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Radiology > GU > Flashcards

GU Flashcards

1
Q

Helpful videos

A

PCKD
https://www.youtube.com/watch?v=JmFpL3WLTAM

CKD
https://www.youtube.com/watch?v=fv53QZRk4hs

HYDRONEPHROSIS
https://www.youtube.com/watch?v=mi7XtyHwVHk

AKI
https://www.youtube.com/watch?v=ISFEgK8sfb8

ACUTE PYELONEPHRITIS
https://www.youtube.com/watch?v=VXFRWFHx6tA

IGA NEPHROPATHY
https://www.youtube.com/watch?v=TvSdcqZLdbk

TESTICULAR CANCER
https://www.youtube.com/watch?v=EcvfE9q7Xbg

FSGS
https://www.youtube.com/watch?v=qNuGqvDdVko

RENAL TUBULE ACIDOSIS
https://www.youtube.com/watch?v=b82-FFxW4nA

RCC
https://www.youtube.com/watch?v=gmg1p2whtto

GLOMERULAR DISEASES
https://www.youtube.com/watch?v=2l059-1Fs2k

GENETIC DISORDERS KIDNEY
https://www.youtube.com/watch?v=pM1CdhkpwC0

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2
Q

Variant renal anatomy

A

LOBULATION
Renal surface indentations overlie space between pyramids

SCARRING
Renal surface indentaitons overlie medullary pyramids

DROMEDARY HUMP
Focal bulge on left kidney from spleen

PROMINENT COLUMN OF BERTIN
Hypertrophied cortical tissue located between pyramids results in splaying of sinus. Otherwise looks totally normal

RENAL AGENESIS
Congenital absence of one or both kidneys. If unilateral asymptomatic but think about gynae anomalies 70% will have unicornuate. In men 20% with renal agenesis have absence ipsilateral epididymis and vas deferens or ipsilateral seminal vesicle cyst
Potter sequence = insult - kidneys dont form - cant make urine - lungs dont develop.
Mayer-Rokitansky-Kuster-Hauser = mullerin duct anomalies including absence or atresia of uterus. Associated with unilateral renal agenesis
Pancake adrenal = flat when absent kidney. Used to differentiate surgically vs congenitally absent kidney

HORESHOE and CROSSFUSED RENAL ECTOPIA
Discussed in paeds

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3
Q

Renal contrast phases

A

NONCON

CORTICOMEDULLARY or ANGIONEPHROGENIC PHASE
25-40 seconds
Contrast in vascular system. Cortex is enhanced, medulla is not. Characterizes renal tumour enhancement relative to cortex. Evaluate renal artery and vein. Good for tumour invasion to vessels.

NEPHROGENIC PHASE
70-180 seconds
Contrast filtered. Uniform enhancement of cortex and medulla. Detect renal tumours, especially central tumuours.

EXCRETORY PHASE
180 sec - 8 mins
Contrast excreted into collecting system. Progressive decrease in nephrogram. Evaluate morphology of papilla and for urothelial lesions.

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4
Q

Renal cell carcinoma

A

Most common primary renal malignancy. Enhances. Calcification in fatty mass. Hypervascular mets, lytic to bone.

RF: tobacco, syndromes like VHL, chronic dialysis, family history.

CLEAR CELL
Most common. Associated with VHL. More aggressive. Cystic mass with enhancing components.

PAPILLARY
Second most common. Less aggressive, Less vascular. T2 dark (along with lipid poor AML and haemorrhagic cyst). Transplanted kidney more at risk.

MEDULLARY
Associated with sickle cell trait. Highly aggressive. Large and met at time of diagnosis. Younger px.

CHROMOPHOBE
Associated with Birt Hogg Dube

TRANSLOCATION
Most common in kids. History of cytotoxic chemotherapy is classic.

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5
Q

RCC staging

A

STAGE 1
Limited to kidney and <7cm

STAGE 2
Limited to kidney and >7cm

STAGE 3
Still inside Gerotas fascia.
A - renal vein invaded
B - IVC below diaphragm
C - IVC above diaphragm

STAGE 4
Beyond Gerotas fascia
Ipsilateral adrenal

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6
Q

Renal lymphoma

A

Can look like anything. Most commonly bilaterally enlarged kidneys with small low attenuation cortically based solid nodules or masses. ‘infiltrative soft tissue in renal hilum’. Lymphoma is most common metastatic tumour to invade the kidneys

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7
Q

Renal leukemia

A

Kidney is most common visceral organ involved. Tyically smooth and enlarged kidneys. Hypodense lesions cortically based only.

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8
Q

Angiomyolipoma

A

Most common benign tumour of kidney. 95% have macroscopic at. Usually incidental.

Associated with tuberous sclerosis. (Bourneville disease)
Risk of bleeding when >4cm
Should never have calcs - think RCC
Can be lipid poor and T2 dark

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9
Q

Oncocytoma

A

Second most common benign tumour. Looks like RCC but has central scar 33%. No vessel infiltration or other malignant features. Cannot be distinguished from RCC on imaging. ‘spoke wheel’ vascular pattern. Hotter than surrounding cortex on PET (RCC is colder).

Birt Hogge Dube gets bilateral oncocytomas

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10
Q

Multilocular cystic nephroma

A

Non-communicating fluid filled locules, surrounded by thick fibrous capsule. Characterised by absence of solid component or necrosis. Buzzword ‘protrudes into renal pelvis’.

Bimodal occurrence 4yo boys, 40yo women (MJ lesion)

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11
Q

Retroperitoneum

A

YES
lower esophagus, most duodenum, asc/desc colon, kidneys, ureters, adrenals, panc minus tail, aorta, IVC, upper 2/3 rectum

NO
Panc tail
lower 1/3 rectum
transverse colon

75% primary retroperitoneal neoplasms are malignant

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12
Q

Retroperitoneal lipomatosis

A

Classic is incomplete bladder emptying in fat person. Overgrowth of benign fat in pelvis, classically perirectal and perivesicular spaces. Bladder displaced anterior and superior ‘pear shaped’ or inverted and tear drop shaped

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13
Q

Retroperitoneal liposarcoma

A

Most common primary malignant RP in adults.

High rate of local recurrence, endless surveillance studies. The deeper a fat containing lesion is the more likely it is to be malignant. Complex features add to malignant potential and likelihood to metastatsize (calcs, solid components, not saturating out on fatsat). Looks like a huge AML with calcs but not in the kidney

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14
Q

Retroperitoneal rhabdomyosarcoma

A

Most common soft tissue sarcoma in children. Think about this when seeing soft tissue mass in kid.

1/2 in neck, 1/4 in pelvis around bladder or testicles.

Heterogenous, enhancing, maybe destroying nearby bone.

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15
Q

Retroperitoneal extra-medullary haematopoiesis

A

Abnormal deposits of haematopoetic tissue outside of bone marrow. Non specific appearance, soft tissue in paravertebral region.

Must tell you patient has haemoglobinopathy, myelofibrosis or leukemia

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16
Q

Retroperitoneal lymphoma

A

Most common RP malignancy. Lots of big nodes or conglomerate soft tissue nodal mass.

NHL nodes larger, non continuous and involve mesentery
HL nodes more likely to involve para-aortic regions early and be more continuous

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17
Q

Retroperitoneal haemorrhage

A

Most commonly from over anticoagulation. 2nd most common from rupture/leaking aorta. 3rd most common bleeding RCC or AML

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18
Q

Mantle like soft tissue mass around Aorta/IVC

A

LYMPHOMA
Displaces aorta forward and can be seen above renal arteries. Pushes/envelopes rather than obstruct.

RP FIBROSIS
Can be hot on PET. Does not usually displace the aorta forward. Uncommon above renal arteries and tends to tether and obstruct.

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19
Q

Bosniak classification

A

CLASS 1
Simple, <15HU with no enhancement

CLASS 2
Hyperdense <3cm. Thin calcs, thin septations

CLASS 2F
Hyperdense >3cm. Minimally thickened calcs (5% chance cancer)

CLASS 3
Thick septations, mural nodule (50% chance cancer)

CLASS 4
Any enhancement >15HU

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20
Q

Hyperdense cysts

A

If mass >70HU and homoenous its benign (haemorrhagic or proteinaceous cyst) 99.9% time

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21
Q

Autosomal Dominant Polycystic Kidney Disease ADPKD

A

Kidneys get progressively larger and lose function (dialysis in 40s). Hyperdense and calcs often seen due to prior haemorrhage.
Autosome Dominant - Adult
Get cysts in liver 70%
Seminal vesicle cysts 60%
Berry aneurysms
No intrinsic risk of cancer but do once theyre on dialysis

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22
Q

Autosomal Recessive Polycystic Kidney Disease ARPKD

A

Get HTN and renal failure
Liver involvement is diff to adult form, instead of cysts they get abnormal bile ducts and fibrosis.
Congenital hepatic fibrosis is always present in APKD.
ratio of kidney and liver disease is inversely related.
Smoothly enlarged and echogenic kidneys with loss of corticomedullary differentiation

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23
Q

Lithium nephropathy

A

Patients taking lithium long term. Can lead to diabetes insipidus and renal insufficiency. Kidneys norma to small with multiple tiny cysts 2-5mm. Probably on MRI with history of bipolar.

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24
Q

Uremic cystic kidney disease

A

40% patients with end stage renal disease get cysts. Rises with duration of dialysis and in 90% people 5 years after dialysis. 3-6x increased risk of cancer with dialysis. Cysts will regress after renal transplant.

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25
Q

Von Hippel Lindau

A

Autosomal dominant multisystem disorder.
50-75% have renal cysts. 25-50% develop clear cell RCC.
Pancreas: cysts, serous microcystic adenomas, neuroendocrine tumour
Adrenal: Pheochromocytoma
CNS: Hemangioblastoma of cerebellum, brain stem and spinal cord
Urogenital: Epididymal cysts, cystadenomas

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26
Q

Tuberous sclerosis

A

Autosomal dominant multisystem disorder
Hamartomas everywhere (brain lung heart skin kidneys)
Multiple bilateral AMLs
Renal cysts and occasional RCC
Lung: LAM thin walled cysts and chylothorax
Cardiac: rhabdomyosarcoma
Brain: Giant cell astrocytoma (SEGA), cortical and subcortical tubers, subependymal nodules
Renal: AMLs, RCC in younger patient

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27
Q

T2 dark renal cyst

A

Cysts are meant to be T2 bright.

LIPID POOR AL
Think tuberous sclerosis, 30% of their AMLs are lipid poor

HAEMORRHAGIC CYST
T1 bright and T2 dark

PAPILLARY RCC
Clear cell is T2 hyperintense
Both clear cell and papillary will enhance

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28
Q

Multicystic dysplastic kidney

A

Paeds thing
Multiple tiny cysts forming in utero from some form of insult.
No functioning renal tissue - shown with MAG3 exam
Contralateral renal anomalies occur 50% (reflux and UPJ obstructions

MCDK vs hydro
In hydro, cystic spaces communicate

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29
Q

Peripelvic vs parapelvic cysts

A

PARAPELVIC
Originates from parenchyma, may compress collecting system. Looks like cortical cysts but bulge in instead of out.

PERIPELVIC
Originates from renal sinus, mimics hydro.

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30
Q

Pyelonephritis

A

Clinical diagnosis. Associated with stones. Most common organism is E.coli. Alternating bands of hypo and hyperattenuation (stirated nephrogram) Wedge shaped areas related to decreased perfusion

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31
Q

Striated nephrogram Ddx

A 
Acute ureteral obstruction
Acute pyelonephritis
Medullary sponge kidney
Acute renal vein thrombosis
Radiation nephritis
Acutely following renal contusion
Hypotension
Infantile polycystic kidney
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32
Q

Abscess

A

Pyelo may be complicated by abscess. Round or geographic low attenuation collections do not enhance centrally. >3cm may need drainage

33
Q

Chronic pyelonephritis

A

Renal scarring, atrophy and cortical thinning with hypertrophy of residual normal tissue.

34
Q

Emphysematous pyelonephritis

A

Life threatening necrotizing infection characterised by gas formation within or surrounding kidney. Diabetics get it. Echogenic foci with dirty shadowing on USS.

35
Q

Ephysematous pyelitis

A

Gass localized to collecting system. More common in women, diabetics and people with urinary obstruction.

36
Q

Pyonephrosis

A

Infected or obstructed collecting system from variety of causes; stones, tumour, sloughed papilla secondary to pyelonephritis. Need urgent nephrostomy

37
Q

Xanthogranulomatous Pyelonephritis (XGP)

A

Chronic destructive granulomatous process basically always seen with staghorn calculus acting as nidus for recurrent infection. Associated psoas abscess possible with minimal perirenal infection. ‘bear paw’ appearance on CT. Kidney non functional, sometimes get nephrectomy.

38
Q

Papillary necrosis

A

Ischemic necrosis of renal papillae involving pyramids. Diabetes most common but can be from pyelonephritis, sickle cell, TB, analgesic use and cirrhosis. Filling defects in calyces may be seen. Necrotic cavity in papillae with linear streaks of contrast inside calyx has been called lobster claw sign

39
Q

TB

A

Most common extra pulmonary site of infection is urinary tract. TB in kidneys similar to TB in lungs with prolonged latency.

Calyceal blunting or moth eaten calyces (look pointy).

Renal calcs common in TB. Punctate, curvilinear or replace whole kidney. ‘putty kidney’ is autonephrectomized end stage TB kidney. Multiple calcified mesenteric nodes can help you zero in on renal TB

40
Q

HIV nephropathy

A

Most common cause of renal impairment in AIDS CD4<200. Kidneys classically enlarged and echogenic.
Big and bright in HIV positive patient clinically in nephrotic syndrome.

Disseminated PCP in HIV patients can result in punctate calcs

41
Q

Contrast induced nephropathy CIN

A

Allergic reactions not considered a risk for CIN
Risk factors include pre-existing renal insufficiency, diabetes, cardiovascular disease with CHF, dehydration and myeloma

42
Q

Nephrolithiasis stone type

A

CALCIUM OXALATE
Most common 75%

STRUVITE STONE
More common in women, UTI

URIC ACID
Not seen on XRay. pH dependent can treat with medical therapy.

CYSTINE
Rare, metabolism disorder

INDINAVIR
HIV patients, only stones not seen on CT

43
Q

Cortical nephrocalcinosis

A

Usually sequale of cortical necrosis seen in acute drop in BP (shock, post partum, burns). Begins as hypodensity that later calcifies. Mimic is disseminated PCP or TB

44
Q

Medullary nephrocalcinosis

A

Hyperechoic renal papilla/pyramids which may or may not shadow

Hyperparathyroidism common
Medullary sponge kidney common
Lasix in kids
Renal tubular acidosis

MEDULLARY SPONGE
Congenital, usually asymmetric. Cystic dilataiton of connecting tubules, associated with Ehlers Danlos and Carolis. Also associated with Beckwidth Wiedemann.

45
Q

Page kidney

A

Subcapsular haematoma causing renal compression which messes with RAAS and causes HTN.

Classic history HTN post biopsy/lithotripsy/trauma

46
Q

Delayed vs persistent nephrogram

A

DELAYED
One kidney enhances the other doesnt. Pressure on kidney from extrinsic or intrinsic due to obstructing stone

PERSISTENT
Hypotension/shock and ATN.

47
Q

Renal infarct

A

Wedge shaped hypodensity - can also be seen in tumour/infecton.

CORTICAL RIM SIGN
Absent immediately after insult but seen 8 days later. Dual blood supply allows cortex to stay perfused

FLIP FLOP ENHANCEMENT
Region of hypodensity becomes hyperdense on delayed

48
Q

Renal vein thrombosis

A

Dehydration, indwelling umbilical venous catheters and nephrotic syndrome. Can mimic stone presenting with flank pain, enlarged kidney and delayed nephrogram

49
Q

Transplant kidney

A

For ESRF, better quality of life than dialysis.
Usually in extraperitoneal iliac fossa to anastomose with iliac vasculature and bladder.

If from cadaver, some aorta taken too. Living and cadaveric do end to side anasamosis to ext iliac artery and vein.

Should have low resistance, brisk upstroke and forward flow in diastole (always ‘on’).

50
Q

Resistance Index (RIs)

A

peak systolic - end diastolic /peak systolic

Remember kidney has a capsule which is unforgiving. If swollen sick kidney with unforgiving kidney, blood vessels will get squeezed and diastolic flow will be impaired and resistance will increase

Higher RI, sicker the kidney. RI should be <0.7.

51
Q

Transplant Urologic Complications

A

OBSTRUCTION
Transplant kidneys all hive minor hydro due to denervation. Obstruction will be at level of ureteric implant to bladder (oedema/scarring/kinking). Transplants morelikely to have stones

HAEMATOMA
Common immediately post op but usually resolves. Complex collection.

URINOMA
In first 2 weeks. Rapidly increasing anechoic collection. Most leaks at ureterovesical anastomosis. MAG3 accumulates.

LYMPHOCOELE
1-2 months after. Leakage of lymph from surgical disruption of lymphatics in setting of inflammation. Most common collection to cause hydro.

With all can get ipsilateral lower limb oedema from compression of femoral vein

52
Q

Transplant Urologic Complications continued

A

HYPERACUTE REJECTION
Immediate failure of graft. Rarely see this imaged.

ACUTE REJECTION
Week 1-3. Antibody/cell mediated. 20% transplants will have some early rejection. Graft may swell and RI go up. Rejection vs ATN is question. MAG3 may help but biopsy is gold standard.

ACUTE TUBULAR NECROSIS
Common and occurs on many transplants. Ischaemia between harvesting and implanting.

CYCLOSPORIN TOXICITY
Immunosuppressive therapy necessary to keep body from rejecting graft can poison it. Usually around one month after. MAG3 can look like ATN.

CHRONIC REJECTION
Gradual process months to years. Kidney enlarges, loses corticomedullary differentiation and raised RI.

53
Q

Transplant vascular complications

A

RENAL ARTERY THROMBOSIS
Within first month but usually within minutes to hours. Tehcnical factors, kinking or torsion of vessel.

RENAL ARTERY STENOSIS
Within first year, usually weeks to months. Most common vascular complication. Occurs at anastomosis. CMV is risk factor. Refractory HTN buzzword. 
PSV>200-300, PSV ratio ?1.8-2.5
Tardus Parvus
Anastomotic jetting

RENAL VEIN THROMBOSIS
Within first week. Kidney is swollen. Artery has reversed diastolic flow (reverse M sign)

ARTERIOVENOUS FISTULA
Secondary to biopsy. 20% time post biopsy usually small and asymptomatic. Tissue vibration artefact, high arterial velocity, pulsatile flow in vein

PSEUDOANEURYSM
Secondary to biopsy but less common. Or in graft infection or anastomotic dehiscence. yin yang colour picture. Biphasic flow at neck of aneurysm

54
Q

Transplant vascular complications continue

A

EARLY
Renal Allograft Compartment Syndrome (RACS). Kidney too big for chosen pelvic extraperitoneal space. Kidney gets squeezed (<2 hours)
Renal artery thrombosis (mins to hours)

MID
Renal vein thrombosis (first 5 days)

LATE
Renal artery stenosis (3 months - 2 years).

POST TRAUMA
AV fistula
Pseudoaneurysm
Traumatic haematoma

55
Q

Transplant Complications Cancer

A

Prolonged immunosuppression therapy puts these patients at greatly increased risk cancer. In particular, skin cancer, lymphoma and colon. Annulad ksin exams recommended.

RCC
Increased risk, with most occuring in native kidney. Likely risk of dialysis and immunosuppression. Risk of primary cancer in the transplant kidney is 6x and will be papilary

POST TRANSPLANT PROLIFERATIVE DISORDER (PTLD)
Uncommon complication of organ transplant associiated with B cell proliferation.. EBV is a risk factor and patients will go onto rituximab. Most common first year post transplant. involves multiple organs.Mass lesion ecasing the hilum

RENAL TRANSPLANT +BK VIRUS = UROTHELIAL MALIGNANCY
BK = urothelial cancer

CYCLOPHOSPHAMIDE
Significant exposure to this increases risk of urothelial cancer

56
Q

Fractured vs shattered kidney

A

FRACTURED
Laceration which extends full depth of parenchyma. Must connect two cortical surfaces.

SHATTERED
More severe form of fractured. Kidney with 3 or more fragments.

57
Q

Renal trauma pearls

A

WEDGE SHAPED PERFUSION ANOMALY
Think segmental arterial injury

DIFFUSE NON PERFUSION
Think devascularized kidney

PERSISTENT NEPHROGRAM
Think renal vein injury/thrombosis

Transplant kidney increased risk of injury due to no overlying ribs and superficial location

58
Q

Grading trauma

A

AAST American Association for Surgery of Trauma

Get arterial chest and PV abdo/pelvis. Add delays if ureteral or bladder injury suspected 5-15 mins.

DELAYS
Show urine leak - hyperdense outside collecting system
Focal collections of decreased attenuation may be pseudoaneurysm or AV fistula
Focal collections of increased attenuation may be active bleeding

1: Subcapsular haematoma, no laceration
2: Haematoma around kidney within perirenal space or <1cm laceration
3: Moderate laceration >1cm with no involvement of renal pelvis and no urine leak. Acitve bleeding within perirenal space
4: Laceration that extends to hilum (fractured kidney). Segmental infarcts. Bleeding outside perirenal space.
5: Shattered kidney. Renal hilum injury (urine leak, main renal vein/artery injury). Devascularised kidney.

59
Q

Ureter infection/inflammation

A

STONES
PUJ, pelvic brim and VUJ

URETERAL WALL CALCS
TB or Schistosomiasis

URETERITIS CYSTICA
Numerous tiny subepithelial fluid filled cysts within wall of ureter. Chronic inflammation from stones/infection. Diabetics recurrent UTI. Increased risk cancer

URETERAL PSEUDODIVERTICULOSIS
Similar to above. Chronic inflammation from stones/infection. Multiple small outpouches. Bilateral 75% and favour upper/middle. Increased risk cancer

MALAKOPLAKIA
Rare chronic granulomatous condition. Soft tissue nodularity/plaques in bladder and ureters. Chronic UTIs often in female immunocompromised patients. Can manifest as mucosal mass with renal obstruction. Michaelis Gutmann bodies. NOT premalignant, gets better with antibiotics

LEUKOPLAKIA
Squamous metaplasia secondary to chronic irritation. Mural filling defects. Premalignant and cancer is squamous NOT transitional

60
Q

Ureter infection/inflammation continued

A

RETROPERITONEAL FIBROSIS
Proliferation of aberrant fibroinflammatory tissue which surrounds aorta/IVC/iliac vessels and frequently traps and obstructs the ureters. 75% idiopathis or can be radiation, medication, inflammatory or malignant
75% idiopathic - Ormonds disease
IgG4 disorder (autoimmune pancreatitis, Riedels thyroiditis, inflammatory pseudotumour)
Medial deviation ureters
Men > women
Malignancy associated 10%

SUBENDOTHELIAL RENAL PELVIS HAEMATOMA
Long term anticoagulation or history of haemophilia. Thickened upper tract wall, mimic for TCC. Hyperdense clot on noncon

61
Q

Ureteric deviation

A

LATERAL
Retroperitoneal adenopathy
Aortic aneurysm
Psoas hypertrophy prox ureter

MEDIAL
Retroperitoneal fibrosis
Retrocaval ureter right side
Pelvic lipomatosis
Psoas hypertrophy distal ureter
62
Q

Ureteral masses

A

TCC (UROTHELIAL CARCINOMA)
90% collecting system cancers. ‘goblet’ or ‘champagne glass’ on CT IVP. Cancer will usually first be where urine sits static so bladder >renal pelvis/ureter.
RFs are smoking, cyclophosphamide, stones, horseshoe kidney, HNPCC, ureteral pseudodiverticulosis
TCC bladder 100x more common than TCC ureter
In ureter 75% TCC in bottom third

BALKAN NEPHROPATHY
Degenerative nephropathy endemic to Balkan states. Very high rate of renal pelvis and upper ureter TCC

SQUAMOUS CELL
Much less common than TCC in ureter. If it is, likely from schistosomiasis

63
Q

Ureteral masses continued

A

HAEMATOGENOUS METS
Rare mets to ureter. Typically infiltrate periureteral soft tissues and demonstrate transmural involvement

FIBROEPITHELIAL POLYP
Benign entity. Filling defect in renal pelvis or prox ureter which mimics TCC. Assumption usually TCC so diagnosis made post nephrectomy. Filling defect either clot/calcium/cancer

64
Q

Bladder developmental anomalies

A

PRUNE BELLY (EAGLE BARRETT SYNDROME)
Occurs in males. Shown on babygram with wide belly.
Deficiency of abdominal musculature
Hydrouretonephrosis
Cryptorchidism (bladder distension interferes with escent of testes)

URACHUS
Primary concern is development of midline adenocarcinoma. Usually midline mass makes it obvious although if calcs should think cancer

BLADDER DIVERTICULA
More common in boys. Acquired seconary to chronic outflow obstruction. Ehlers Danlos

HUTCH DIVERTICULUM
NOT associated with urethral valves or neurognic bladder. Associated with ipsilateral reflux. Bladder diverticula usually at lateral walls near ureteric orifices. Anterior/superior is more likely to be urachal diverticular
Most are acquired

BLADDER EARS
Transitory extraperitoneal herniation of bladder. Not a diverticulum, transient lateral protrusion of bladder into inguinal canal.

65
Q

Bladder cancer

A

Gross haematuria 4x more risk than microscopic haematuria. If >50 with gross haematuria needs triphasic and cystoscopy.

MARCELUS WALLUS BLADDER CANCER
Soft tissue in bladder. Focal wall thickening or nodules considered cancer till proven otherwise.

DIFFUSE CIRCUMFERENTIAL BLADDER WALL THICKENING
Usually isnt cancer. Inflammation or infection likely or chronic outlet obstruction.

ENHANCEMENT
Usually hypovascular but can enhance early but if on MCQ it is on delayed phase

66
Q

Bladder cancer and mimics

A

RHABDOMYOSARCOMA
Most common bladder tumour <10yo. Infiltrative , hard to tell where it originated. Paratesticular mass buzzword. Met to lungs/bones/nodes. Grape like

TCC
Bladder most common site and this is most common subtype 90%. Superficial papillary (frond like) most common subtype. Smoking and site or urinary stasis

SQUAMOUS CELL CARCINOMA
S for S. Schistosomiasis. Heavily calcified bladder and distal ureters. also longstanding Suprapubic catheter.

ADENOCARCINOMA
Think of urachus or bladder extrophy. 90% in midline bladder dome. 70% will have calcs.

LEIOMYOMA (FIBROID)
Benign tumour usually at trigone.

67
Q

Diversion surgery

A

After radical cystectomy for badder cancer. Several urinary diversion procedures can be done. Incontinent vs continent. Piece of bowel made into conduit then ureters attached to it.

EARLY COMPLICATION
Adynamic ileus 25% cases.
Urinary leakage 5% usually at ureteral reservoir anastomosis.
Fistula - uncommon

LATE COMPLICATION
Urinary infection
Stones
Parastomal hernia
Urinary stricture, left side higher risk secondary to angulation (brought through under mesentery)
Tumour recurrence more advanced than original disease.

68
Q

Psoas hitch

A

Procedure done when youve had an injury/pathology with long segment of distal ureter involved. Excise distal ureter and if remaining ureter is too short the ipsilateral bladder portion is brought up and hitched to psoas muscle. Unique appearance.

69
Q

Acquired bladder infection/inflammation

A

EMPHYSEMATOUS CYSTITIS
Gas forming organ in wall of bladder. Diabetic usually. E.coli.

TB
Upper GU tract more commonly effected with secondary involvement of bladder. Can lead to thickened contracted ‘thimble’ bladder. May have calcs

SCHISTOSOMIASIS
Third world common. Eggs deposited in bladder wall which leads to chronic inflammation. Entire bladder will calcify and you get squamous cell cancer

FISTULA
Diverticulitis, Crohns and cancer
Women after hysterectomy also at risk.
Colovesical fistula - diverticular
Ileovesical fistula - Crohns
Rectovesical fistula - neoplasm or trruma
70
Q

Acquired bladder infection/inflammation continued

A

NEUROGENIC BLADDER
Small contracted bladder or atonic large bladder
‘pine cone bladder’. Can lead to urinary stasis (and cancer), stones and infection

ACQUIRED BLADDER DIVERTICULA
Usually from outlet obstruction. Most common at VUJ. Leads to stasis (and cancer), stones and infection

BLADDER STONES
Dropped kidney stones or developing in bladder from stasis or neurogenic bladder. Chronic irritation can follow RF for TCC and SCC

PEAR SHAPED BLADDER
Pelvic lipomatosis and haematoma

71
Q

Bladder trauma

A

Cystography is gold standard with retrofilled bladder via foley catheter. Either fluro or CT. Need 300-400mls

EXTRAPERITONEAL RUPTURE
80-90% almost always associated with pelvic fracture. If pelvic fracture chance of bladder injury is 10%. molar tooth sign is contrast surrounding bladder in prevesicle space of Retzius. Often medically managed.

INTRAPERITONEAL RUPTURE
Less common. Direct blow to full bladder and it pops and blows top off (dome is weakest part). Contrast outlining bowel loops. and in paracolic gutters. Needs surgery.

Pseudorenal failure. If bladder rupture and creatinine in urine reabsorbed by peritoneal lining giving falsely elevated creatinine level. Kidneys normal.

72
Q

Male urethra

A

ANTERIOR
penile and bulbar urethra
Most anterior part is fossa navicularis
Fills with retrograde study

POSTERIOR
membranous and prostatic urethra
Verumontanum is ovoid mound in posterior wall prostatic urethra where prostatic utricle is
Fills with antegrade study

73
Q

Trauma

A

Trauma and blood in meatus - do retrograde urethrogram (RUG)

ANTERIOR INJURY
Straddle injury (bicycle).

POSTERIOR INJURY
Pelvic fracture and bladder injury often associated

GRADING

1: stretched.
2: membranous urethra tear
3: membranous and bulbar urethra tear
4: bladder base injury extending into prostatic urethra
5: bulbous urethra

74
Q

Urethral strictures

A

STRADDLE INJURY
Most common external cause of traumatic stricture. Compression of urethra against inferior edge of pubic symphysis. Bulbous urethra is site of injury. Short segment.

GONOCOCCAL URETHRAL STRICTURE
Long irregular stricture. Distal bulbous urethra

75
Q

Other male urethral pathologies

A

PANCREATIC TRANSPLANT
Has been known to cause urethral injuries. Usually from pancreatic enzymes damaging the ureter.

CONDOLYMA ACUMINATUM
Multiple small filling defects on RUG.

URETHRORECTAL FISTULA
Can occur post radiation and classicaly described with brachytherapy

URETHRAL DIVERTICULUM
Long term foley placement in male

CANCER
Malignant tumours of urethra rare. 80% squamous apart from prostatic urethra which is TCC

URETHRAL DIVERTICULUM CANCER
Adenocarcinoma

76
Q

Female urethra

A

FEMALE URETHRAL DIVERTICULUM
More common in females. Repeated infection in pereiurethral glands. Usually on sag MRI. Middle third urethra on posterolateral wall.

can coexist with urinary incontinence and infection. Saddle bag configuration. Stones can develop in these. Increased risk of cancer and is most commonly adenocarcinoma

77
Q

Renal cancer (adenocarcinoma)

A

CLEAR CELL
Enhances equal to cortex on corticomedullary phase. Most common. VHL.

PAPILLARY
Enhances less than cortex on corticomedullary phase. Hereditary papillary renal carcinoma. Transplant kidney.

CHROMOPHOBE
Birt Hogg Dube

MEDULLARY
Sickle cell

TRANSLOCATION
Denser than cortex. Most common in kids and post chemo.

78
Q

Ureteral cancer

A

Location of urinary stasis. Renal pelvis 2x more common than ureter.Distal third of ureter most common in ureter. Bladder cancer 100x more common. Ureteral cancer usually also has bladder

TCC
90%. Favours base. 40% multiple. frond like papillary most common.

SQUAMOUS CELL
Calcs. favours trigone and lateral wall. Schistosomiasis, stasis, suprapubic

ADENOCARCINOMA
Midline, urachus, bladder exstrophy

Prostatic urethra: 90% TCC
Urethral diverticulum: Adenocarcinoma
Bulbar/penile urethra: 80% squamous

Radiology (16 decks)

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