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Diagnostic Imaging The Urinary System

Diagnostic Imaging The Urinary System. Dr. LeeAnn Pack Diplomate ACVR. Retroperitoneal Space. Should be fat opacity ventral to sublumbar musculature Retroperitoneal fat allows visualization of the kidneys Thigh musculature often overlies caudal aspect and causes an increased opacity

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Diagnostic Imaging The Urinary System

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  1. Diagnostic ImagingThe Urinary System Dr. LeeAnn Pack Diplomate ACVR

  2. Retroperitoneal Space • Should be fat opacity ventral to sublumbar musculature • Retroperitoneal fat allows visualization of the kidneys • Thigh musculature often overlies caudal aspect and causes an increased opacity • Bifurcation of the deep circumflex iliacs often seen ventral to approximately L4

  3. Retroperitoneal Space -Should be fat opacity -Thigh muscles will overlie caudal aspect

  4. Retroperitoneal Space • Always examine the retroperitoneal space • Identify the kidneys cranially • Will see the sublumbar musculature • May see circular mineral looking opacities ventral to L4 and 5—circumflex iliac arteries • May see thigh musculature overlying the caudal aspect of the retroperitoneal space • Remainder should be fat opacity

  5. Loss of Detail in the Retroperitoneal Space • Consider the following • Young animal with minimal body fat • Emaciated animal • Free fluid in the space • Mass in the space

  6. Young Animal • This animal lacks body fat • Notice the poor detail in the retroperitoneal space and also in the peritoneal space

  7. Fluid in the Retroperitoneal Space • Will see loss of detail • Fat opacity replaced with soft tissue-may have a streaky/whispy appearance • Most common fluids to consider are urine (generally trauma related) and blood (trauma, ruptured tumor, bleeding disorder • An IVP is indicated to distinguish

  8. Fluid in the Retroperitoneal Space • Notice the loss of detail in the RS • Streaky soft tissue opacities are seen

  9. Mass in the RPS • Will distend RPS if mass is large enough • May have mass effect on other organs • Consider kidney, adrenal, lymph node, body wall as most likely sources

  10. Kidneys • Evaluate on both lateral and VD view • Best measured on the VD view • Right kidney—T13-L1 (dog), L1-L4 (cat) • Left kidney—L2-L4 (dog), L2-L5 (cat) • Dog: 2.5-3.5 times the length of L2 • Cat: 2.4-3.0 times the length of L2

  11. Canine rt lt

  12. Feline -kidneys usually easier to ID -shape is more round than the dog

  13. Renal Calculi

  14. IVP • Also called EU- excretory urogram • Start with a well prepared abdomen (enema) • Patient must be well hydrated! • Always do survey films • Inject 400mg I/lb intravenously as a bolus • Acquire films immediately, 5, 10, 20 and 40 minutes (both lateral and VD)

  15. IVP Phases • Arteriogram-immediately • Nephrogram-within 20 seconds of injection • Pyelogram-begins 3-5 minutes post injection • Cystogram-as contrast is cleared into the lower urinary tract

  16. Arteriogram • Documents initial blood flow to the kidney • Phase is very short • Seldom imaged • Occasionally will see a vascular blush if the first image is literally taken immediately at the time of injection

  17. Nephrogram • Contrast is filtered and accumulates within the renal tubules • Should see good initial opacification that gradually fades over the study period • Opacification of the kidneys should be uniform and symmetrical

  18. Pyelogram • Contrast is outlining the collecting system • Will be able to evaluate the renal pelvis and diverticuli • Pelvis should be <2mm wide • Recesses should be <1mm wide • Proximal ureters should be <2.5mm

  19. Cystogram • This is contrast material entering the lower urinary tract • Will see segmental images of the ureters and the outline of the bladder • A formal cystogram is superior for imaging the bladder

  20. Renal Anatomy -renal pelvis -renal sinus -diverticuli -cortex -medulla -ureter

  21. Normal IVP-Immediate Films Nephrogram Phase

  22. Normal IVP-Five Minutes Nephrogram and Pyelogram

  23. Normal IVP-Twenty Minutes Pyelogram and Cystogram

  24. Contrast Induced Renal Failure • See opacification of kidneys that persists or becomes more intense over time • Hypotension—acute tubular necrosis—tubular obstruction—acute renal failure • Generally reversible but important to recognize this • Liver and GI are alternative routes of excretion

  25. Contrast Induced Renal Failure-several hours post IVP -kidneys still opacified -contrast material within Gi tract -contrast material within the gall bladder

  26. Kidneys • Always assess for number, size, shape, margination, location and opacity • Changes observed on radiographs will help you to refine your differential diagnosis list • Can you see them? Normal in size? What is the contour like? Any opacification changes?

  27. Small Regularly Shaped Kidney • Most likely a congenital anomaly-hypoplasia • Usually bilateral and therefore usually young dogs with signs of renal disease • Can see with some chronic diseases but those are more commonly irregularly shaped • IVP-usually poor but uniform opacification with normal clearance into the lower urinary tract

  28. Small Irregularly Shaped Kidney • May involve one or both kidneys • Consider the following • End-stage kidney • Infarcts • Chronic pyelonephritis • Chronic nephritis

  29. Renal Irregularities Note the renal marginal irregularities

  30. Large Regularly Shaped Kidneys • May be unilateral or bilateral • Consider the following • Acute pyelonephritis/nephritis • Hydronephrosis • LSA • Large parenchymal cyst or perirenal pseudocyst • FIP • Amyloidosis • Compensatory hypertrophy

  31. Hydronephrosis-Bilateral -Suggestive of obstruction at trigone -This was secondary to TCC

  32. Hydronephrosis-Unilateral -Hydronephrosis secondary to TCC

  33. Polycystic Renal Disease • Most commonly diagnosed in young Persians and Himalayans • Congenital disease-multiple parenchymal renal cysts • May have cysts in other organs -liver, pancreas

  34. Polycystic Renal Disease -Large irregularly shaped kidneys -Cat is also in thin body condition-possibly secondary to renal dysfunction -Cysts enlarge and destroy normal tissue

  35. Perirenal Pseudocysts • These are outside the renal parenchyma and may be within the capsule or outside the capsule • Most common in older male cats • Kidney is enlarged and smoothly marginated-shape depends on the symmetry of the cyst

  36. Renal Neoplasms • Kidney(s) are generally enlarged and irregularly shaped due to a mass • Occasionally will see mineralization associated with the neoplasm • Nephrogram-inhomogenous opacification, marginal irregularity +/- filling defects • Pyelogram-pelvis and diverticuli may be distorted-mass could obstruct pelvis

  37. Renal Neoplasm IVP-irregular margin -pelvic distortion Irregular on surveys

  38. LSA • This is the most common renal neoplasm in the cat and also occurs in dogs • Generally bilateral • May be regular or irregularly marginated-some are more uniformly infiltrated • May see evidence of other organ involvement-spleen, liver, LN

  39. Abnormal Renal Opacity • Mineralization-calculi, parenchymal mineralization or deposition, or neoplastic mineralization • Gas-may be renal or perirenal

  40. Ureters • Small soft tissue structures extending from the renal pelvis to the bladder • Normally not seen on survey films

  41. Normal

  42. Hydroureter • Seldom seen on survey films • May see tubular soft tissue structure in the RPS if the dilation is severe • Best documented with contrast-IVP

  43. Hydroureter -occasionally you may see enlarged ureters on plain films

  44. Hydroureter -usually requires contrast opacification to identify the dilated ureter(s)

  45. Severe Hydroureter

  46. Ureteral Calculi • Examine the RPS carefully for mineral opacities • They may be very small-best seen on the lateral but try to identify on both views • *remember the deep circumflex arteries-they will look like small calculi

  47. Ureteral Calculi

  48. Ectopic Ureter • Usually shows evidence if hydroureter on that affected side • May also see hydronephrosis in the kidney • Ureter may enter the vagina, tunnel by bladder, urethra etc. • Oblique views made at 5 minutes

  49. Ureteral Rupture • Most of the ureter is within the RPS—becomes peritoneal as it enters the bladder • May see loss of detail in the RPS or the peritoneal space due to urine leakage • IVP-free contrast material in the RPS or the peritoneal space

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