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Genitourinary Radiology Jerry Glowniak, MD Department of Radiology Detroit Receiving Hospital Detroit Medical Center/Wayne State University

Genitourinary Radiology

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Genitourinary Radiology. Jerry Glowniak, MD Department of Radiology Detroit Receiving Hospital Detroit Medical Center/Wayne State University. Radiological Anatomy: Kidneys and adjacent spaces. - PowerPoint PPT Presentation

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Page 1: Genitourinary Radiology

Genitourinary Radiology

Jerry Glowniak, MDDepartment of RadiologyDetroit Receiving Hospital

Detroit Medical Center/Wayne State University

Page 2: Genitourinary Radiology

Radiological Anatomy:Kidneys and adjacent

spaces

The radiological anatomy of the kidneys consists of the cortex, medulla (renal pyramids), renal sinus, and the collecting system.

The kidneys and their adjacent spaces lie in the retroperitoneum in the abdomen and pelvis.

Page 3: Genitourinary Radiology

Retroperitoneal Spaces

Radiologically, the retroperitoneum in the abdomen is divided into the perinephric spaces, and the anterior and posterior pararenal spaces.

The retroperitoneal (extraperitoneal) spaces in the pelvis are more complex. The abdominal pararenal spaces continue into the pelvis The perinephric spaces are confined to the abdomen.

Page 4: Genitourinary Radiology

The Perinephric Spaces The largest retroperitoneal spaces. Contents: the kidneys, adrenal

glands, proximal ureters, and perirenal fat. The right and left spaces communicate inferiorly.

Delimited by the renal fascia which has a well-defined anterior component (Gerota’s fascia, anterior renal fascia) and thinner posterior component (Zuckerkandl’s fascia, posterior renal fascia).

Page 5: Genitourinary Radiology

Retroperitoneal Spaces: Abdomen

AC – Ascending Colon

DC – Descending Colon

D – Duodenum K – Kidney A – Aorta V – Vena Cava

Page 6: Genitourinary Radiology

Anterior Pararenal Space Single space anterior to the

perinephric spaces. Contents: Pancreas, second and third

portions of the duodenum, aorta, inferior vena cava, ascending and descending colon

Anterior boundary: posterior parietal peritoneum.

Posterior boundary: Anterior renal fascia

Page 7: Genitourinary Radiology

Posterior Pararenal Spaces

Right and left spaces posterior and lateral to the perinephric spaces.

Contents: Fat Anterior boundary: posterior renal

fascia and lateroconal ligament Posterior boundary: Transversalis

fascia Anterior to the colon, it is continuous

with the properitoneal fat.

Page 8: Genitourinary Radiology

Retroperitoneal Spaces: Detailed View

DC – Descending Colon

K – Kidney

PM – Psoas Muscle

Page 9: Genitourinary Radiology

Imaging Modalities

Intravenous pyelogram Computed Tomography (CT) Ultrasound Nuclear Medicine Magnetic Resonance Imaging (MRI) Plain Film

Page 10: Genitourinary Radiology

Intravenous Pyelogram

Gold Standard 20 years ago Becoming an obsolete technique Limited views of kidneys Two dimensional technique Largely replaced by CT

Page 11: Genitourinary Radiology

Normal excretory phase of an IVU

(intravenous urogram), 10

minute image. Kidneys are

excreting contrast into non dilated

calyces (arrows), renal pelvis (p), ureters (*) and bladder (B).

Page 12: Genitourinary Radiology

Computed Tomography

Imaging modality of choice for most abnormalities.

Advantages: Fast, widely available, high resolution.

Disadvantages: Radiation, intravenous contrast, less specific than MRI

Page 13: Genitourinary Radiology

CECT kidneys, 60 sec (nephrogram phase) ,

  would show renal parenchymal lesions well

CECT kidneys; 4 min ( pyelogram phase), showing excretion of contrast into collecting system, would show urothelial lesions well, such as TCC , stones, blood clots

Page 14: Genitourinary Radiology

CECT scan of abdomen with (1) axial, (2) coronal, and (3) sagittal 3D reconstructions shows multiple cysts (c) of varying sizes in the right kidney in a pattern most consistent with multicystic dysplastic kidney disease.

1 2

3

Page 15: Genitourinary Radiology

3D reconstructed image from CT scan of the abdomen and pelvis, a CT “IVP”, 

shows RK (K), a normal ureter (arrows), and the ureter's insertion into the bladder.

Page 16: Genitourinary Radiology

Ultrasound Useful in a wide variety of genitourinary

tract abnormalities. Advantages: Highest resolution, non-

invasive, widely available, fast. Real-time assessment of blood flow (color flow imaging).

Disadvantages: Highly operator dependent, images in nonsequential format which makes anatomy more difficult to appreciate.

Page 17: Genitourinary Radiology
Page 18: Genitourinary Radiology

Nuclear Medicine Used primarily for obtaining functional

information. Limited role in GU imaging. Advantages: Lower radiation dose than

CT, no adverse effects except for radiation. A few unique advantages, e.g. In-111 white blood cell scanning is highly specific for infections.

Disadvantages: Long imaging times, few specific indications, radiation.

Page 19: Genitourinary Radiology

Magnetic Resonance Imaging Increasing role in abdominal/pelvic

imaging Advantages: Many imaging

sequences allow highly tailored studies, no radiation, more specific than CT

Disadvantages: Cost, longer imaging times than CT, unable to imaging calcium (renal/ureteral calculi, calcifications)

Page 20: Genitourinary Radiology

Plain Films Useful as a first test in several

applications: Renal calculi, emphysematous pyelonephritis, renal size.

Advantages: Cheap, fast, widely available.

Disadvantages: Rarely diagnostic. Further tests required.

Page 21: Genitourinary Radiology

Renal Imaging: Radiologic Parameters In the more commonly used exams

in which contrast is given – CT, MRI, IVP – and to a lesser extent, nuclear medicine, images are obtained dynamically.

Three phases defined: Arterial (corticomedullary) 10-20 seconds; Venous (nephrogram) 40-80 seconds; excretory – beyond 80 seconds.

Page 22: Genitourinary Radiology

Arterial (corticomedullary) phase – 10 to 20 seconds

Renal artery and vein prominent (arrows)

Cortex clearly differentiated from medulla

Page 23: Genitourinary Radiology

Venous (nephrographic) phase 40 – 80 seconds

Vasculature less prominent

The cortex and medulla have the same degree of enhancement

Page 24: Genitourinary Radiology

Excretory phase – beyond 80 seconds

Most variable phase

Begins when contrast is seen in the collecting systems

Page 25: Genitourinary Radiology

Renal Infections

Pyelonephritis Renal and perinephric abscess Emphysematous pyelonephritis Xanthogranulomatous

pyelonephritis

Page 26: Genitourinary Radiology

Acute Bacterial Pyelonephritis

Two main routes of infections: reflux and blood borne.

Vesicoureteral reflux, primarily in children, caused by E. coli

Hematogenous, usual cause of infection in adults, caused by Staph aureus.

In uncomplicated infections, imaging usually not necessary.

Page 27: Genitourinary Radiology

CT imaging of pyelonephritis

In mild cases, there may be no imaging findings.

The most specific finding is the “striated nephrogram” – alternating stripes or wedges of opacified and nonopacified parenchyma caused by nonhomogeneous edema

Focal defects, global enlargement, and delayed opacification are other less specific findings

Page 28: Genitourinary Radiology

Striated Nephrogram

Page 29: Genitourinary Radiology

Pyelonephritis with renal enlargement

Page 30: Genitourinary Radiology

Renal/perirenal abscess CT is highly sensitive, but somewhat

nonspecific for abscesses. The clinical picture of pyuria, flank

pain, fever, and tenderness with characteristic findings are usually definitive.

CT shows a low attenuation region without enhancement with a thick, enhancing capsule, adjacent fascial thickening, and fat stranding.

Page 31: Genitourinary Radiology

Renal abscess

Page 32: Genitourinary Radiology

Perinephric abscess

Page 33: Genitourinary Radiology

Emphysematous Pyelonephritis

Emphysematous pyelonephritis is a life-threatening infection of the kidneys in which gas is produced. There are 2 types.

Type I: More than one third of the kidney destroyed, no fluid collections. 70% mortality.

Type II: Less than one third of kidney destroyed with fluid collections. Mortality 18%.

Usual treatment: nephrectomy.

Page 34: Genitourinary Radiology

Emphysematous pyelonephritis

Page 35: Genitourinary Radiology

Emphysematous cystitis

Gas in the bladder wall usually caused by E. coli.

Occurs in diabetes, bladder outlet obstruction, neurogenic bladder

If no other abnormalities present (abscess, gangrene), usually responds readily to antibiotics

Page 36: Genitourinary Radiology

Emphysematous cystitis

Page 37: Genitourinary Radiology

Emphysematous cystitis

Page 38: Genitourinary Radiology

Xanthogranulomatous pyelonephritis

Chronic indolent, renal infection Renal parenchyma replaced by lipid

laden macrophages which can form large masses.

Unusually entire kidney involved. CT: Low attenuation masses, renal

enlargement, usually a calculus (staghorn) present, renal enlargement.

Page 39: Genitourinary Radiology

Xanthogranulomatous pyelonephritis

Staghorn Calculus

Page 40: Genitourinary Radiology

Xanthogranulomatous pyelonephritis

Page 41: Genitourinary Radiology

Renal Focal Lesions Renal cysts are the most common

focal renal lesion. Cysts are ubiquitous with 50% of the

population older than 50 having a simple renal cyst.

Simple cysts are easily recognized, but complicated cysts are more difficult to assess in terms of a benign or malignant lesion.

Page 42: Genitourinary Radiology

BOSNIAK CLASSIFICATION

I Simple Cyst : Nonoperative II Septated, minimal calcium described

as “egg shell”, thin septa and walls, high-density cysts (> 20HU), non-enhancing : Nonoperative

III Multiloculated, thick walled, dense calcifications; nonenhancing solid component: Renal-sparing surgery

IV Marginal irregularity, enhancing solid component: Radical Nephrectomy

Page 43: Genitourinary Radiology

Simple cyst of RK: Bosniak I

Page 44: Genitourinary Radiology

Bosniak II: Faint calcification with hair thin septation , no contrast enhancement

Page 45: Genitourinary Radiology

Bosniak III:lobulated,

cystic lesionwith

irregular, calcified septum

Page 46: Genitourinary Radiology

Bosniak IV: Cystic and solid lesion with enhancing solid component: Renal Cell Carcinoma

Page 47: Genitourinary Radiology

Angiomyolipoma

Angiomyolipomas are hamartomas containing fat, smooth muscle, and blood vessels

Most are asymptomatic, but large lesions (> 4 cm) may bleed.

80 % of pts with tuberous sclerosis have AML, usually multiple lesions bilaterally.

Page 48: Genitourinary Radiology

AML ; Large fatty mass of RK

pathognomonic finding

Page 49: Genitourinary Radiology

AML in tuberous sclerosis Ultrasound shows multiple, small, hyperechoic

foci representing fat containing lesions typical of AML

Page 50: Genitourinary Radiology

Oncocytoma

Oncocytomas are benign renal tumors with no metastatic potential but are indistinguishable radiographically from Renal Cell Carcinoma (RCC)

Biopsy is of little use because RCC can contain elements of oncocytoma

If there is a strong suspicion that the mass in question is benign, a renal sparing procedure is an option

Page 51: Genitourinary Radiology

Testicular imaging

Ultrasound is the method of choice for imaging the scrotum and its contents

The most common indications for testicular imaging are torsion and epididymitis/epididymo-orchitis

Page 52: Genitourinary Radiology

Scrotal anatomy

Page 53: Genitourinary Radiology

Testis (T) and epididymal head (arrow): saggital image

T

Page 54: Genitourinary Radiology

Epididymitis Ultrasound image Color flow image

Page 55: Genitourinary Radiology

Epididymo-orchitis with hydrocele

Page 56: Genitourinary Radiology

Testicular abscess with hydrocele

Ultrasound image Color flow image

Page 57: Genitourinary Radiology

Right testis Left testis Color flow images of both testes in a

patient with left sided scrotal pain shows no flow to the left testis. It is important to

compare both testes using the same setting for color flow.

Page 58: Genitourinary Radiology

Take Home Thought

When I die, I want to go peacefully, like my grandfather, who died in his sleep – not screaming like the passengers in his car.

Page 59: Genitourinary Radiology
Page 60: Genitourinary Radiology

Renal Tuberculosis Putty Kidney

Page 61: Genitourinary Radiology

Emphysematous pyelonephritis

Ultrasound findings

Longitudinal view Transverse view

Page 62: Genitourinary Radiology

Renal Tuberculosis

Uncommon infection in the United States

Classic findings are from scarring with parenchymal destruction and obstruction from strictures

Calcifications can be prominent – Putty kidney

Page 63: Genitourinary Radiology

Renal abscess with staghorn calculus

Page 64: Genitourinary Radiology

Perinephric abscess

Page 65: Genitourinary Radiology

Renal abscess with staghorn calculus