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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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Urinary tract imaging basic principles campbell s chapter 4


Urinary Tract Imaging- Basic PrinciplesCampbell’s Chapter 4

Christi Hughart, D.O.

Plain films


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

Plain film left distal ureteral calculus


Plain Film- Left Distal Ureteral Calculus

Contrast films


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


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

Normal urogram


Normal Urogram

Urogram with prone film better visualization of ureters


Urogram with Prone Film- better visualization of ureters




  • 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


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


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

Normal male cystogram


Normal Male Cystogram



Retrograde urethrogram rug


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

Normal rug


Normal RUG

Retrograde pyelography


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

Normal rp


Normal RP




  • 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




  • 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


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











  • 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


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



  • 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




  • 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


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)



  • Gadolinium

  • Indications- abdominal aorta, ranal artery stenosis, pre-donor nephrectomy

Nuclear scintigraphy


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


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


Renal Cortical Scintigraphy

  • DMSA to evaluate for cortical scars or pyelo

  • Do 3 months after infection