Transcript Urinary system and Adrenals.ppt

Urinary System
and Adrenal glands
Department of Radiology
Huashan Hospital, Fudan University
Huijin He, MD,PhD
Imaging Modalities of Urinary System
（Ⅰ） KUB (Kidney-ureter-bladder survey)
• A plain film of the kidneys and bladder.
• Useful for the diagnosis of calculi, soft-tissue
calcifications and gas.
• Should always be performed prior to contrast
medium injection.
Imaging Modalities of Urinary System
（Ⅱ）Urography
• Excretory Urography
• Retrograde Urography
Excretory Urography
IVP ( Intravenous Pyelography )
• After KUB, contrast medium is injected into a vein.
• Films taken 1,15 and 30 min. post contrast.
• Abdominal compression is applied in order to
retain the opacified urine in the pelvis and ureter.
• The compression is then removed and a full
abdominal exposure is obtained.
Excretory Urography
IVP ( Intravenous Pyelography )
• Clinical application:
• Rapid overview of the entire urinary tract.
• Detailed anatomy of the collecting system.
• Important for the diagnosis of early transitional cell
carcinoma in the upper urinary tract.
• Congenital anomalies such as fusions, rotation
anomalies, calyceal variants and duplications are
well demonstrated by IVP.
• Indication: Normal renal function; No iodine allergy.
Retrograde Urography
• Water-soluble contrast medium is injected
retrogradely through the urethra by catheters
and up into the bladder (Retrograde
cystography), or up into the ureter and pelvis by
intra-ureteral cannula (Retrograde Pyelography).
• Useful for the diagnosis of urethral strictures,
diverticula, tumors and in trauma.
• Check the urinary tract obstructive lesions.
• Indication: renal dysfunction, fail of IVP.
• Contraindication: Lower urinary tract infection.
Retrograde cystography
Retrograde cystography
shows urethral stricture and filling defects
Retrograde cystography
shows urethral stricture of posterior urethra
Retrograde Pyelography
Retrograde Pyelography shows dilation of left renal pelvis
Imaging Modalities of Urinary System
（Ⅲ）Angiography
（1）Abdominal aortography or slective renal
arteriography：percutaneous femoral artery
catheterization technique used, catheter placed in the
top opening of the two renal arteries or inserted
directly into the renal artery, a continuous rapid
injection of contrast agent and radiography.
（2） Indications : suspected renal artery stenosis,
vasculitis (e.g. polyarteritis nodosa), aneurysms and
arterio-venous fistulae.
Slective renal arteriography and Abdominal aortography
Imaging Modalities of Urinary System
（Ⅳ）Computed Tomography (CT)
• Most important and most commonly used method.
• Plain CT scan, Enhanced CT, CT angiography (CTA), CT
urography (CTU)
Imaging Modalities of Urinary System
（Ⅳ）Computed Tomography (CT)
• Scanning techniques and methods:
(1) Bowel preparation: fasting, water deprivation, oral
contrast agent
(2) Scanning range: kidney, bladder, ureter, etc.
(3) Window width and window level, thickness, pitch
(4) The period of time and enhanced scan phase:
arterial phase (renal cortex phase), renal parenchymal
phase and excretory phase
Imaging Modalities of Urinary System
（Ⅳ）Computed Tomography (CT)
• Plain CT scan: the most commonly used method to
display the lesion shape, density and position. MPR
image shows the relationship with surrounding
structures. Most sensitive for urinary tract stones.
• Multi-phase enhanced scan: caution in renal
dysfuction patients. Excellent in detecting and
differentiating renal masses and in staging renal
malignancies.
Imaging Modalities of Urinary System
（Ⅳ）Computed Tomography (CT)
• Special methods:
(1) Renal artery CTA: thin slice scan, 3D reconstruction
of renal vessels using MIP, SSD, or VRT technology.
(2) CTU: the whole urinary tract scan, 3D
reconstruction of urinary tract using MIP technology.
Imaging Modalities of Urinary System
（Ⅴ）MRI：
• Important complement to CT and ultrasound
• Non-enhanced MRI, Enhanced MRI, MR
angiography (MRA), MR Urography (MRU)
Imaging Modalities of Urinary System
（Ⅴ）MRI
• 1、 Scanning techniques and methods:
(1) respiratory gating and respiratory
compensation
(2) imaging sequences: SE, FSE, T1WI and T2WI of
GRE, enhanced T1WI, fat suppression techniques
(3) scan range, scan time and the period of
enhanced phase (similar as CT)
Imaging Modalities of Urinary System
（Ⅴ）MRI
2、Non-enhanced MRI: to determine the histological
characteristics of lesions (fat, hemorrhage,
calcification, etc.).
3、Enhanced MRI：its value is similar to CT
4、Special methods：
（1）renal artery MRA: CE MRA with contrast agents
(2）MRU： heavy T2W imaging for the examination
of urinary tract obstruction
Normal Imaging Findings
（Ⅰ） Normal X-Ray Findings
• Kidney：
• Ureters：
• Bladder：
1、Kidney：KUB shows kidney shadows due to
perirenal fat.
（1）Bean-shaped, central of inner edge slightly
concave, outer edge smooth.
（2）“八”-shaped located on both sides of spine,
the right kidney is slightly lower, the long axis of the
kidney out from the inside top of the ramp below.
Renal ridge angle 15 ~ 25 °.
（3）Height 12~13cm, width 5~6cm.
（4） Homogeneous density, move with respiration.
But excursion may be less than 1 vertebral body
height when from supine to standing position.
（Ⅱ） Normal Urography Findings
1、Kidney：
（1） parenchyma: Homogeneous density,
bilateral identical.
（2）Renal calyces: minor calyces (usually 6-14)
and major calyces (usually 2-4).
1）Minor renal calyces: egg-cup shaped.
2）Major renal calyces: long tubular shaped,
neat edge.
3）Renal pelvis: horn shaped, within the
confines of kidney, but may also be extrarenal.
（Ⅱ） Normal Urography Findings
2、Ureters: Total length of about 25 ~ 30cm, width 3 ~
7mm.
（1）Segments: Abdominal segment is connected with
renal pelvis, down the line along the spine. After across
the pelvis over the inside edge of sacroiliac joints, it is
called basin segment. Curved into bladder, it is called wall
segment.
（2） Three physiological narrowing: Junction with renal
pelvis; over the pelvis; bladder entrance.
3、Bladder: Size and shape depends on degree of filling.
Kidneys and ureters
Normal male bladder
Normal female bladder
（Ⅳ） Normal CT Findings
1、Plain CT scan:
（1）Kidney: Renal parenchyma, renal hilum, renal
sinus and renal pelvis.
（2）Ureter:
（3）Bladder: Cavity, wall.
（Ⅳ） Normal CT Findings
2、Enhanced CT:
（1）Kidney: renal cortex phase,
renal parenchymal phase and excretory phase
（2）Ureter: showed on excretory phanse
（3）Bladder: wall enhanced
3、 Renal artery CTA :
4、CTU:
Normal CT scan of kidneys
Normal CT scan of bladder
CTA
CTU
（Ⅴ） Normal MRI findings
1、Non-enhanced MRI: T1WI and T2WI
（1）Kidney: Cortex and medulla, renal sinus and
renal pelvis, renal vessles
（2）Ureter:
（3）Bladder: Cavity and wall
2、Enhanced MRI:
（1）Kidney: similar to CT
（2）Ureter: fat suppression
（3）Bladder:
3、MRA：
4、MRU：
MRI of kidneys
Renal arteries and renal vein
MRU: Neurogenic bladder
with right hydronephrosis and hydroureter
Abnormal imaging findings
（Ⅰ）Abnormal findings of X-ray
1、Abnormal calcification:
（1）Cause: mainly stones, renal tuberculosis, renal
carcinoma and renal artery aneurysm.
（2）Location and shape of calcification: renal pelvis
stones, renal carcinoma calcification, calcification of
renal tuberculosis, renal cyst calcification.
2、Changes of location, size, contour of renal shadows:
（Ⅱ）Abnormal findings of Urography
1、Abnormal developing of renal parenchyma:
（1）Does not develop: common in hydronephrosis
（2）Lighting develop: common in renal dysfunction
（3）Enhancing develop: common in ureteral obstruction
2、Stretch and deformation of renal pelvis and renal calyces:
common in renal masses, including renal cysts, renal cancer,
renal hematoma and renal abscess.
3、Destruction of renal pelvis and renal calyces: renal
tuberculosis, renal transitional cell carcinoma and renal cell
carcinoma.
（Ⅱ）Abnormal findings of Urography
4、 Filling defect of renal calyx, renal pelvis, ureter and bladder:
stones, tumors, blood clots and air bubbles, etc.
5、 Hydronephrosis, hydroureter and giant bladder: a variety of
causes of urinary tract obstruction.
6、 Vesicoureteral reflux: congenital abnormalities, urinary
tract obstruction, infection, etc.
Right ureteral stones with right hydronephrosis
（Ⅲ）Abnormal findings of renal
arteriography
1、Artery stenosis: atherosclerotic plaque, artery
fibromuscular dysplasia and Takayasu arteritis.
2、 Aneurysm: cystic or fusiform expansion of blood
vessels.
3、 Arterial thrombosis, embolism:
4、Artery expansion：common in hypervascular
tumor.
5、Abnormal changes secondary to direct erosion of
the vessels from renal cancers.
Stenosis of left renal artery
Stenosis of renal arteries
Aneurysm of renal artery
（Ⅳ）Abnormal findings of CT and MRI
1、Kidney:
（1）Abnormal of location, size, number and shape of kidneys
（2）Abnormal of renal parenchyma: mainly masses
1）Different masses have different performances of CT density,
shape and enhancement.
2）Renal parenchymal tumors have different performance of
MRI signal intensity and enhancement.
（Ⅳ）Abnormal findings of CT and MRI
1、Kidney:
（3）Abnormal renal calyx and renal pelvis:
1） kidney stones: CT high-density, MRI low signal intensity
2）Expansion of renal calyx and pelvis：CT low-density, MRI
3）Mass in renal calyx and pelvis：soft tissue density in CT and
enhanced, MRI
4） Perirenal abnormalities: CT and MRI are similar. Perirenal
fat has higher density, thickening of renal fascia, perinephric
fluid.
Renal cell carcinoma
（Ⅳ）Abnormal findings of CT and MRI
2、Ureter:
（1）Obstructive expansion, hydroureter:
1）Calcification in ureter:
2）Ureteral wall thickening, soft tissue mass：
3）Soft tissue mass around ureter：
（2）Non-obstructive expansion, hydroureter:
3、Bladder:
（1）Bladder wall thickening：
（2）Bladder mass：
4、Renal vessel CTA and MRA: mainly renal artery stenosis
5、CTU and MRU: similar to urography
Ureteral stone
Ureteral carcinoma with
obstruction
Bladder carcinoma
Renal artery stnosis
Renal artery stenosis of
transplanted kidey
Obstruction on the entrance of ureter
Obstructive expansion of
right kidney and ureter
Neurogenic bladder
with hydronephrosis and hydroureter
Diseases of Urinary System
Anomalies of Urinary System
Ⅰ、Congenital solitary kidney
Ⅱ、Renal duplication
Ⅲ、Abnormal renal fusion
Ⅳ、Cystic malformation of kidney
Solitary kidney: Branch-shaped left renal pelvis,
and the right kidney does not develop
Right renal duplication
Bilateral renal duplication
Kidney malrotation and
horseshoe kidney
Horseshoe kidney
Ⅳ．Cystic malformation of kidney
Including polycystic kidney,
medullary sponge kidney,
medullary cystic disease,
multi-cystic dysplastic kidney, etc.
polycystic kidney
（Ⅱ） Medullary sponge kidney
Congenital anomalies, may be related to heredity, with
hypercalciuria and urinary tract stones, susceptible to
infection.
Plain films show clusters of small calculi in the
distribution of the papillae or medulla.
Intravenous urography is diagnostic and shows linear
dilated collecting tubules ("streaks" or "brush"
appearances), some of which contain calculi.
Calculi has no signal on MRI.
Calculi of Urinary System
Ⅰ、Kidney stones
Ⅱ、Ureteral stones
Ⅲ、Bladder stones
Urinary tract stones are the most common
diseases of urinary system.
Stone composition is different, but most stones
contain calcium and can be seen in the X-ray
imaging ( accounting for about 90%).
Clinical symptoms: renal colic, hematuria,
secondary infection.
Appropriate Choice of Imaging Modalities
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Suspected stones: KUB + ultrasound
Further: Plain CT scan
Much further: IVP
MRU is helpful
Ⅰ．Kidney stones : most common
Mostly unilateral, but can also be bilateral.
Most stones locate in the renal pelvis or calyx.
X-ray shows single or multiple round, oval, antlershaped or amorphous high density shadows with
different size in the renal pelvis or calyx.
Typical staghorn or coral-like form in the renal pelvis
or calyx.
In lateral view, the stone shadows overlap with spine.
In urography, if stone is positive, it can be covered
by contrast media. Negative stones appear as
filling defect with smooth edges.
Urography can also show urinary tract obstruction
caused by stones, like dilation of the pyelocalyceal
system and hydronephrosis.
Kidney stones should be differentiated with
gallstones, calcification of cartilage, and
calcification of abdominal lymph nodes.
CT is more sensitive to small calyceal stone.
Ⅱ．Ureteral stones
Often come from the migration of kidney stones,
generally about a few mm size.
X-ray shows round, oval, or mulberry-shaped stones,
consistent with the long axis of ureter, common in
physiological stenosis area.
Urography has different appearance according to the
different location of the stones.
If stone is at the ureteropelvic junction, it shows
expansion of renal pelvis and hydronephrosis.
If stone is at the lower part of ureter, it shows
flattening of calyx cup, but expansion of renal pelvis is
not obvious.
If stone obstruction has been a long time, there are
serious hydronephrosis, renal dysfunction, renal
cortical thinning, and widening of the ureter above the
obstruction.
Ureteral stones should be differentiated with lymph
node calcification, venous stone.
Ⅲ．Bladder stones
Most can be diagnosed by plain film.
Usually single, can also multiple, with different size. The
most common is the oval stone in the middle of the lower
pelvis or near the midline, can move with the position.
Generally smooth edges, homogeneous density, up to
10cm large or more.
A small number of bladder stones have low density,
shows filling defect in cystography, should be
differentiated with bladder tumors.
Right kidney stone
Right lower ureteral stone
Staghorn stones in
the right renal
collecting system
and left ureteral
stone
Staghorn stones in the right renal collecting system
Right ureteral stone with right hydronephrosis
Right upper ureteral stone
Bladder stones
Posterior urethral stones
Urinary tumors and tumor-like lesions
Ⅰ、Renal cysts
Ⅱ、Renal angiomyolipoma
Ⅲ、Renal cell carcinoma
Ⅳ、Wilms' tumor
Ⅴ、Renal transitional cell carcinoma
Ⅵ、Bladder cancer
Appropriate Choice of Imaging Modalities
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Ultrasound preferred
Further: CT or MRI
IVP and DSA are used for differential diagnosis
IVP is sensitive to renal transitional cell carcinoma
CT and MRI can be used for tumor staging
Ⅰ．Renal cysts, including para-pelvic cysts
Simple renal cysts are mostly solitary, but also multiple.
Plain film may show changes in renal outline, as
lobulated or semi-circular protuberance.
Urography may show calyceal compression,
elongation, separation and deformation.The pressure
trace is curved with smooth edges.
CT can find small renal cysts with round low-density
and smooth contour.
CT of right renal cyst
MRI of left renal cyst
Simple renal cyst
Renal cyst accompanied by hemorrhage
Ⅱ. Renal angiomyolipoma, also known as renal
hamartoma, the most common benign renal tumor
（Ⅰ）CT: multi-component, multi-density, multi-room
separation performance, a clear boundary.
CT characteristic features: fat content
（Ⅱ）MRI: high signal on T1WI and T2WI. Solid part
enhanced. Use sequence with fat suppression.
Right renal angiomyolipoma
Left renal angiomyolipoma
Ⅲ．Renal cell carcinoma (RCC) , the most
common renal malignancy
Originated from epithelial cells of the proximal
tubule, clear cell carcinoma is the most common
type, tend to be bleeding and necrosis.
Plain film: only to see the expansion of the renal
shadow, limited protruding of renal outline.
Sometimes patchy or irregular calcification is
visible.
Urography: calyceal compression or elongation is
visible, with its edge regular or irregular, or like motheaten destruction.
If the tumor invaded the renal pelvis, filling defect of
the renal pelvis can be seen.
• CT: low-density space-occupying lesions,
heterogeneous enhancement (arterial phase,
venous phase); necrosis, hemorrhage, and
calcification.
• MRI: hypo or iso-intensity on T1WI and hyperintensity on T2WI (relative hypointense); low
degree enhancement.
Invasion, metastasis, and tumor thrombus can be
seen.
Renal arteriography :
Very helpful for RCC diagnosis.
Display irregular tumor blood vessels. Show tumor
staining at parenchymal phase, outlining the shape
and size of the tumor.
Vascular lake and arteriovenous fistula can be seen in
the tumor area.
Retrograde pyelography showed left RCC
Left RCC
Left RCC
Right RCC
Right RCC
T1WI
PDWI
T2WI
T1WI C＋
Right RCC
Right RCC
Ⅳ. Nephroblastoma, also called renal embryoma,
Wilms tumor
The most common renal malignancy in children.
More common in the renal parenchyma, a huge
tumor, often with necrosis, liquefaction, and
bleeding.
KUB: kidney shadow is significantly enlarged.
IVP: calyceal and pelvis compression, displacement,
deformation, and damage can be seen.
Ⅳ. Nephroblastoma, also called renal embryoma,
Wilms tumor
CT: a huge mass, slightly enhanced, involving the
renal vessels , metastasis.
MRI: low signal on T1WI and high signal on T2WI,
bleeding signals.
Ⅴ. Renal transitional cell carcinoma
A common renal tumor after RCC.
Originated from the transitional cell of the renal
pelvis, can be single or multiple.
The tumor can occur in the renal calyces or pelvis,
often spread to the ureter and bladder.
X-ray: often without positive findings.
Urography: shows irregular filling defect of renal pelvis.
If the tumor blocks the ureter, may cause hydronephrosis.
If the tumor invades the renal parenchyma, its imaging
findings are similar to RCC.
Selective angiography: not typical because of its lack of
blood supply.
CT is helpful for diagnosis.
Left renal transitional cell carcinoma
• CT：intrapelvic iso-density occupying lesion,
delayed mild enhancement, invasion of the renal
parenchyma.
• MRI：iso-intensity on T1WI, slightly hyperintensity on T2WI.
• Tumor hemorrhage, necrosis, and so on.
• Metastasis and tumor thrombus.
Left renal transitional cell carcinoma
Ⅵ. Bladder tumors
The vast majority of bladder tumors are originated
from the transitional epithelium, such as benign
papilloma and transitional cell carcinomas. The
papillomas tender to be malignant transfer.
The main X-ray findings : partial filling defect , with
different size. Small tumors are often covered by the
contrast agent, not easy to be displayed.
Benign tumors show filling defect with smooth edge ,
pedunculated.
Malignant tumors show irregular contour, like
cauliflower.
Bladder tumors
• X ray: filling defect
• CT：iso-density, enhanced, wall thickening
• MRI：iso-intensity on T1WI, hyper-intensity on
T2WI
• Invasion and metastasis
• Stage
Bladder tumors
Bladder tumors
Imaging Modalities of Adrenal glands
Ⅰ CT Examination
1, Scanning techniques and methods:
2, Unenhanced and enhanced scans:
(1) CT is the best screening method, the most
important diagnostic methods
(2) Thin-layer CT scan is conducive to the detection
of small functional lesions.
(3) Enhanced scan is needed for mass diagnosis.
Imaging Modalities of Adrenal glands
Ⅱ MRI examination
1, Scanning techniques and methods:
2, Unenhanced and enhanced scans:
(1) Tissue resolution is high.
(2) Spatial resolution is relatively low.
(3) Value of enhanced MRI scan is equal to CT.
Normal Imaging Findings of Adrenal glands
Ⅰ Normal CT findings
1、 Plain scan:
(1) position:
(2) Density: soft tissue density
(3) Shape: the right adrenal gland is inverted "V" or
inverted "Y" shaped, the left adrenal gland is inverted
"V“, inverted "Y 'or triangle shaped.
(4): Size: adrenal collateral thickness is not exceed the
foot of the ipsilateral phrenic.
2、 Enhanced CT scan: homogeneous enhancement
Normal Imaging Findings of Adrenal glands
ⅡNormal MRI findings
1、Plain scan:
(1) Axial: location, shape and size is similar to CT.
(2) Signal intensity: similar to the liver parenchyma.
2、 Enhanced MRI scan: homogeneous enhancement
Normal CT scan of adrenal glands
Normal CT scan of adrenal glands
Normal MRI scan of adrenal glands
Abnormal imaging findings of adrenal glands
• CT and MRI abnormalities of adrenal glands:
1, Size change: usually bilateral
(1) diffuse enlarged with normal morphology and density: adrenal
hyperplasia
(2) diffuse enlarged with nodules at the edge, normal density:
adrenal nodular cortical hyperplasia
(3) diffuse decreased with normal morphology and density:
adrenal atrophy
2, Adrenal masses: the number, size, density (signal intensity) and
enhanced performance
(1) mass number: bilateral tumor, unilateral tumor
(2) the size of tumor: benign functional mass is usually small; nonfunctional malignant tumor is usually larger.
(3) mass density (signal): the water density, fatty, mixed density
Diffuse hyperplasia of the adrenal glands
Adrenal adenoma
Diseases of Adrenal Glands
Ⅰ Adrenal hyperplasia
Ⅱ Adrenal adenoma
Ⅲ Pheochromocytoma
Ⅳ Adrenal cortical carcinoma
Ⅴ Adrenal tuberculosis
Ⅵ Adrenal cyst and pseudocyst
Appropriate Choice of Imaging Modalities
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Ultrasound: Screening
CT: first choice
MRI: supplementary of CT
Pheochromocytoma: should expand the scope of
the inspection
Ⅰ Adrenal hyperplasia
Can be caused by excessive secretion of one or
more of adrenal cortical hormone.
Cushing syndrome is the most common type.
Secondly, primary aldosteronism.
The main pathological changes: adrenal cortical
hyperplasia.
Cushing syndrome
Nodular hyperplasia of the adrenal cortex
Aldosteronism
Ⅱ Adrenal adenoma
Including adenomas and carcinomas.
Adenomas are mostly unilateral, with small size,
intact membrane.
Fast-growing will induce necrosis, hemorrhage
and calcification.
CT is helpful for the diagnosis of adenoma, with
smooth edges; round, oval or drop-shaped
shadows.
Left adrenal adenoma
Left adrenal adenoma
Left adrenal carcinoma
Ⅲ Pheochromocytoma
Mostly occurs in one side of the adrenal medulla.
More common in young adults.
Paroxysmal hypertension is a typical symptom.
For adrenal pheochromocytoma, CT shows a round,
oval-shaped solid mass with clear edge.
The density can be homogeneous or inhomogeneous.
Large tumor could have central low-density irregular
necrosis or liquefaction zone.
Pheochromocytoma
Pheochromocytoma
Pheochromocytoma