Urinary tract

• The four basic examinations of the urinary tract are

ultrasound, intravenous urography (IVU), computed
tomography (CT) and radionuclide examinations.
• Magnetic resonance imaging (MRI), arteriography and studies
requiring catheterization or direct puncture of the collecting
systems are limited to selected patients.
• Fluorodeoxyglucose positron emission tomography (FDG-
PET)/CT is still under investigation as an imaging tool in the
urinary tract, as there are currently several limitations due to
excretion of the tracer in the renal tract and poor uptake in
many urologic malignancies.
• Ultrasound, CT and MRI are essentially used for anatomical
information; the functional information they provide is
limited.
• The converse is true of radionuclide examinations where
functional information is paramount.
• The IVU provides both functional and anatomical information.
• IMAGING TECHNIQUES
• ULTRASOUND:
• Ultrasound is the first-line investigation in most patients,
providing anatomical information without requiring ionizing
radiation or the use of intravenous contrast medium.
• The main uses of ultrasound are to:
• • Investigate patients with symptoms thought to arise from
the urinary tract.
• • Demonstrate the size of the kidneys and exclude
hydronephrosis in patients with renal failure.
• • Diagnose hydronephrosis, renal tumours, abscesses and
cysts including polycystic disease.
• • Assess and follow-up renal size and scarring in children with
urinary tract infections.
• • Assess the bladder and prostate.
• NORMAL RENAL ULTRASOUND:
• At ultrasound, the kidneys should be smooth in outline.
• The parenchyma surrounds a central echodense region,
known as the central echo complex (also called the renal
sinus), consisting of the pelvicaliceal system, together with
surrounding fat and renal blood vessels.
• In most instances, the normal pelvicaliceal system is not
visible within the renal sinus.
• The renal cortex generates homogeneous echoes that are of
equal reflectivity or less reflective than those of the adjacent
liver or spleen, and the renal pyramids are seen as triangular
hypoechoic areas adjacent to the renal sinus.
• During the first 2 months of life, cortical echoes are relatively
more prominent and the renal pyramids are
disproportionately large and strikingly hypoechoic.
• The normal adult renal length, measured by ultrasound, is 9–
12 cm.
• Renal length varies with age, being maximal in the young
adult. There may be a difference between the two kidneys,
normally less than 1.5 cm.
• A kidney with a bifid collecting system is usually 1–2 cm
larger than a kidney with a single pelvicaliceal system.
• Normal ureters are not usually visualized due to overlying
bowel gas.
• The urinary bladder should be examined in the distended
state:
• the walls should be sharply defined and barely perceptible.
• The bladder may also be assessed following micturition, to
measure the postmicturition residual volume.
 UROGRAPHY:
• Urography is the term used to describe the imaging of the
renal tract using intravenous iodinated contrast medium.
• The traditional intravenous urogram or IVU has largely been
replaced by a combination of ultrasound and CT urography.
• CT has the advantage of being highly sensitive for the
detection of stones including those which may be radiolucent
on plain fi lm, allows the characterization of renal lesions, the
detection of ureteric lesions and demonstrates the
surrounding retroperitoneal and abdominal tissues.
• In addition, CT overcomes the overlap of superimposed
tissues which can cause difficulty when interpreting the
traditional IVU.
• The principles of both techniques are similar. Firstly, ‘non-
contrast’ imaging of the renal tract is required, in order to
identify all renal tract calcifications.
• In some cases, where the clinical question relates to renal
calculi, the non-contrast CT may be sufficient (known as the
CT KUB).
• However, where a renal mass is suspected or a possible
ureteric or bladder mass is suspected, then the non-contrast
study is followed by the injection of iodinated contrast
medium, with images being obtained at specific time intervals
in order to demonstrate the nephrogram (contrast within the
kidneys) and the urogram (contrast within the ureters and
bladder).
• CONTRAST MEDIUM AND ITS EXCRETION:
• Urographic contrast media are highly concentrated solutions of
organically bound iodine.
• A large volume, e.g. 100 ml, is injected intravenously and is
carried in the blood to the kidneys, where it passes into the
glomerular filtrate.
• The contrast medium within the glomerular filtrate is
concentrated in the renal tubules and then passes into the
pelvicaliceal systems.
• Patients are allowed to drink up to 500 mL of fl uid in the 4 hours
before IVU or CT but should not eat.
• It is particularly important not to fluid-restrict patients with
impaired renal function before they are given contrast medium,
as this may predispose to contrast medium-induced
nephrotoxicity.
 INTRAVENOUS UROGRAM:
• The plain film Identify all calcifications.
• Calcifications seen in the line of the ureters or bladder must
be reviewed with post contrast scans, to determine whether
the calcification lies in the renal tract.
• Note that calcification can be obscured by contrast medium
and stones are missed if no plain film is taken.
• The major causes of urinary tract calcification include calculi,
diffuse nephrocalcinosis, localized nephrocalcinosis (e.g. TB or
tumors) and prostatic calcification.
 FILMS TAKEN AFTER INJECTION OF
CONTRAST MEDIUM:
Kidneys
1 Check that the kidneys are in their normal positions (Fig. 6.4).
The left kidney is usually higher than the right.
2 Identify the whole of both renal outlines.
If any indentations or bulges are present they must be
explained.
• Local indentations .
The renal parenchymal width should be uniform and
symmetrical, between 2 and 2.5 cm.
Minor indentations between normal calices are due to
persistent fetal lobulations.
All other local indentations are scars.
 • Local bulges of the renal outline. A bulge of the renal outline
may be due to a mass or a cyst, which often displaces and
deforms the adjacent calices.
An important normal variant causing a bulge of the outline is
the so called splenic hump.
3. Measure the renal lengths. The normal length of the adult
kidney at IVU is between 10 and 16 cm.
• CALICES:
• The calices should be evenly distributed and reasonably
symmetrical. The shape of a normal calix is ‘cupped’ and
when it is dilated it is described as ‘clubbed’.
• Caliceal dilatation has two basic causes: destruction of the
papilla or obstruction.
• RENAL PELVIS AND URETER:
• The normal renal pelvis and pelviureteric junction are funnel-
shaped.
• The ureters are usually seen in only part of their length on
any one fi lm of an IVU because of obliteration of the lumen
by peristalsis.
• Dilatation of the renal pelvis and ureter may be secondary to
obstruction but there are other causes (e.g. congenital variant
or secondary to vesicoureteric reflux).
• Bladder:
• The bladder is a centrally located structure that should have a
smooth outline.
• It often shows normal smooth indentations from above
owing to the uterus or the sigmoid colon, and from below by
muscles of the pelvic floor.
• After micturition the bladder should be empty, apart from a
little contrast trapped in the folded mucosa.