GENITOURINARY IMAGING 4 Flashcards
What has similar pattern as ATN but occurs later in the posttransplant period.
Cyclosporine toxicity has similar pattern as ATN but occurs later in the posttransplant period.
What are the imaging features of chronic Cystitis?
What is this condition?
Imaging Features
-
Cystitis cystica:
- serous fluid–filled cysts;
- multiple smooth round filling defects
- Cystitis glandularis:
- mucin-secreting glandular hypertrophy:
- multiple cyst like filling defects along mucosa
- Same findings as in acute cystitis
https://www.liebertpub.com/doi/10.1089/cren.2017.0010
Describe the staging of bladder cancer
Staging
T1: mucosal and submucosal tumors
T2: superficial muscle layer is involved
T3a: deep muscular wall involved
T3b: perivesicular fat involved
T4: other organs invaded
N: the presence and distribution of malignant adenopathy affects the prognosis.
https://pubs.rsna.org/doi/10.1148/rg.322115125
Malacoplakia
Rare inflammatory condition that most commonly affects the bladder.
Yellow-brown subepithelial plaques consist of mononuclear histiocytes that contain Michaelis-Gutmann bodies.
On IVP, multiple mural filling defects with flat or convex border are seen, giving a cobblestone appearance.
Obstruction is a rare complication.
Mimics Malignancy.
How often do perirenal fluid collections occur in renal transplants?
What % persist?
Perirenal Fluid Collections
Perirenal fluid collections occur in 40% of transplants.
The collections persist in 15%.
Lymphocele with pressure effect on Tx Kidney
What are 4 causes of this condition?
Vesicovaginal fistula:
- surgery,
- catheters,
- cancer,
- radiation
Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 48793
What are the imaging features of ATN?
on US
on MAG3
on Urogram
Imaging Features
- Smooth large kidneys
- Normal renal perfusion (MAG 3 angiography)
- Diminished or absent opacification after IV contrast administration
- Persistent dense nephrogram at late time points, 75%
- Variable US features:
- Increased cortical echogenicity with normal corticomedullary junction
- Increased echogenicity of pyramids
Striated Nephrogram:
Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 28077
Radiographic features
Imaging demonstrates preserved renal parenchyma perfusion, but with minimal or absent excretion into the urinary collecting system.
Fluoroscopy / CT urography
Imaging with iodinated contrast typically demonstrates an immediate or mildly delayed nephrogram, but without excretion into the collecting system. Delayed 24 hour imaging would also demonstrate persistent nephrogram or striated nephrogram due to stasis of contrast within the renal tubules 3,4.
Ultrasound
Ultrasound is usually performed in this setting to assess the renal parenchyma and exclude other causes of obstruction. In acute tubular necrosis, the kidneys usually have a normal appearance on ultrasound, but may be enlarged and increased echogenicity 5.
What are 3 causes of Bladder adenocarcinoma?
Adenocarcinoma, 2%
- Bladder exstrophy
- Urachal remnant
- Cystitis glandularis; 10% pass mucus in urine
What are 5 causes of bladder outlet obstruction in children?
- Posterior urethral valves (most common in males)
- Ectopic ureterocele (most common in females)
- Bladder neck obstruction
- Urethral stricture
- Prune-belly syndrome
What are the signs of renal vein thrombosis in the kidneys on USS?
Early and late phases
Kidneys
- Renal enlargement
- US:
- Early
- hypoechoic cortex (early edema);
- hyperechoic cortex after 10 days
- (fibrosis, cellular infiltrates
- preserved corticomedullary differentiationm (CMD);
- late phase (several weeks):
- decreased size,
- hyperechoic kidney with loss of CMD
- Early
https://www.eurorad.org/case/4596
What are the imaging features of this?
Schistosomiasis
Imaging Features
- Extensive calcifications in bladder wall and ureter (hallmark)
- Inflammatory pseudopolyps: “bilharziomas”
- Ureteral strictures, fistulas
- SCC (suspect when previously identified calcifications have changed in appearance)
Figure 2 Photomicrograph (original magnification, ×200; hematoxylin-eosin stain) shows a fresh ovum from S haematobium, floating in a human urine specimen. Note the terminal spine at one end of the ovum.
Adult schistosomes do not usually cause an inflammatory reaction in the venous system. In fact, their presence there is associated with increased protection of the host against reinfection by cercariae. In general, dead eggs and dead flukes cause a more severe inflammatory reaction than living ones do (22).
Pathologic changes in the urinary tract due to schistosomiasis are far more common in chronic infections than in acute ones. Such changes result from the deposition of eggs (not adult flukes) in and around vessels, which leads to chronic inflammatory lesions and induces an immune response with granuloma formation and associated fibrotic changes (23).
https://pubs.rsna.org/doi/10.1148/rg.324115162
What are the four types of
Congenital urachal anomalies?
- Patent urachus
- Umbilical–urachal sinus
- Vesicourachal diverticulum
- Urachal Cyst
The majority of patients with urachal abnormalities (except those with a patent urachus) are asymptomatic.
However, these patients may become symptomatic if these abnormalities are associated with infection.
What are the 7 causes of Acute Tubular Necrosis?
2 categories
which category is more common?
- Renal ischemia, 60%
- Surgery, transplant, other causes
- Pregnancy related
- Nephrotoxins, 40%
- Radiographic contrast material, now controversial. Risk is probably real in patients with GFR ≤30
- Aminoglycosides
- Antineoplastic agents
- Hemoglobin, myoglobin
- Chemicals: organic solvents, HgCl 2
What are the imaging features of Leukoplakia?
What is the significance of Leukoplakia?
- Imaging Features
- Mucosal thickening
- Filling defect
- Treatment and prognosis
- Leukoplakia is considered a premalignant condition.
- There is an association with bladder neoplasia in 25% of cases.
What are the signs of RVT on IVP?
What sign is this?
Delayed nephrogram
IVP:
- little opacification,
- prolonged nephrogram,
- striated nephrogram (stasis in collecting tubules);
- intrarenal collecting system is stretched and compressed by edema
https://pubs.rsna.org/doi/pdf/10.1148/radiographics.6.6.3685518
What is Bladder Leukoplakia a/w?
What is the underlying pathological process
Leukoplakia
Squamous metaplasia of transitional cell epithelium (keratinization).
Associated with:
- chronic infection (80%) and
- calculi (40%).
Bladder > renal pelvis > ureter
r. Premalignant? Clinical findings include hematuria in 30% and passage of desquamated keratinized epithelial layers.
What are the findings of FLOW and Excretion with the following?
(NUCLEAR SCANS, INTRAVENOUS PYELOGRAM)
Paroxysmal Nocturnal Hemoglobinuria
Rare acquired hemolytic disorder. The renal cortex appears hypointense on T2/T2* because of hemosiderin deposition.
Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 14460
Radiopedia:
- Renal haemosiderosis results from accumulation of haemosiderin in the kidneys.
- It is usually considered a benign and incidental radiologic finding and rarely results in clinically apparent renal dysfunction.
Pathology
- Renal haemosiderosis is a known complication of the following conditions:
- chronic intravascular haemolytic states such as haemolytic anaemias like sickle cell anaemia and thalassaemia 1,3
- paroxysmal nocturnal haemoglobinuria (PNH)
- mechanical haemolysis from prosthetic cardiac valve
https://www.youtube.com/watch?v=6OwlmIMU7L4
What are 6 vascular complications RE renal Transplant?
For each what are the causes/treatment options?
Vascular Complications
- RVT:
- most occur in first 3 days after transplantation.
- Renal artery occlusion or stenosis.
- Anastomotic stenosis is treated with angioplasty with up to 87% success rate.
- Infarction
- Pseudoaneurysm of anastomosis:
- surgical treatment
- AV fistula:
- usually from renal biopsy;
- if symptomatic, embolization is performed.
- Ureterovesical anastomosis obstruction may result from
- edema,
- stricture,
- ischemia,
- rejection,
- extrinsic compression, or
- compromised position of kidney.
What rarely occurs after 1 month post renal transplant?
ATN rarely occurs beyond 1 month after transplant.
What are the imaging features of bladder cancer?
What is the preferred modality for local staging?
Imaging Features
- Mass in bladder wall
- MRI is now preferred for local staging
- Obstructive uropathy because of involvement of ureteric orifices
SIGN
What sign is seen here?
Tuberculosis
- Chronic interstitial cystitis that usually ends in fibrosis.
- Typically coexists with renal TB.
- Imaging Features
- Cystitis cystica or glandularis often coexist, causing filling defects in bladder.
- THIMBLE. BLADDER Small, contracted thick-walled bladder
- Mural calcification (less common)
https: //www.researchgate.net/figure/Thimble-bladder-Axial-image-A-and-curved-MPR-in-the-coronal-plane-B-of-the_fig5_315832565
https: //pubs.rsna.org/doi/10.1148/rg.323115004
SPOTTED NEPHROGRAM
Figure 5A
A late arterial phase from an aorto- gram shows bilateral spotted neph- rognams in a patient with polyartenitis nodosa.
Figure 5B
This is a late phase from a selective renal arteniogram in the same patient; it demonstrates occlusion of multiple peripheral vessels with cortical irregu- lanity.
https://pubs.rsna.org/doi/pdf/10.1148/radiographics.6.6.3685518
What is the only renal process with normal renal flow but reduced excretion.
ATN is the only renal process with normal renal flow but reduced excretion.
What are the imaging features of this?
What is found on Bx?
What is the underlying cause?
Malacoplakia
- What are the imaging features of this?
- Single or multiple filling defects
- Requires cystoscopy and biopsy to differentiate from TCC
- What is found on Bx?
- Michaelis-Gutman bodies in biopsy specimen are diagnostic.
- What is the underlying cause?
- Chronic inflammatory response to gram-negative infection. More prevalent in patients with DM.
Figure 13b. Malacoplakia. (a) Axial CT image shows marked circumferential bladder wall thickening. (b) Photograph of the cut, resected specimen shows a friable, hemorrhagic mucosal surface and dramatic wall thickening.
https://pubs.rsna.org/doi/10.1148/rg.266065126#F12
What are the signs of renal vein thrombosis on IVP?
IVP:
- little opacification,
- prolonged nephrogram,
- striated nephrogram (stasis in collecting tubules);
- intrarenal collecting system is stretched and compressed by edema
Of those with Ureteral Tumours, what % are unilateral?
75% of tumors are unilateral.
What are the imaging features of Acute Bacterial Cystitis?
Imaging Features
- Mucosal thickening (cobblestone appearance)
- Reduced bladder capacity
- Stranding of perivesical fat
Case Discussion
- Case courtesy of Dr Fazel Rahman Faizi, Radiopaedia.org, rID: 68007
- The urinary bladder is distended showing abnormal irregular wall thickening. The mural thickness is approximately 7 mm.
- The normal urinary bladder wall thickness should not exceed 3 mm in the distended state and 5 mm in the non-distended state.
Interstitial cystitis: most common in women; small, painful bladder
Severe interstitial cystitis associated with Sjögren’s syndrome.
A 53-year-old woman presented with oliguria, urinary frequency, abdominal pain and severe edema of the lower extremities. Her serum creatinine was 8.1 mg/dl. Computed tomographic and ultrasonographic studies showed a severely dilated urinary bladder, and bilateral hydroureteronephrosis. Examination of a urinary bladder biopsy specimen showed subepithelial edema and infiltration by lymphocytes and plasmacytes. However, the patient complainted of dry mouth and dry eyes. Ophthalmologically, the Schirmer test was positive. A biopsy of the minor salivary glands in the lip showed chronic sialoadenitis. A diagnosis of Sjögren’s syndrome complicated by interstitial cystitis was made. Since she had been anuric, secondary to urinary obstruction, intermittent self-catheterization was started. Combination of corticosteroid and cyclosporin therapy was initiated. Spontaneous urination began, and gradually the patient’s symptoms remitted. After 8 months of therapy, bladder capacity increased from 140 ml to 350 ml, and she voided approximately 1,200 ml by herself and 600 ml by catheterization daily. This case suggests that when severe interstitial cystitis is associated with Sjögren’s syndrome, a therapeutic trial of corticosteroids and cyclosporin may be beneficial.
https://www.semanticscholar.org/paper/Severe-interstitial-cystitis-associated-with-Shibata-Ubara/7e75419c3986a49c840c06340958baf3dbd16ae6
In transplant patients with renal insufficiency which has been image quality?
DTPA or MAG3
MAG 3 results in better quality images in transplant patients with renal insufficiency compared with DTPA.
Four top bugs causing acute bacterial cystitis?
Acute Bacterial Cystitis
Pathogens:
- E. coli
- Staphylococcus
- Streptococcus
- Pseudomonas
What are the 3 major types of Bladder cancer?
Which is the most common?
Which is the least common?
- TCC, 90%
- Aniline dyes
- Phenacetin
- Pelvic radiation
- Tobacco
- Interstitial nephritis
- SCC, 5%
- Calculi
- Chronic infection, leukoplakia
- Schistosomiasis
- Adenocarcinoma, 2%
- Bladder exstrophy
- Urachal remnant
- Cystitis glandularis; 10% pass mucus in urine
What is this?
- Distal ureteroileal stenosis.
- History of ileal conduit formation for bladder cancer. Progressively rising creatinine. Prior noncontrast CT showed dilatation of the left upper collecting system.
- In this investigation of the patient’s ileal conduit (loopogram), the right kidney fills quickly. The right upper tract is mildly dilated, which is not unexpected for a retrograde study of the kidney.
- The left kidney, however, does not fill readily. Eventually a small amount of contrast opacifies the distal left ureter. When the patient is turned into a steep RPO, a short segment narrowing/stricture at the ureteral anastomosis is evident.
- On the post void images (draining the conduit), the right upper collecting system decompresses, but the left does not decompress very well and retains a faintly dilated appearance.
- The red arrow points to the tight distal ureteroileal stenosis.
- A superimposed radiopaque pill measures 12 mm.
- Case Discussion
- An ileal loop conduit can be investigated with either retrograde urography (loopogram) or with CT urography (CTU), and both have advantages and disadvantages.
- CTU allows one to investigate the soft tissues around the urinary diversion more thoroughly than a loopogram does. If there is thickening of the ureter, mass effect on the ileal conduit or ureter, or a filling defect, a CTU may be able to characterise it with more specificity than a loopogram can.
- A loopogram, on the other hand, allows a dynamic component to the evaluation of the ileal conduit. A narrowing can be mildly stressed with pressure from contrast and one can watch if the narrowing is fixed and over what length. The rate of opacification (and voiding) also offers diagnostic information, as seen in this case.
- Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rID: 39757
What are 6 common renal transplant complications?
Common Transplant Complications
- ATN
- Rejection
- Cyclosporine toxicity
- Arterial or venous occlusion
- Urinary leak
- Urinary obstruction
7 Essential things to cover in a CT Report For Renal Transplant Donor evaluation.
Renal Transplant Donor Evaluation
Transplant donor evaluation is most commonly done by CT or MRI and involves the following steps:
- Location of kidneys. It is important that both kidneys are located in their normal retroperitoneal locations. Pelvic and horseshoe kidneys are associated with complex anomalous vascular and collecting systems, making them difficult to use for transplantation.
-
The presence of solid and complex cystic renal masses must be excluded.
- The contralateral kidney should be evaluated in the donor to exclude any neoplasm.
-
Number of renal arteries supplying the kidneys.
- Transplant surgeons prefer single arterial anastomosis in the recipient;
- the presence of multiple renal arteries increases the donor organ warm ischemia time and also increases the complexity of the operation.
-
Left renal arteries that branch within 2 cm of the aorta
- are difficult to transplant because there is not a sufficient length of the main trunk for clamping and anastomosis in the recipient.
-
Accessory renal arteries to the lower pole of the kidneys must be identified.
- These arteries may supply the renal pelvis and proximal ureter;
- accidental injury to this vessel can predispose to ureteral ischemia and possible compromise of ureteral anastomosis.
- Aberrant renal venous anatomy.
- Collecting system anomalies (duplication).
Ovarian Vein Syndrome
Ureteral notching (vascular impression), dilatation, or obstruction as a result of ovarian vein thrombosis or varices.
Usually associated with pregnancy.
Normally the right gonadal vein crosses the ureter to drain into the IVC and the left gonadal vein drains into the left renal vein.
The ovarian vein crosses the ureter obliquely in the retroperitoneum at the L3 level and normally does not cause ureteral compres- sion.
The term ovarian vein syndrome refers to ob- structive uropathy, which is right sided in about 95% of cases and is thought to be due to ureteral compression at the pelvic brim by a dilated, aber- rant, or thrombosed ovarian vein.
OVS is uncom- mon in nulliparous women and generally occurs during or after pregnancy.
Figure 23. Proximal ureteral compression in a 57-year-old woman with left-sided ab- dominal pain, a sensation of flank fullness, and hematuria. Coronal reformatted (a) and 3D VR (b) images from a CT urographic study show mild proximal left hydroureter (ar- rowhead in b) and hydronephrosis, findings that are the result of extrinsic compression by a crossing left ovarian vein (arrow in a).
https://pubs.rsna.org/doi/pdf/10.1148/rg.341125010
Eosinophilic cystitis: severe allergic reactions
- Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 19555
- Eosinophilic Cystitis
- Eosinophilic cystitis is a very rare disease in which a type of white blood cell, the eosinophil, causes injury and inflammation to the bladder.
- Eosinophilic cystitis is reported to be more common in males, and may affect both adults and children.
- Symptoms:
- Painful urination
- Blood in the urine
- Feeling the need to urinate frequently
- Pain in the lower abdomen
- Urinary tract infections
- Associated Diseases:
- Environmental allergies
- Asthma
- ?food allergies
- Causes:
- Medication reaction (antibiotics, chemotherapy)
- Allergies
- Diagnosis:
- Urine sample for analysis
- Ultrasound of the bladder
- Eosinophils may be found in the blood and/or urine (not always present)
- Biopsy of the bladder is necessary to make the diagnosis. Biopsy is done during a cystoscopy.
- Findings:
- Ultrasound may show thickening or a mass in the bladder
- Biopsy:
- Eosinophils invading the bladder wall. Biopsy may show chronic inflammation.
- Eosinophils should be carefully sought when chronic inflammation is seen.
- Allergy Testing
- Allergy testing may be helpful in patients with other allergic diseases to identify and remove offending allergens.
- Treatment:
- Anti-inflammatory
- Anti-histamines
- Steroids
- Avoid known allergens or triggers
- Prognosis:
- May resolve with treatment
- Recurrent episodes can occur.
- Untreated episodes may cause scar tissue to form in the bladder and cause problems with bladder function.
- Author:
- Wendy Book MD, updated 8-30-11, reviewed by Dr. Stephen Kramer MD (Mayo Clinic, pediatric urology)
- https://apfed.org/about-ead/eosinophilic-cystitis/
What is this?
Cystitis cystica
https://www.liebertpub.com/doi/10.1089/cren.2017.0010
Ureteral Diverticulum ( Fig. 4.17 )
Congenital blind-ending ureter. Probably caused by aborted attempt at duplication.
https://radiologykey.com/diagnostics-of-ureteral-diverticula/
What are the causes of renal infarcts?
Causes
- Trauma to renal vessels
- Embolism
- Cardiac causes
- atrial fibrillation
- endocarditis
- Catheter
- Cardiac causes
- Thrombosis
- Arterial
- Venous
SIGN
What are the imaging features of bladder outlet obstruction?
What is this sign?
- Imaging Features ( Fig. 4.20 )
- Distended bladder with incomplete emptying
- (postvoid residual);
- best seen by US or IVP
- trabeculae and diverticula
- Enlarged prostate:
- Rounded central filling defect at base of bladder
- Hooking of ureters with massively enlarged prostate on IVP
- Upper urinary tract changes:
- Reflux
- Dilated ureter
- Distended bladder with incomplete emptying
Fishhook ureters, also known as J-shaped ureters or hockey stick ureters describe the appearance of the distal ureter in patients with significant benign prostatic hypertrophy. It has also been used to describe the appearance of a retrocaval ureter in type 1 or low loop variety. As the right ureter hooks behind the IVC, it has also been referred to as an S-shaped ureter.
Prostatic hypertrophy results in elevation of the bladder floor and distortion of the distal ureter, giving it a fishhook appearance.
Original photo of inset fishing hook taken by Mike Cline (available through Wikipedia.org)
https://radiopaedia.org/articles/fishhook-ureters
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 2612
RVT in an Infant (prem new born)
FIG. Ia and b.-Inferior vena cavagram revealing obliteration of IVC, with collateral flow through the azygos veins.
https://adc.bmj.com/content/archdischild/40/210/214.full.pdf
Case1. A whitemaleinfantweighing2,150g.was born prematurely on August 17, 1959 to an 18-year-old toxaemicprimipara. Urinepassedonthefirstdaywas brick red in colour, and tetany-like tremors of the upper extremities were observed. General condition was consideredonlyfair. Alarge,smoothglobularmasswas feltintherightupperquadrant. Serumelectrolytes,includingcalcium,werenormal. Bloodureanitrogen (BUN)was45mg./100ml.,amoderateleucocytosisexistedandurinalysisshowedhaematuria. Bloodculture wasnegative. Intravenousurogramshowedanormalfunctioningleftkidneybutnovisualizationoftheright. Pre-operativediagnosiswaspolycystickidney.
At operation on August 24, the right kidney was three timesnormalsize,andred-brownincolouraswasthe rightadrenal. Theleftkidneywasofnormalsizeand consistency. Therightkidneyandadrenalwereremoved, the right renal vein being filed with a thrombus that involvedtheentireinferiorvenacavabelowtherenal vein. Thesuprarenalsegmentoftheinferiorvenacava wasfreeofthrombosisanddilated.Noattemptwas madetoremovethethrombusfromthevenacavaandnoligationofthevenacavawascarriedout.
After operation the child was treated with heparin.
READ PICTURE
andafollow-upfiveyearslatershowedanormalchild withoutevidenceofabnormalrenalfunction.
What is congenital weakness of muscles near the VUJ called?
What is it a/w?
- Hutch diverticulum:
- congenital weakness of musculature near UVJ
- Usually associated with reflux
https://www.urologyhealth.org/urology-a-z/b/bladder-diverticulum
SIGN
What sign Sign is this?
What does it signify?
Figure 42. Coiled catheter sign. (a) On a retrograde ureteropyelogram, persistent coiling of a guide wire was seen in the distal ureter during an attempt at retrograde stent placement. (b) Retrograde ureteropyelogram demonstrates dilatation of the ureter (arrow) below a site of complete ureteral obstruction caused by transitional cell carcinoma.
https://www.semanticscholar.org/paper/URORADIOLOGIC-SIGNS-S-247-Classic-Signs-in-1-CME-Dyer-Chen/62a3b8a1440bed14d6f2c581d2ed3b46e9fe1ff2/figure/25
3 causes of this condition:
- Vesicorectal/enteric fistula:
- diverticular disease (most common cause),
- Crohn disease,
- cancer
- Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 21274
- This case was 2ndary to rectal ca
What are 4 causes of perirenal fluid collections in Renal transplants?
What is the time course for each?
4 causes of perirenal fluid collections in Renal transplants
-
Lymphocele:
- in 10%–20% of transplants at 1–4 months posttransplant.
- Usually inferomedial to kidney;
- linear septations are detectable in 80%.
- Most lymphoceles are inconsequential;
- if large and symptomatic or obstructing,
- percutaneous sclerosis with tetracycline or povidone-iodine may be tried.
-
Abscess:
- develops within weeks;
- complex fluid collection;
- fever
-
Urinoma:
- develops during first month;
- near UVJ;
- may be “cold” on nuclear medicine study if leak is not active at time of examination;
- may be associated with hydronephrosis
-
Hematoma:
- immediate postoperative period;
- hyperechoic by US;
- pain,
- hematocrit drop
http://www.learningradiology.com/lectures/facultylectures/US%20Renal%20Transplantation%20HTML5/US%20Renal%20Transplantation/US%20Renal%20Transplantation.html
Path
What is the histology of this?
Urachal adenocarcinoma
Histologically, this tumor is classified as:
- Adenocarcinoma, 90%
- SCC, TCC, sarcoma
Case Discussion
Primary adenocarcinoma of the bladder is rare. Although it is most classically associated with bladder exstrophy and patent urachus, two-thirds of cases are non-urachal (favouring the bladder base) and only one-third urachal. Risk factors include chronic mucosal irritation and urinary diversions. Patients can present with haematuria, irritative symptoms, mucus in the urine, or umbilical discharge.
Most cases of urachal adenocarcinoma occur near the bladder, with the remainder along the course of the urachus. These are distinguished by the prominent extravesicular components of the mass and often contain calcifications. They are typically large at presentation (mean 6 cm), high grade, and have diffusely invaded the bladder wall at diagnosis. Extravesicular spread and metastases are common.
Due to the location, urachal adenocarcinoma usually presents late and has a poor prognosis. Aggressive surgical excision is often performed including the posterior rectus fascia, peritoneum, and abdominal wall. In this case of pathology-proven adenocarcinoma, the patient was treated with partial cystectomy instead of more aggressive surgery, due to the small size and lack of invasion of adjacent structures.
Squamous cell and urothelial carcinoma can also occur in the urachus, but less frequently than adenocarcinoma. Metastatic adenocarcinoma to the bladder is more common than primary disease, and typically a late manifestation of cancer.
Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 57372
https://radiopaedia.org/cases/urachal-adenocarcinoma
Does this lead to malignancy?
What decade does it occur?
What is the condition related to?
Bilateral or Unilateral?
Pyeloureteritis Cystica ( Fig. 4.16 A )
- Asymptomatic ureteral and/or pyelocalyceal cysts 2–4 mm in diameter (may be up to 2 cm), usually related to infection or calculi.
- Radiographically, there are multiple small intraluminal filling defects (cysts originate from degenerated uroepithelial cells).
- Most common in 6th decade, usually unilateral.
- Female
- Diabetics
- recurrent UTIs
- May resolve with treatment of underlying infection or remain unchanged for months or years.
- Not a premalignant condition.
Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 25166
What is this?
Loopogram
- Insert 18- to 24-Fr Foley catheter with 5-mL balloon inflated in conduit.
- Administer 30–50 mL of 30% water-soluble contrast by gravity (<40 cm H 2 O). Reflux in an ileal loop is a normal finding.
- Search for drainage, stasis, stenosis, extravasation, calculi, or tumor.
Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 38261
5 top causes of Neurogenic Bladder
Epidemiology
In a large cohort study, the mean age of neurogenic bladder patients was 62.5 years.
Aetiologies included 4:
- Multiple sclerosis: ~17%
- Parkinson disease: ~15%
- Cauda equina syndrome: ~9%
- Paralytic syndrome: ~8%
- Stroke complications: ~6%
Clinical Presentation
Depending on the location of the injury in the nervous system, patients typically present with increased frequency, nocturia, urinary incontinence/urgency, urinary tract infection and urinary retention.
The bladder may be hyperreflexic, hyporeflexic or areflexic with impaired to no sensation 3.
Case Discussion
Multimodality appearances of a neurogenic bladder. The bladder becomes elongated as opposed to its normal ‘ball-like’ appearance, with an apex in the cranial direction. In addition the bladder wall becomes trabeculated - the combined appearances give the distinct Aunt Minnie appearance of a Christmas tree bladder.
In this case a number of other interesting additional findings are present:
- left sided undescended testis
- chronic right hydronephrosis
- iatrogenic abnormality of a urethral catheter balloon inflated in the posterior urethra - this may be possible depending on the patient’s neurogenic status. Inflate a balloon in the posterior urethra beyond 2-3 mL in a normal patient and they/you will know it!
Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 29058
https://radiopaedia.org/articles/neurogenic-bladder
Vesico-uterine fistula
Renal excretory phase CT images show a connection between the superior surface of bladder and the post-gravid uterus, which can be better seen on reformatted sagittal and coronal images. The distal end of urinary catheter is located just below the fistula. Small amount of fluid in pelvis.
Case Discussion
Vesico-uterine fistula is a rare complication of Caesarean section due to a transverse incision into the lower segment. The symptoms are menouria and urinary incontinence.
Excretory phase CT images show a fistulous tract between the uterus and bladder, indicating a vesico-uterine fistula.
Case courtesy of Dr Dario Giambelluca, Radiopaedia.org, rID: 48834
Cystitis glandularis is a proliferative disorder of the urinary bladder in which there is glandular metaplasia of the transitional cells lining the urinary bladder. This entity is closely related to cystitis cystica, with which it commonly co-exists. It is a relatively common chronic reactive inflammatory disorders that occur in the setting of chronic irritation of the bladder mucosa, often identified on biopsies and cystectomies. It usually occurs in the trigone of the urinary bladder.
Case courtesy of Dr Imran Ahmad Khan, Radiopaedia.org, rID: 66765
What is this?
What is the sign?
Retrocaval Ureter
- Ureter passes behind IVC and exits between aorta and IVC.
- Medial looping at L2-L3 level is seen on IVP.
- May result in ureteral narrowing and obstruction.
- The “fish hook” sign of retrocaval ureter
- https://link.springer.com/article/10.1007/s00261-017-1248-7
Who is this seen in?
How does it form?
What is the mineral?
Bladder Calculi
Usually seen in patients with bladder outlet obstruction. Calculi usually form around a foreign body nidus (catheter, surgical clip). Calcium oxalate stones may have an irregular border (mulberry stones) or spiculated appearance (jack stones).
https://casereports.bmj.com/content/2010/bcr.06.2009.1978
What is a colon conduit?
What is done to avoid reflux?
Colon Conduit
Ureter(s) drain into isolated colon segment. Ureters are tunneled submucosally for antireflux.
SIGN
What sign is this?
What does it signify?
Goblet Sign.
Blue arrow points to “Goblet” or “Champagne glass sign” of ureteral dilatation distal to a filling defect in the right ureter which allows for differentiation from a calculus impacted in the ureter, which causes distal spasm and narrowing
http://learningradiology.com/archives2009/COW%20380-Goblet%20Sign/gobletcorrect.htm
What is the most common cause of acute REVERSIBLE renal failure in transplant patients?
Acute Tubular Necrosis
Most common form of acute, reversible renal failure in transplant patients, usually seen within 24 hours
https://radiologykey.com/116-acute-tubular-necrosis/
Technique
- Inject 10 mCi of 99mTc-MAG-3 with a tight intravenous bolus. 99mTc-DTPA (10–20mCi) can also be used.
- Use a low-energy, medium-resolution collimator.
- Image native kidneys in the posterior view and pelvic transplant kidneys in the anterior view.
- Image for the first minute with 1- to 2-second frames. Then image for 2 to 30 minutes with 30- to 60-second frames. A 5-minute static image at the end may help to demonstrate ureteral uptake.
- A 1mg/kg (max 40 mg) dose of furosemide can be administered if the initial set of images suggests obstruction. Image another 20 to 30 minutes after the furosemide injection, and compute the final residual activity in the collecting system (renal pelvis ± ureter) plus the half-time of emptying (see Case 115).
Image Interpretation
Anterior dynamic images (Fig. 116.1) obtained on postoperative day 2 show prompt perfusion of the transplant kidney in the left iliac fossa. This key finding excludes arterial thrombosis as a cause of the patient’s anuria. There is good cortical uptake, with at most a slight lack of homogeneity, and blood pool activity visibly decreases as tracer is concentrated in the kidney. However, no activity is seen in the renal pelvis, ureter, or bladder, either on the dynamic images or on a 5-minute static image taken after 30 minutes (Fig. 116.2). The time–activity curve (Fig. 116.3) shows steadily increasing uptake, which does not maximize until the end of the study.
Anterior dynamic images taken from a repeated study 3 weeks later (Fig. 116.4) show good cortical uptake, with only slight clearance from the transplant kidney toward the end of the study. A modest amount of activity is seen in the bladder, indicating that urinary excretion is now taking place. This is confirmed on pre- and post-voiding 5-minute static images taken after 30 minutes (Fig. 116.5). Note the presence of a small amount of uptake in a remaining native kidney in the right upper quadrant.
Differential Diagnosis
- Acute tubular necrosis
- Acute rejection
- Cyclosporin A toxicity
- Acute interstitial nephritis
Diagnosis and Clinical Follow-Up
The diagnosis was acute tubular necrosis, with partial resolution between the initial and follow-up studies. The serum creatinine was 3.97 mg/dL on the day of imaging. One week later, it had risen to 9.71 mg/dL. Three weeks later, at the time of the second renogram, it had normalized to 1.58 mg/dL. No hemodialysis or renal biopsy was performed. Only routine clinical follow-up was needed afterward.
Discussion
Acute tubular necrosis, also known as vasomotor nephropathy, is a form of acute renal failure. It can be seen (1) in the setting of ischemia or hypovolemia caused by cardiac arrest, major surgery, trauma, or burns; (2) as the consequence of intrarenal vasoconstriction induced by radiographic contrast agents or cyclosporin A; and (3) as a direct toxic effect of drugs such as aminoglycosides, amphotericin B, cisplatin, carboplatin, and ifosfamide, as well as endogenous toxins such as myoglobin, hemoglobin, and myeloma light chains. Once the inciting cause is corrected, renal function will typically remain low for 1 to 2 weeks, followed by a gradual spontaneous recovery. Treatment is therefore mainly supportive. However, it is essential to accurately distinguish acute tubular necrosis from other causes of acute failure, such as transplant rejection, glomerulonephritis, and vascular thrombosis, which may require more aggressive therapy.
In a transplanted kidney, acute tubular necrosis can be impossible to distinguish from acute rejection or cyclosporin A toxicity on scintigraphic appearance alone. All of these show delayed uptake and markedly delayed clearance from the renal cortex. Various indices have been proposed to aid in making the differential diagnosis, such as the effective renal plasma flow (ERPF) and excretory index (Table 116.1).
However, none of these indices is in wide use, and the differential diagnosis ultimately rests on clinical criteria. Acute tubular necrosis and acute rejection both commonly occur in the early postoperative period. Acute tubular necrosis will typically show a stable or improving pattern on repeated scans, correlating with a rise in urinary volume. Acute rejection may show a worsening pattern if inadequately treated. Cyclosporin A toxicity is usually manifested several months after surgery.
What is this?
How often does it calcify?
What age does it occur?
Prognosis?
Where does it arise from?
Urachal Carcinoma
- Rare tumor
- 0.4% of bladder cancers,
- 40% of bladder adenocarcinomas
- arising from urachus
- fibrous band extending from bladder dome to umbilicus;
- remnant of allantois and cloaca
- Tumors are usually located anterior and superior to dome of bladder in midline (90%).
- In contradistinction to bladder tumors, calcifications occur in 70%.
- Seventy percent occur before the age of 20.
- Prognosis is poor.
Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 20977
https://radiopaedia.org/cases/urachal-adenocarcinoma
How many RADs results in this?
What %?
Radiation cystitis occurs in 15% of patients receiving 6500 rad for pelvic malignancies.
https://www.eurorad.org/case/9228
What are 8 imaging features of Renal Transplant rejection?
Rejection
- Increased renal size, 90% (in chronic rejection, size is decreased)
- Thickened cortex may be hypoechoic or hyperechoic
- Large renal pyramids, edematous uroepithelium
- Indistinct corticomedullary junction
- Focal hypoechoic areas in cortex and/or medulla, 20%
- Increased cortical echogenicity, 15%
- Decrease or complete absence of central echo complex echogenicity
- Resistive index >0.7 by Doppler US; nonspecific
What are the predisposing factors to this condition?
What organism is responsible usually?
Emphysematous Cystitis
- Infection (most commonly E. coli) that causes gas within the bladder and bladder wall.
- Conservative management unless there is coexisting emphysematous pyelonephritis.
- Predisposing diseases include:
- DM (most common)
-
Long-standing urinary obstruction
- (neurogenic bladder,
- diverticulum
- outlet obstruction)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840514/
what is the underlying cause of this?
Schistosomiasis (Bilharziosis)
- Caused by Schistosoma haematobium (S. japonicum and S. mansoni affect gastrointestinal [GI] tract).
- Infected humans excrete eggs in urinary tract; eggs become trapped in mucosa and cause a severe granulomatous reaction.
-
Case discussion:
- Urinary bladder wall calcification and right-sided ureteric calculi.
- Status post ureteric stent implantation.
- Irregular cortical thinning, calcifications, and asymmetric pelvicalyceal dilatation in the right kidney.
- Note that the left distal ureter also displays dilatation and inhomogeneous wall calcifications.
- Urinary bladder wall calcification, ureteric, and renal involvement in a patient with schistosoma haematobium infection.
Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 10537
What are the features of a normal renal transplant
Normal Renal Transplant
- Morphology of normal transplanted kidney:
- Well-defined kidney, elliptical contour (i.e., not enlarged)
- CMD should be present but may not always be very well defined.
- Cortical echogenicity should be similar to liver echogenicity.
- The central echo complex should be well defined.
Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org, rID: 15865
What are Michaelis-Gutmann bodies seen in?
Malacoplakia
Rare inflammatory condition that most commonly affects the bladder.
Yellow-brown subepithelial plaques consist of mononuclear histiocytes that contain Michaelis-Gutmann bodies.
On IVP, multiple mural filling defects with flat or convex border are seen, giving a cobblestone appearance.
Obstruction is a rare complication.
Malacoplakia is an uncommon chronic granulomatous inflammatory disease that can affect essentially any part of the body but most frequently involves the bladder wall.
Epidemiology
Malacoplakia has a peak incidence in middle age and has a reported female-to-male ratio of 4:1 1. Other risk factors include immunosuppression, AIDS and diabetes mellitus.
Clinical presentation
Presenting symptoms depend on the region involved.
In the most common setting, when the bladder is the site of diseases, patients present with gross haematuria, lower urinary tract symptoms and recurrent urinary tract infection (most commonly with Escherichia coli ). Papules, plaques and ulceration on direct visualisation during flexible cystoscopy have been described 5.
Pathology
In the urinary system, although infection with E. coli is very often observed, impaired host bactericidal defences and defective phagocytosis are considered an important part of the pathogenesis 1.
Histology
Von Hansemann cells (ovoid histiocytes) which contain calcific Michaelis-Gutmann bodies are a histologic hallmark which are pathognomonic for this diagnosis 2,5. Identification may require special stains.
Location
The urinary bladder is the most frequently affected organ (40% of patients with malacoplakia).
Radiographic features
Imaging characteristics of malacoplakia are varied and depend on the region involved.
Urinary system
Malacoplakia is most commonly observed within the bladder, although plaques may also occur in the ureters.
It may present as multiple, polypoid, vascular, solid masses or as circumferential wall thickening, associated with vesicoureteral reflux and dilatation of the upper urinary tract. These masses vary in size from a few millimetres to several centimetres. Occasionally, malacoplakia can be locally aggressive and invades surrounding structures even causing bone erosions 1.
Treatment and prognosis
Although malacoplakia may be extremely aggressive, invading the adjacent spaces and even causing bone destruction, non-surgical medical management is the mainstay of treatment. As such, biopsy for accurate diagnosis is essential.
Treatment of urinary involvement usually includes antibiotics, ascorbic acid, and a cholinergic agonist 1.
Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 83974
https://www.pathologyoutlines.com/topic/bladdermalakoplakia.html
Last revised by Dr Michael P Hartung◉ on 26 Nov 2020
https://radiopaedia.org/articles/malacoplakia-1
Renal Infarcts
what are the 3 types?
Renal infarcts may be focal and wedge shaped or larger, involving the anterior or posterior kidney or entire kidney. CECT or IVP may show thin, enhancing rim from capsular arteries.
What is it?
Complications?
Epidemiology?
- Ureteral Pseudodiverticulosis ( Fig. 4.16 B )
- Outpouchings of 1–2 mm produced by outward proliferation of epithelium into lamina propria. Associated with inflammation.
- Fifty percent eventually develop a uroepithelial malignancy.
- Path
- Ureteral pseudodiverticulosis are acquired false diverticula resulting from herniation of epithelium through the muscularis layer of the ureter and characterized by the presence of multiple outpouchings smaller than 5 mm.
- It is sometimes bilateral
- and is often located in the upper two-thirds of the ureter.
- Ureteral pseudodiverticulosis are acquired false diverticula resulting from herniation of epithelium through the muscularis layer of the ureter and characterized by the presence of multiple outpouchings smaller than 5 mm.
- Epidemiology
- The prevalence is relatively uncommon.
- It is most often seen in men between 40-60 years old.
- Clinical presentation
- Most patients are asymptomatic, but it may be seen in patients with a history of chronic urinary tract infection or hematuria.
- Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rID: 44101
Case Discussion
This case demonstrates typical appearance of vesicocutaneous fistula that was initially suspected on routine CT and CT cystogram, subsequently confirmed on MRI pelvis. In addition, patient had bladder neck/proximal urethral calculus as well as osteomyelitis of pubic bones with pubic symphysis septic joint.
Initial CT with IV contrast demonstrated bladder wall thickening with inflammatory stranding in the retropubic space. The inflammatory changes extended into the suprapubic soft tissues suggestive of phlegmon and cellulitis as well as raising the possibility of vesico-cutaneous fistula. In addition, a 10 mm calculus was also noted in the bladder neck/proximal urethra. A CT cystogram was requested by Urology to confirm the presence of fistula.
CT cystogram demonstrated contrast extravasation along the anterior aspect of the bladder/prostatic urethra, extending through the pubic symphysis into the suprapubic soft tissues. These findings were suggestive of a fistula in the bladder or the proximal urethra. The urethral stone was dislodged back into the bladder during placement of Foley catheter. Erosive changes were also noted in the pubic symphysis, suggestive of possible osteomyelitis.
Case courtesy of Dr Irfan Masood, Radiopaedia.org, rID: 71684
What drug causes this?
In what %?
Cyclophosphamide treatment results in hemorrhagic cystitis in 40% of patients.
Case courtesy of Dr Chris O’Donnell, Radiopaedia.org, rID: 29842
What are 6 benign Bladder tumours?
Benign Bladder Tumors
-
Primary leiomyoma
- (most common);
- ulcerated leiomyomas may cause hematuria.
-
Hemangioma
- associated with cutaneous hemangiomas
- Neurofibromatosis
- Nephrogenic adenoma
- Endometriosis
- Pheochromocytoma
https://bmcurol.biomedcentral.com/articles/10.1186/s12894-020-00722-2
How are the two types of bladder injury treated?
- Intraperitoneal rupture
- treated surgically
- extraperitoneal rupture
- is treated conservatively with Foley catheter
- https://i1.wp.com/medicoapps.org/wp-content/uploads/2019/07/med_extraperitoneal.jpg?w=1020&ssl=1
- https://www.slideshare.net/dhanushanand2011/bladder-injury-by-dhanush
