urinary tract imaging basic principles campbell s chapter 4
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Urinary Tract Imaging- Basic Principles Campbell’s Chapter 4

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0. Urinary Tract Imaging- Basic Principles Campbell’s Chapter 4. Christi Hughart, D.O. 0. Plain Films. Scout film, primary survey, to follow known stones, check placement of catheters/stents/drains/foreign bodies

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plain films

0

Plain Films
  • Scout film, primary survey, to follow known stones, check placement of catheters/stents/drains/foreign bodies
  • False +: vascular calcifications, bowel opacities, phleboliths, appendicoliths, GS
  • False -: stone over sacrum/ilium, radiolucent (uric acid)
  • If scout before ESWL shows no stone, may need to reassess
contrast films

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Contrast Films
  • Rapidly concentrated by kidneys and opacifies urinary tract
  • Low osmolar nonionic contrast material (LOCM)- 50% less osmolar load- fewer complications than high osmolar
  • Reactions: dose related or idiosyncratic
    • Allergic, CV changes, renal toxicity, shock
    • Tx- antihistamines, beta agonist, epinephrine
    • Renal toxicity risk (average patient)- 1%
      • Direct toxicity to renal tubules, ischemia, altered circulation, precipitation of uric acid
      • Prevention- well hydrated, LOCM, small load
iv urography

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IV Urography
  • Renal parenchyma, collecting system, ureter
  • Evaluates- urothelial abnormality, hematuria, urolithiasis
  • +/- bowel prep/npo
  • Scout, +/- obliques
  • Contrast- bolus or drip
  • Nephrographic phase- immediate to first minutes- parenchyma
  • Pyelographic phase- 5 minutes- collecting system
    • +/- compression, oblique- calyces, prone to distend ureter, upright- renal ptosis/layering in severe hydro, post-void- evaluate BOO/diverticulae/filling defect
loopography

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Loopography
  • Imaging of urinary conduit or diversion (always order with indication clearly explained)
  • Reflux required to see ureters if no IV contrast used (constrast sensitivity not contraindication)
  • If non-refluxing anastamosis- need IVU, antegrade nephrostomy, CT, MRI
  • Indications- hematuria, stones, stoma stenosis, loop ischemia, urinary fistulae, urine leak, stricture at anastamosis, hydro, tansitional cell cancer surveillance
  • Prep- bowel prep if previous contrast, antibiotics, GU irrigant
  • Contrast goes in thru catheter
  • Scout, supine, conduit distension, drainage film
static cystourethrography

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Static Cystourethrography
  • Evaluate bladder lesion, rupture, leak, s/p trauma/sx- bladder integrity/anast/fistulas
  • Scout, fill bladder with 200-400 mL contrast via catheter, A/P and obliques (shows extravasation posterior to bladder), post-drainage film
voiding cystourethrogram vcug

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Voiding Cystourethrogram (VCUG)
  • Functional and anatomic evaluation of bladder
  • Typically for children with recurrent UTIs
  • Dx- reflux, urethral valves, ureterocele, dysfunctional voiding, urethral strictures, bladder/urethral diverticula
  • Scout
  • Pediatric: 5 or 8 F feeding tube, fill bladder with contrast (age +2 x 30)
  • Adult: standard catheter
  • Film during filling- bladder pathology, early reflux
  • Films during void- reflux, urethral abnormality
  • Oblique- evaluate grade 1 reflux, males
  • Post-void film
retrograde urethrogram rug

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Retrograde Urethrogram (RUG)
  • Evaluate anterior and posterior urethra- strictures, trauma
  • 8-16 F foley in fossa navicularis, fill balloon with 1-2 mL and inject 30-50% contrast while filming obliquely
  • Some resistance at membranous urethra and sphincter
retrograde pyelography

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Retrograde Pyelography
  • Evaluate renal collecting system and ureters
  • Indications- hematuria, contrast sensitivity, suboptimal IVU, needs cysto
  • Pre-op- get sterile urine culture
  • IV sedation
  • Scout, injection catheter placed in UO, inject 50% contrast under real time fluoro, drainage film at 5-10 minutes
  • Backflow- contrast extravasation into surrounding tissues due to high injection pressure
nephrostogram

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Nephrostogram
  • Antegrade urogram- inject contrast into nephrostomy tube
  • Indications- post-sx to evaluate for urine leak, post-perc neph to evaluate residual stones, evaluate site of ureter obstruction, dx ureteral fistulas
  • Prep- sterile urine sample, +/- antibiotics
ultrasound

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Ultrasound
  • Grayscale and doppler
  • High frequency- high resolution but low penetration depth
  • Renal- parenchyma, solid vs cystic, hydro
    • Use with IVP to evaluate hematuria
    • Assess allografts, congenital abnormalities, stones
    • Cortex vs medulla- pyramids (medulla) less echogenic than cortex
  • Adrenal- CT/MRI better except in peds (no RP fat)
    • Nodules, cysts, hemorrhage, location, tumors
    • Cortex hypoechoic, medulla echogenic
  • Bladder- examine wall, lesions
    • Transvaginal, transabdominal, transrectal
    • Normal wall >= 6 mm
    • Echogenicity in bladder fluid- debri, FB, infection
    • PVR, bladder volume
    • Ureteral jets- should appear in 15 minutes unless obstruction exists
  • Prostate- transrectal, access for biopsy
ultrasound cont

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Ultrasound (cont.)
  • Scrotal-
    • Use high frequency probe (up to 10 MHz)
    • Evaluate- mass, pain, torsion, orchitis, epididymitis, hydrocele, hernia, varicoceles
    • Testicle- granular, 4 x 3 cm, small anterior fluid collection- tunica, epididymis- hyperechoic
    • Veins- >2mm= varicocele- evaluate in erect position with valsalva
  • Urethral-
    • Male- evaluate stricture- scar length and depth, longitudinal along phallus or intraluminal
    • Female- diverticulum
slide29

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CT
  • Contrast- parenchyma, adrenals
  • 3-D or CTA- evaluate vascular abnormality
  • 100-150 mL IV bolus injection
  • Renal-
    • Precontrast- stones, parenchyma, vascular calcifications, renal contour
    • Corticomedullary- 30 sec- cortex vs medulla
    • Nephrographic- 100 sec- uniform enhancement of parencyma (masses)
    • Pyelographic- excretory- collecting system
    • Left renal vein- anterior to aorta, inf/post to SMA
    • Right renal vein- extends posterolateral from IVC
ct cont

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CT (cont.)
  • Adrenal-
    • Malignancy, mets, functional adenoma
    • Adenoma- HU <0
    • HU >20- ? Mets- do perc bx
    • MRI if suspect pheo
  • Bladder-
    • Depends on amount of distension
  • Prostate/seminal vesicle-
    • To detect abscess or cyst
    • If prominent median lobe- appears to extend into bladder
  • CT urography-
    • Enhanced CT of ureters
slide31

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CTA
  • Rapid contrast injection with helical CT during arterial phase
  • Soft tissue and bone reduced
  • 3D reconstruction
  • Indications- prep for donor nephrectomy, eval extra vessels to eval UPJ obstruction, renal artery stenosis
slide33

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MRI
  • No iodinated contrast
  • Soft tissue resolution better than CT
  • Contraindications- pacer, aneurysm clips, FB, prosthesis
  • Allignment of protons in response to external magnet- radiofrequency applied causes difference in their energy
  • T1- fluid dark, fat bright
  • T2- fluid bright, fat dark
mri cont

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MRI (cont.)
  • Renal- do if need cross-sectional images but contrast contraindicated, will not evaluate stones, determine tumor thrombus in IVC, cortex bright on T1
  • Adrenal- adenomas contain more fat than cancers/pheos, pheo bright on T2, gland seen easily on T1, T2- adrenals isodense with liver
  • Bladder- to id invasion of wall by transitional cell cancer or other pelvic neoplasms (on T2)
  • Prostate- evaluate prostate cancer for capsular invasion. T1-distinct from surrounding fat/seminal vesicles (intermediate intensity), T2- peripheral zone (high intensity), central (intermediate), neurovascular bundles bright, seminal vesicles (high)
  • Urethral- intraluminal coil to evaluate stricture/diverticulum
  • MRU- to id obstruction- ureters/collecting system- T2- fluid bright, tissue dark (can’t distinguish stone from clot/tumor)
slide35

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MRA
  • Gadolinium
  • Indications- abdominal aorta, ranal artery stenosis, pre-donor nephrectomy
nuclear scintigraphy

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Nuclear Scintigraphy
  • Physiologic and anatomic info
  • TC-99 m (t ½= 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
diuretic scintigraphy

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Diuretic Scintigraphy
  • For hydro not necessarily caused by obstruction
  • Done with DTPA or MAG3 (better for renal insufficiency)
  • When tracer reaches collecting system, diuretic given and t ½ calculated based on slope of curve given in response to diuretic
renal cortical scintigraphy

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Renal Cortical Scintigraphy
  • DMSA to evaluate for cortical scars or pyelo
  • Do 3 months after infection
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