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Imaging of the Genitourinary TractBlok 17
Keluhan dan penyakit berkaitan dengansistem uropoetik
Semester V
Mashuri, dr.,Sp.Rad.,M.Kes
Department of RadiologyFaculty of Medicine
University of Lambung
Mangurat!
Ulin "ospital
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%maging Modalities
&onventional non contrast 'lain ()Ray
&onventional *ith contrast %ntravenous pyelography +ntegrade pyelography Retrograde 'yelography Retrgograde &ystography Retrograde Urethrography
&ystourethrography #ipolar cystourethrography oiding &ystourethrography Retrograde cystourehtrography
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-on)conventional Ultrasound &omputed omography Scan
Digital Substraction +ngiography /DS+0 -uclear Medicine /Scintigraphy0 Magnetic Resonance %maging /MR%0
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Position of kidneys:
R: L1-L3
L: T12-L3
Kidneys
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Long axis of the kidneys is directed downward and outward, parallel to the
lateral border of the psoas uscles
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Ureter
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Urinary #ladder
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Urethra
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'lain 'hoto +bdomen /KU#0
or #-1 %ndication2 Renal opa3ue calculi, 'reparation for %U
&hec placement ofcatheters!stents!drains!foreign bodies
&ontraindication2 none
echni3ue2 supine position
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'lain photo abdomen
KU#
All exposures at endof expiration for anyurinary system study
he Last 4 Ribs +ll Lumber +nd Sacral
ertebrae 'soas Muscles Symphysis 'ubis
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Plain X-ray film
Renal shadow !astrointestinal tract shadow "alcification or radiopa#ue shadow
$soas shadow %one
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%U /dulu %'0
5. Suspected congenital anomaly
4. Renal umor
6. Renal colic
7. 'ersistent urinary tract infection8. Renal rauma
%ndications
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'reparation
+fter midnight2 -il 'er 1s /9puasa: ; < hours0
#o*el cleansing
&lear li3uid diet
Don=t tal to much and smoing
>mpty bladder
Free from contrast agenthypersensitivity
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Complications
1 . Immediate Minor: ausea! "omiting! arm pain! and headach Sever allergic:#rythema! urticaria! facial or glottic
edema.
Treatment$ antihistamines! steroids and%or epinephrine.
Chemotoxic or idiosyncratic reactions$ &most serious'Include$ con"ulsions! pulmonary edema! cardio"ascular
collapse! thrombosis! cardiac arrest. 1 of e"ery 7!()) The mortality rate for contrast administration! 1$1))!)))
*. +elayedephroto,icity$ -atients ith diabetic nephropathy!
creatinine le"els are /0 mg%dl. This nephroto,icity isusually re"ersible.
Complications
1 . Immediate Minor: ausea! "omiting! arm pain! and headach Sever allergic:#rythema! urticaria! facial or glottic
edema.
Treatment$ antihistamines! steroids and%or epinephrine.
Chemotoxic or idiosyncratic reactions$ &most serious'Include$ con"ulsions! pulmonary edema! cardio"ascular
collapse! thrombosis! cardiac arrest. 1 of e"ery 7!()) The mortality rate for contrast administration! 1$1))!)))
*. +elayedephroto,icity$ -atients ith diabetic nephropathy!creatinine le"els are /0 mg%dl. This nephroto,icity isusually re"ersible.
&ontrast +gent and +dverse Reactions
Crucial not to leave pt alone for first5 minutes after injection!
Crucial not to leave pt alone for first5 minutes after injection!
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%U procedure
5. 'reliminary /'lain photo04. %mmediate6. 8 minute
7. +bdominal compression8. Release?. 'ost micturation
Should ideally be tailored to answer theclinical question
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'reliminary Film /Foto %0
'recontrast KU#radiograph. o demonstrate
opacities that may lie
*ithin the urinary tract. o chec abdominal
preparation, positioningand e@posure factor.
+dditional radiograph)e@piration or obli3ue ofthe renal areas todetermine the positionof any opacities lie
*ithin the urinary tract.
(All exposures at end
of expiration for any
urinary system study)
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%mmediate film /Foto %%0
5)6 min post contrast radiograph
collimated to the idneys. o demonstrate the nephrogram phase.
he renal parenchyma opacified by the
contrast in the renal tubules.
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8 minute film /Foto %%%0
8 min post contrast KU# radiograph. o determine if e@cretion is symmetrical or
a further dose of contrast is re3uired if the
opacification is poor.
+bdominal compression is then applied if
no contraindication.
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+bdominal compression
&ontraindications2 >vidence of obstruction on 8 minute image
+bdominal mass
+bdominal aortic aneurysm
Recent abdominal surgery
Severe abdominal pain
Suspected urinary tract trauma
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&ompression Film /Foto %0
+ 58 min post contrast
collimated to the idneys.
o demonstrate
distended collecting
systems and pro@imalureters.
) effectively produces
partial ureteric
obstruction) %mproved calyceal detail
and more reliable ureteric
opacification upon release
of compression.
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Release film /Foto )%%0
+ 6A min post contrast KU# radiograph
follo*ing release of compression.
o demonstrate the entire urinary tract
particularly the lo*er ureters.
+dditional radiograph ) prone or upright
KU# *hen the lo*er ureters are not seen
ade3uately.
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'ost Micturation Film /Foto %%%0
'ost micturation KU# radiograph.
o demonstrate complete bladder
empting and any hold)up of contrast in
the collecting system.
'ersistence dilatation on post void image
suggest obstruction and decompression
indicates physiologic distension.
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>valuation of %U 'reliminary radiograph
Bas, mass, stones, bones
Renal shado*s) siCe, a@is,calcification
&ourse of ureter
%mmediate film/nephrogram0 SiCe, shape, symmetry,
contour
'yelogram &alices, ureters, urinary
bladder
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'yelography
+ntegrade pyelography /+'B0
1utline the pelvicalyceal system and
ureteric anatomy
&ontrast is in$ected into the '& system
and outline the '& and ureter
Retrograde pyelography /R'B0
Re3uires cystoscopy, placement of the
catheter to the distal part of ureter
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+ntegrade pyelography /+'B0
%ndications2 +natomic evaluation of pelvocalyceal
system
Ureteric drainage for evaluate
urine lea,
post)percutanea nephrostomy
residual stones
site of ureteric obstruction
ureteral fistulas
echni3ue2 Under flouroscopy
ia catheter nephrostomy *ith using
contras media
Supine position
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Retrograde Urography
%ndications2 "ematuria, &ontrast sensitivity, Suboptimal %U, -eeds cystoscopy
echni3ue2 Under fluoroscopy &ontrast in$ected
directly intopelvicaliceal systemvia cathethers fromurethrae
Supine positions
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&ystography
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&ystography
%ndications2 esicoureteral reflu@/bac*ard flo* of urine intoureters0
Recurrent lo*er urinarytract infection
-eurogenic bladder2/dysfunction due to diseaseof central nervous system orperipheral nerves0#laddertrauma
'rostate enlargement Lo*er urinary tract fistulae Urethral stricture 'osterior urethral valves
/obstructive congenital defect ofthe male urethra0
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&ystography techni3ue
echni3ue2 &ontrast administration usually performed
retrograde via catheter urethra,
&atheter cystostomy %U /e@cretory cystography0
&ystography Routine Series Scout vie*
filled +' both obli3ues Lateral oiding
post)void
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>@cretory&ystogram /%U0 Retrograde"ystogra
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Urethrography
&ndications: o diagnose urethral stricture o evaluate urethra after trauma
Techni#ue: Urethra may be visualised as part of M&U/descending0 or ascending urethrogram
+scending urethrogramtip of catheter is inthe fossa of navicular.
Spot film is taen *hen contrast is in$ected
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&ystourethrography
Static &ystourethrography
9Retrograde
&ystourethrography:9&ystourethrography:
#ipolar &ystourethrography
oiding &ystourethrogram /&UB0
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&ystourethrography
%ndications2 >valuate bladder lesion, rupture, lea, post
trauma!surgery bladder
integrity!anastomose!fistulas
echni3ue2 Scout,
Fill bladder *ith 4AA)7AA mL via urethrae syringe
or tip of catheter is in the fossa of navicular. +!' and obli3ues /sho*s e@travasation posterior
to bladder0,
'ost)drainage film
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&ystourethrography
echni3ue2
+' 1bli3ue 'ro$ection )
R'1!L'1
'atient is supine, rotated 68
) 7A degrees
Urethral syringe /or #rodney
clampE0 is used to introduce
contrast images are obtained
as contrast is in$ected
>ntire urethra must be
visualiCed
#ladder can be filled to
obtain antegrade voiding
study
Techni#ue: +' 'ro$ection /maybe obli3ues0
#ladder can be filled and patient
void for antegrade studies
&assette should be centered as
for cystography
+bduct thighs to prevent
superimposition of bone or soft
tissue
Male Female
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&ystourethrography
h &
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Micturating cystourethrogram/M&U0!
oiding &ystourethrogram /&UB0
'unctional and anatoic e(aluation of bladder
&ndication:
1) To detect (esicoureteric reflux who ha(e recurrent
infection
2) %ladder rupture
3) *eonstrate posterior urethral (al(e
+) reterocele,
) *ysfunctional (oiding.) rethral strictures
/) %ladder0urethral di(erticula
Micturating cystourethrogram/M&U0!
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Micturating cystourethrogram/M&U0!
oiding &ystourethrogram /&UB0
Scout 'ediatric2 8 or < F feeding tube, fill bladder *ith contrast
/age ;4 @ 6A0. Mainly for peadiatric patient
+dult2 standard catheter
Filling the bladder with contrast introduced via urethralcatheter
Film during filling) bladder pathology, early reflu@
Films during void) reflu@, urethral abnormality
1bli3ue) evaluate grade 5 reflu@, males
'ost)void film
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M&U
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(oidingcystourethrogra"!4 of a patient withgrade &&& (esicoureteral
reflux R4) 5ote thatthe contrast flows up theureter and into the renalpel(is) The calyces aresharp
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This is an exaple of
grade
(esicoureteral reflux
R4) 5ote thedilated renal pel(is
and calyces) The
ureter also is dilated
and tortuous)
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This is bilateral
(esicoureteral reflux
R4
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Ultrasound
&ndication
1) Renal ass
2) 6aeaturia
3) 'lank pain+) %lood urea ele(ation
) $oor non functioningkidney on &
.) %iopsy 0inter(entionalguidance
echni3ue
+ 6.8 transducer isgenerally used toscan the adult idney
Liver and spleen act asacoustic *indo* forevaluation R and Lidneys respectively
'atient position2Supine, decubitus orprone
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ltrasound of Right 7idney
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Ultrasound of Kidneys
NORMAL STUDY
DILATED RENAL
PELVIS
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The parenchya is
relati(ely noral in
thickness)
The dilation of thecollecting syste
extends fro the
renal pel(is to the
calyces)
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&omputed tomography
Biving predominantlyanatomicalinformation
Used *hen USfinding is inconclusive
Staging of tumor Renal trauma
Renal artery stenosis &alculi ! obstructive
uropathy
>mphysematous pyelonephritis
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>mphysematous pyelonephritis.
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&ystic renal cell carcinoma.
R&& *ith inferior vena cava
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R&& *ith inferior vena cava
invasion
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MR%
+natomical information
hen US or & is inconclusive
MR+2 for renal artery stenosis
Multiplanar imaging G sag, coronal and
a@ial
ime consuming ! e@pensive
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Large right renal cell carcinoma *ith renal vein
and inferior vena cava invasion.
T2-weighted axial
8R&
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*ynaic gadoliniu-enhanced agnetic
resonance angiogra 8R4 shows noralrenal arteries)
Renal +ngiography
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Renal +ngiography
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-uclear Scintigraphy
'hysiologic and anatomic info Renograph2
-on)imaging /Ulin "ospital0 ith imaging /Bamma camera0
Radioisotop;Radiofarmaa &)HH m /t I ? hrs0 M+B6) cleared by tubular secretion, no glomerular
infiltration) evaluate renal function and renal plasma
flo* D'+) glomerular filtration) evaluate obstruction
and renal function DMS+) cleared by filtration and secretion) renal
cortical image
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Urogenital Disease
+e"elopmental "ariations disorders
ollecting system &2bstruction! stone!hydronephrosis'
3cute and chronic inflammation
irculation disorders &reno"ascularhypertension! function failure'
&+iseases of the parenchyma' Trauma
Space occupying lesions%S24 &cystic! solid'
-ormal variations and
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-ormal variations and
congenital disorders
Fusion abnormalitiy "orseshoe odney
>@trarenal pyelon &ongenital malposition /ectopic idney0
+genesis, hypoplasia
1bstruction stone
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1bstruction, stone,
hydronephrosis +cute2
>nlarged idney
Slo* perfusion and e@cretion
Moderate dilatation of the pyelum, stone, othercauses
&hronic2
Dilated collecting system hin parenchyma
'ure e@cretion
Stone
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+utoimmun2 large!small idney
+cute pyelonephritis /acute focalbacterial nephritis, etc0
>mphysematous pyelonephritis2 large
idney, hypodensity, decreased contrast
uptae, space occupation, thiening of
the renal fascia, gas in the parenchyma
'yonephros 2 hydronephrosis, thi *all of
the pyelon
+bscess2 +'- ; abscess cavity
Segmental, polar, global atrophy
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Infarction &partial! complete'$ noenhancement! absence of e,cretion
5enal "ein thrombosis$ large kidney!
slo perfusion! "enous filling defect!perirenal collaterals! no e,cretion
5enal artery stenosis! reno"ascular
hypertension aneurysma Kidney failure$ parenchyma
destruction! calcification! pure
e,cretion &contrast material66'
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rauma
#lount or penetrating in$uries, contusion
"aematoma /subcapsular!perirenal0
Urinoma
'arenchyma laceration
+rtery!vein in$ury
Ureter ruptur
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S1L
&ystic Simple /soliter!multiple0
"erediter /poliisti disease0
+typical /closed caly@, diverticula, cystictumour, abscess, cystic nephroma0
Solid
#eigne /+ML, adenoma0 Malignant 'rimary /R&&, &&, ilms umor0
Secondary /"L, -"L, Metastasis0
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&ase 5. "orseshoe idney
xis and positionalteration in
horseshoe kidney)
& 4 filli d f i %U
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&ase 4. filling defect in %U
"oon causes
1) "alculi
2) "yst
3) Tuours+) %lood clot
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&ase 6. focal #ulge
Renal cyst withsplaying of calyces
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&ase 7. simple cyst
%ncreased parenchymal thicness Jdistortion of collecting system ) simple
cyst /confirm by us0
&ase ?. pcs
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&ase ?. pcs
duple@ 9xcretory urography in a
woan shows coplete
ureteral duplication on the
right) The upper oiety
ureter epties below andedial to the ureter of the
lower oiety)
5ote the duplex collecting
syste on the left
&ase . bilateral ureteral
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&ase . bilateral ureteral
duplication 9xcretory urography
in an adult patient
with bilateral
coplete ureteral
duplication)
& < d l i h id
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&ase
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&ase H.&alculus
&ntra(enous urogra) fter the intra(enous inection, contrast
aterial in the collecting syste obscures the calculus
& 5A U t
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&ase 5A. U stone
Standing column ofcontrast *ith mild
hydronephrosis ) U
stone.
&ase 55. "ydronephrosis J
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&ase 55. "ydronephrosis J
hydroureter ) ureterocele.
& 54 #'"
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&ase 54. #'"
#ladder base
defect )
prostate
enlargement
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"+-KS 1U