary radiograph
Gas, mass, stones, bones
Renal shadows- size, axis,
calcification
Course of ureter

Immediate film
(nephrogram)
Size, shape, symmetry,
contour

Pyelogram
Calices, ureters, urinary
bladder

Evaluation of IVU

Pyelography
Antegrade pyelography (APG)
Outline the pelvicalyceal system and
ureteric anatomy
Contrast is injected into the PC system
and outline the PC and ureter
Retrograde pyelography (RPG)
Requires cystoscopy, placement of the
catheter to the distal part of ureter

Antegrade pyelography (APG)

Indications:
Anatomic evaluation of pelvocalyceal
system
Ureteric drainage for evaluate
urine leak,
post-percutanea nephrostomy
residual stones
site of ureteric obstruction
ureteral fistulas
Technique:
Under flouroscopy
Via catheter nephrostomy with using
contras media
Supine position

Retrograde Urography
Indications:
Hematuria,
Contrast sensitivity,
Suboptimal IVU,
Needs cystoscopy
Technique:
Under fluoroscopy
Contrast injected
directly into
pelvicaliceal system
via cathethers from
urethrae
Supine positions

Cystography

Cystography
Indications:
Vesicoureteral reflux
(backward flow of urine into
ureters)
Recurrent lower urinary
tract infection
Neurogenic bladder:
(dysfunction due to disease
of central nervous system or
peripheral nerves) Bladder
trauma
Prostate enlargement
Lower urinary tract fistulae
Urethral stricture
Posterior urethral valves
(obstructive congenital defect of
the male urethra)

Cystography technique
Technique:
Contrast administration usually performed
retrograde via catheter urethra,
Catheter cystostomy
IVU (excretory cystography)

Cystography Routine Series

Scout view
filled AP
both obliques
Lateral
Voiding
post-void

Excretory Cystogram (IVU)

Retrograde Cystogram

Urethrography

Indications:

To diagnose urethral stricture

To evaluate urethra after trauma

Technique:

Urethra may be visualised as part of MCU

(descending) or ascending urethrogram
Ascending urethrogramtip of catheter is in
the fossa of navicular.
Spot film is taken when contrast is injected

Cystourethrography
Static Cystourethrography=
Retrograde
Cystourethrography=Cystourethrography
Bipolar Cystourethrography
Voiding Cystourethrogram (VCUG)

Cystourethrography
Indications:
Evaluate bladder lesion, rupture, leak, post
trauma/surgery bladder
integrity/anastomose/fistulas

Technique:
Scout,
Fill bladder with 200-400 mL via urethrae syringe
or tip of catheter is in the fossa of navicular.
A/P and obliques (shows extravasation posterior
to bladder),
Post-drainage film

Cystourethrography
Technique:
AP Oblique Projection RPO/LPO
Patient is supine, rotated 35
- 40 degrees
Urethral syringe (or Brodney
clamp?) is used to introduce
contrast images are obtained
as contrast is injected
Entire urethra must be
visualized
Bladder can be filled to
obtain antegrade voiding
study

Male

Technique:
AP Projection (maybe obliques)
Bladder can be filled and patient
void for antegrade studies
Cassette should be centered as
for cystography
Abduct thighs to prevent
superimposition of bone or soft
tissue

Female

Cystourethrography

Micturating cystourethrogram(MCU)/
Voiding Cystourethrogram (VCUG)
Functional and anatomic evaluation of bladder
Indication:
1. To detect vesicoureteric reflux who have recurrent
infection
2. Bladder rupture
3. Demonstrate posterior urethral valve
4. Ureterocele,
5. Dysfunctional voiding
6. Urethral strictures
7. Bladder/urethral diverticula

Micturating cystourethrogram(MCU)/
Voiding Cystourethrogram (VCUG)

Scout
Pediatric: 5 or 8 F feeding tube, fill bladder with contrast
(age +2 x 30). Mainly for peadiatric patient
Adult: standard catheter
Filling the bladder with contrast introduced via urethral
catheter
Film during filling- bladder pathology, early reflux
Films during void- reflux, urethral abnormality
Oblique- evaluate grade 1 reflux, males
Post-void film

MCU

 A voiding
cystourethrogram
(VCUG) of a patient with
grade III vesicoureteral
reflux (VUR). Note that
the contrast flows up the
ureter and into the renal
pelvis. The calyces are
sharp

 This is an example of
grade V
vesicoureteral reflux
(VUR). Note the
dilated renal pelvis
and calyces. The
ureter also is dilated
and tortuous.

 This is bilateral
vesicoureteral reflux
(VUR)

Ultrasound
Indication
1. Renal mass
2. Haematuria
3. Flank pain
4. Blood urea elevation
5. Poor non functioning
kidney on IVU
6. Biopsy /
interventional
guidance

Technique
A 3.5 transducer is
generally used to
scan the adult kidney
Liver and spleen act as
acoustic window for
evaluation R and L
kidneys respectively
Patient position:
Supine, decubitus or
prone

Ultrasound of Right Kidney

Ultrasound of Kidneys

NORMAL STUDY

DILATED RENAL
PELVIS

 The parenchyma is
relatively normal in
thickness.
The dilation of the
collecting system
extends from the
renal pelvis to the
calyces.

Computed tomography
Giving predominantly
anatomical
information
Used when US
finding is inconclusive
Staging of tumor
Renal trauma
Renal artery stenosis
Calculi / obstructive
uropathy

Emphysematous pyelonephritis.

Cystic renal cell carcinoma.

RCC with inferior vena cava

invasion

MRI
Anatomical information
When US or CT is inconclusive
MRA: for renal artery stenosis
Multiplanar imaging sag, coronal and
axial
Time consuming / expensive

Large right renal cell carcinoma with renal vein

and inferior vena cava invasion.

T2-weighted axial
MRI

 Dynamic gadolinium-enhanced magnetic

resonance angiogram (MRA) shows normal
renal arteries.

Renal Angiography

Nuclear Scintigraphy
Physiologic and anatomic info
Renograph:
Non-imaging (Ulin Hospital)
With imaging (Gamma camera)

Radioisotop+Radiofarmaka
TC-99 m (t = 6 hrs)
MAG3- cleared by tubular secretion, no glomerular
infiltration- evaluate renal function and renal plasma
flow
DTPA- glomerular filtration- evaluate obstruction
and renal function
DMSA- cleared by filtration and secretion- renal
cortical image

Urogenital Disease
Developmental variations disorders

Collecting system (Obstruction, stone,

hydronephrosis)
Acute and chronic inflammation
Circulation disorders (renovascular
hypertension, function failure)
(Diseases of the parenchyma)
Trauma
Space occupying lesions/SOL (cystic, solid)

Normal variations and

congenital disorders
Fusion abnormalitiy
Horseshoe kodney

Extrarenal pyelon
Congenital malposition (ectopic kidney)
Agenesis, hypoplasia

Obstruction, stone,
hydronephrosis
Acute:
Enlarged kidney
Slow perfusion and excretion
Moderate dilatation of the pyelum, stone, other
causes

Chronic:
Dilated collecting system
Thin parenchyma
Pure excretion
Stone

 Autoimmun: large/small kidney

Acute pyelonephritis (acute focal
bacterial nephritis, etc)
Emphysematous pyelonephritis: large
kidney, hypodensity, decreased contrast
uptake, space occupation, thikening of
the renal fascia, gas in the parenchyma
Pyonephros : hydronephrosis, thik wall of
the pyelon
Abscess: APN + abscess cavity
Segmental, polar, global atrophy

 Infarction (partial, complete): no

enhancement, absence of excretion
Renal vein thrombosis: large kidney,
slow perfusion, venous filling defect,
perirenal collaterals, no excretion
Renal artery stenosis, renovascular
hypertension aneurysma
Kidney failure: parenchyma
destruction, calcification, pure
excretion (contrast material?!?)

Trauma

Blount or penetrating injuries, contusion

Haematoma (subcapsular/perirenal)
Urinoma
Parenchyma laceration
Artery/vein injury
Ureter ruptur

SOL
Cystic
Simple (soliter/multiple)
Herediter (polikistik disease)
Atypical (closed calyx, diverticula, cystic
tumour, abscess, cystic nephroma)

Solid
Beigne (AML, adenoma)
Malignant
Primary (RCC, TCC, Wilms Tumor)
Secondary (HL, NHL, Metastasis)

Case 1. Horseshoe kidney

Axis and position
alteration in
horseshoe kidney.

Case 2. filling defect in IVU

Common causes
1. Calculi
2. Cyst
3. Tumours
4. Blood clot

Case 3. focal Bulge

Renal cyst with
splaying of calyces

Case 4. simple cyst

Increased parenchymal thickness &
distortion of collecting system - simple
cyst (confirm by us)

Case 6. pcs
duplex
Excretory urography in a
woman shows complete
ureteral duplication on the
right. The upper moiety
ureter empties below and
medial to the ureter of the
lower moiety.
Note the duplex collecting
system on the left

Case 7. bilateral ureteral

duplication
Excretory urography
in an adult patient
with bilateral
complete ureteral
duplication.

Case 8. duplex right kidney

Excretory urography
in a patient with a
duplex right kidney
shows
hydronephrosis of the
lower moiety.

Case 9.Calculus

Intravenous urogram. After the intravenous injection, contrast

material in the collecting system obscures the calculus

Case 10. VUJ stone

Standing column of
contrast with mild
hydronephrosis - VUJ
stone.

Case 11. Hydronephrosis &

hydroureter - ureterocele.

Case 12. BPH

Bladder base
defect prostate
enlargement

THANKS YOU