IMAGES Chapter 33 - Pelvicalyceal System, Ureters, Bladder and Urethra Flashcards
IDENTIFY. [FIGURE 33.1]
EXTRARENAL PELVIS
The position of the left renal pelvis (white arrow) outside of the renal sinus enables the pelvis to distend with urine and to be larger than the normal right renal pelvis (black
arrow). The extrarenal pelvis is a normal variant, not to be mistaken for hydronephrosis.
DIAGNOSIS ? [FIGURE 33.2]
URETERAL DUPLICATION
A. Reconstructed three-dimensional pyelogram-phase image from thin slice MDCT urogram shows complete
duplication of the left renal collecting system and ureter.
B. Axial image from the same study shows the upper pole ureter (arrowhead) bypassing the origin of the lower pole ureter (arrow). Although this patient’s upper pole ureter inserted ectopically in the lower bladder, no
obstruction was present.
C. Axial image at the level of the mid-ureters shows the lower pole ureter (arrow) anterior to the upper pole ureter (arrowhead). The duplicated ureters tend to meander and twist about each other as they course to the bladder.
DIAGNOSIS ? [FIGURE 33.3]
OBSTRUCTED DUPLICATION
A. CT urogram pyelogram-phase image through the upper pole (UP) of the right kidney shows marked
dilatation of the calyces, pelvis, and ureter. The upper pole parenchyma (arrows) enhances but is markedly atrophic.
B. Image through the lower pole (LP) shows contrast excretion into the nondilated lower pole collecting system. The markedly dilated upper pole ureter (arrow) courses past the origin of the lower pole ureter.
DIAGNOSIS ? [FIGURE 33.4]
STAGHORN CALCULUS
A conventional radiograph (without administration of any radiographic contrast agent) demonstrates a complex calculus creating a cast of the collecting system of the left kidney.
This staghorn calculus, named (imprecisely) for its resemblance to the antlers of a male deer, is formed in the presence of obstruction with chronic infection and is composed of struvite.
DIAGNOSIS ? [FIGURE 33.5]
RENAL STONE
A. CT image through the kidneys in a patient with left fl ank pain demonstrates mild enlargement of the left renal pelvis (arrow). Streaks and strands of edema (arrowhead) are seen in the fat adjacent to the renal pelvis.
B. CT in a different patient with a stone in the distal ureter shows mild hydronephrosis (arrow) associated with fluid in the perinephric space (arrowhead).
These findings indicate rupture of the collecting system at a fornix resulting from high-grade obstruction and high urine output.
C. A stone (arrow) at the ureteropelvic junction is apparent in this patient. Absence of hydronephrosis or edema in the perinephric fat indicates that obstruction is very low grade. Note the rim of tissue around the stone is somewhat obscured by bloom artifact from the marked high attenuation of the stone.
D. A stone in the left ureter (arrow) has impacted at the level of the pelvic brim. Note the irregular shape characteristic of renal stones. The rim of soft tissue
density surrounding the stone represents the swollen wall of the ureter (tissue rim sign).
E. CT at the level of the seminal vesicles (S) shows a high density stone (arrow) in the distal left ureter. The “tissue rim sign” is evident. “All” urinary tract stones appear “white” on CT viewed at soft tissue windows.
F. A more caudal image at the level of the base of the prostate (P) shows a phlebolith (arrow), not to be mistaken for a ureteral stone. The location is below the level of the distal ureter and the calcification lacks a tissue rim sign. The tubular structure (arrowhead) extending from the calcification represents the thrombosed vein (the tail sign). B, bladder.
DIAGNOSIS ? [FIGURE 33.6]
CHRONIC OBSTRUCTION
Image from a noncontrast renal stone CT shows marked dilatation of the calyces (C) and the renal pelvis (P). The renal parenchyma (between arrowheads) is markedly thin. A subsequent radionuclide renal scan showed no function in the right kidney. Findings are indicative of chronic proximal high-grade obstruction.
DIAGNOSIS ? (INDICATE LOCATION) [FIGURE 33.7]
OBSTRUCTION; RIGHT KIDNEY
Pyelogram-phase image from a CT urogram shows contrast filling the left renal pelvis on this scan performed at 4 minutes following IV contrast injection. The right kidney shows delayed excretion with contrast enhancement only of the cortex. The medulla (black arrow) is not enhanced and the collecting system (long white arrow) is not opacified with contrast. This patient
had high-grade obstruction from a stone impacted at the ureterovesical junction. Note the presence of perirenal fluid (arrowhead) indicating rupture at the fornix of an obstructed calyx caused by high renal
output in the setting of high-grade obstruction.
DIAGNOSIS ? [FIGURE 33.8]
CHRONIC OBSTRUCTION DUE TO
URETERAL STONE
A. T2-weighted MR image in coronal plane performed without contrast shows advanced hydronephrosis with dilation of the calyces (short arrows) and renal pelvis (arrowhead). The renal parenchyma is thinned.
B. Matching T2-weighted axial plane image shows dilation of the ureter (arrow).
C. Axial plane T2WI of the distal ureter shows the stone
(arrow) as a focus of black signal void surrounded by bright urine confined by the low-signal wall of the ureter.
D. T1-weighted coronal plane MR image obtained approximately 5 minutes following IV gadolinium
administration shows the obstructed left kidney, the normal right kidney, the normal bladder, and the obstructing stone (arrow) in the distal left ureter. This figure illustrates use of the noncontrast as well as the
post-contrast MR urogram.
DIAGNOSIS ? [FIGURE 33.9]
HEMORRHAGE INTO COLLECTING SYSTEM
Image from noncontrast renal stone CT in a patient with acute right flank pain shows the calyces (short arrows) and the renal pelvis (arrowhead) filled with
high-attenuation material measuring 55 H. This patient on supratherapeutic doses of anticoagulants hemorrhaged into his right renal collecting system.
DIAGNOSIS ?
IDENTIFY THE DISEASE FEATURE POINTED BY THE ARROW. [FIGURE 33.11]
TRANSITIONAL CELL CARCINOMA—RENAL PELVIS—WALL THICKENING.
Nephrogram-phase image from a CT urogram demonstrates circumferential wall thickening (arrow) of the left renal pelvis caused by transitional cell carcinoma.
DIAGNOSIS ?
DISEASE FEATURE POINTED BY THE ARROW.
[FIGURE 33.10]
TRANSITIONAL CELL CARCINOMA—RENAL PELVIS—
INTRALUMINAL MASS.
Pyelogram-phase image from a CT urogram
shows an intraluminal mass ( arrow ) in the left renal pelvis. This lesion proved to be a papillary transitional cell carcinoma.
DIAGNOSIS ?
DISEASE FEATURE PRESENTED BETWEEN THE TWO WHITE ARROWS.
[FIGURE 33.12]
TRANSITIONAL CELL CARCINOMA—RENAL PELVIS—
INFILTRATIVE TUMOR
Coronal reformatted pyelogram-phase image from
a CT urogram shows an enhancing tumor (between white arrows )infiltrating the collecting system and the renal parenchyma of the lower pole of the right kidney. Note that the tumor infiltration does not distort the shape of the kidney. The tumor obstructs upper pole
collecting system and pelvis (P) causing hydronephrosis. A metastasis (black arrow) in the liver is also evident. Biopsy confirmed stage IV transitional cell carcinoma.
DIAGNOSIS ? SPECIFY ITS LOCATION. [FIGURE 33.13]
TRANSITIONAL CELL CARCINOMA (TCC)—URETER
A. Pyelogram-phase image from a CT urogram in a patient with hematuria reveals a polypoid mass seen as a filling defect (arrow) in the proximal right ureter. Biopsy confirmed transitional cell carcinoma.
B. Post-contrast CT in a different patient demonstrates an enlarged right ureter (arrow) with ill-defined margins. This image was obtained at the level of a ureteral stricture.
The ureter above this level was distended and filled with contrast. Surgery confirmed TCC. The left ureter (arrowhead) is filled with contrast and is normal in appearance.
DIAGNOSIS ? DIFFERENTIAL DIAGNOSIS? [FIGURE 33.14]
TRANSITIONAL CELL CARCINOMA
—NONCONTRAST CT.
BLOOD CLOT
Image from a noncontrast renal stone CT shows an intermediate attenuation mass (arrow) distending the right renal pelvis.
Differential diagnosis would include blood clot versus tumor. Ureteroscopic directed biopsy revealed transitional cell carcinoma.
DIAGNOSIS ? [FIGURE 33.15]
TRANSITIONAL CELL CARCINOMA—URETER
A. A retrograde ureterogram demonstrates widening of the ureter (arrow) distal to an obstructing tumor. The distal ureter assumes a champagne glass configuration because of the slow growth of the tumor.
B. Additional contrast administration demonstrates the full extent of the tumor (between arrows).
DIAGNOSIS ? [FIGURE 33.16]
PAPILLARY NECROSIS
A. Coronal plane reformatted pyelogram-phase image from a CT urogram shows a focus of papillary necrosis (arrow) filling with contrast at the lower pole.
B. Multiple cavities (arrows) in the papilla fill with
contrast during this excretory urogram in a patient with sickle cell trait.
Low oxygen tension and high blood osmolality in the papillary tips predispose to sickling and ischemic injury.
DIAGNOSIS ? [FIGURE 33.17]
CALYCEAL DIVERTICULUM
A. Pyelogram-phase image from a CT
urogram demonstrates a cavity (D) that fills with contrast and is connected to the collecting system by a thin channel (arrow). This calyceal diverticulum is
associated with a deep scar in the renal parenchyma.
B. A radiograph from an excretory urogram in a different patient reveals a contrast-filled diverticulum
(D) in the renal parenchyma. A tiny stream of contrast (arrow) fills the tract, providing communication between the diverticulum and the calyceal fornix.
DIAGNOSIS ? [FIGURE 33.18]
URACHAL CARCINOMA
Early post-contrast CT urogram image shows a urachal diverticulum (arrowhead) extending from the midline dome of the bladder (B) to the midline of the anterior
abdominal wall. A solid mass (arrow) occupies the proximal aspect of the diverticulum. Several high-attenuation stones and dystrophic calcifications are seen within the mass and proven to be adenocarcinoma on biopsy. The wall of the bladder is thickened.
DIAGNOSIS ? [FIGURE 33.19]
BENIGN PROSTATIC HYPERTROPHY
A radiograph from an excretory urogram shows marked uplifting of the bladder base because of massive enlargement of the prostate (P). The trigone (open arrow) and the ureteral orifices (black arrows) are markedly elevated, resulting in a J-shaped appearance to the distal ureters. The bladder wall is thickened (between black arrowheads ) and the bladder (B)
mucosal pattern is prominent.
DIAGNOSIS ? [FIGURE 33.20]
CYSTITIS
CT in a patient with pyuria and hematuria shows thickening of the wall of the bladder (B) and edema (short arrows) in the fatty tissues adjacent to the bladder. Urine culture confirmed cystitis caused by Escherichia coli.
DIAGNOSIS ? [FIGURE 33.21]
EMPHYSEMATOUS CYSTITIS
A. Air in the bladder wall is seen as a pattern of layering linear lucencies (arrows) outlining the bladder (B) on this conventional radiograph in a 67-year-old man with cystitis due to Escherichia coli.
B. CT in a different patient with diabetes shows streaks and bubbles of air (arrows) in the wall of the bladder (B).
DIAGNOSIS ? [FIGURE 33.22]
The patient is a 25-year-old Egyptian male.
SCHISTOSOMA HAEMATOBIUM
Conventional radiograph demonstrates calcification in the wall of the bladder (arrows) and in the wall of the left ureter (arrowhead). The bladder is filled with urine.
The patient is a 25-year-old Egyptian male.
DIAGNOSES ? [FIGURE 33.23]
SIMPLE AND ECTOPIC URETEROCELES
A. Conventional radiograph from an excretory urogram demonstrates mild dilation of the right ureter associated with a simple ureterocele (u) that protrudes into the lumen of the bladder (B). The radiolucent
wall of the ureterocele (arrowhead) is outlined by contrast within the ureterocele and contrast within the bladder lumen. The wall of the ureterocele is made up of the wall of the ureter and the bladder mucosa.
B. Radiograph from an excretory urogram shows a normal ureter (arrowhead) from the normal lower pole of the kidney and a dilated ureter with ectopic ureterocele (arrow) from the obstructed upper pole of the kidney. The ectopic ureter inserts medial and caudad to the normal insertion of the
upper pole ureter.
DIAGNOSIS ? [FIGURE 33.24]
TRANSITIONAL CELL CARCINOMA
A. CT urogram image demonstrates a flat mucosal lesion (arrow) arising from the right lateral wall
of the bladder (B). Contrast enhancement of the lesion is slightly greater than that of the bladder wall revealing the extent of the tumor. This is a
T1 lesion, confined to the bladder wall. The bladder wall is thickened (between arrowheads) and irregular because of muscle hypertrophy induced by the chronic obstruction of an enlarged prostate. On this early phase CT image, the bladder is distended with low-attenuation urine.
B. Coronal plane delayed image from CT urogram reveals the papillary growth pattern of a transitional cell carcinoma (arrow) well outlined by contrast
opacified urine.
C. Early post-contrast image from a CT urogram shows enhancement of the tumor (arrow) and distinct enhancing nodules (arrowhead) of soft tissue in the perivesical fat. This is strong CT evidence of spread of tumor through the bladder wall, making this a pT3b stage lesion.
D. Early phase post-contrast CT urogram image shows an enhancing tumor (arrow) involving the right ureterovesical junction (arrowhead). This is a stage T2 lesion. S, seminal vesicles.
DIAGNSOSIS ? [FIGURE 33.25]
BLADDER STONES
Multiple high-attenuation stones (arrow) are seen within the lumen of the bladder on this noncontrast CT. Contrast opacification of the bladder may obscure the presence of
bladder stones. This patient has a neurogenic bladder resulting in chronic urine stasis within the bladder.
DIAGNOSIS ? [FIGURE 33.26]
BLADDER DIVERTICULUM
Delayed phase image from a CT urogram shows a bladder diverticulum (arrow) partially filled with contrast-opacified urine. The narrow neck of the diverticulum is
apparent.
DIAGNOSIS ?
Image from a CT cystogram performed in a patient with a pelvic fracture. [FIGURE33.27]
EXTRAPERITONEAL BLADDER RUPTURE
Image from a CT cystogram performed in a patient with a pelvic fracture reveals contrast extravasation (arrowheads) from the bladder into the retropubic space of Retzius indicating bladder rupture into the extraperitoneal compartment. Contrast has also tracked into the subcutaneous tissues (curved arrow). Contrast was instilled into the bladder through a Foley catheter (arrow).
DIAGNOSIS ? [FIGURE 33. 28]
INTRAPERITONEAL BLADDER RUPTURE
Image from a CT cystogram demonstrates extravasation of contrast from the bladder into the intraperitoneal space.
Contrast (arrowheads) enveloping loops of bowel confirms its intraperitoneal location. This finding on a
CT cystogram is diagnostic of intraperitoneal bladder rupture. A fracture (arrow) of the ilium is evident.
IDENTIFY THIS NORMAL MALE STRUCTURE.
A. Retrograde urethrogram (RUG).
B. Voiding cystourethrogram (VCUG). [FIGURE 33.29]
NORMAL MALE URETHRA
The anterior urethra consists
of the penile urethra and the bulbous urethra. The penile urethra (PU) extends from the urethral meatus to the suspensory ligament of the penis
(straight arrows) at the penoscrotal junction. The bulbous urethra (BU) extends from the penoscrotal junction to the urogenital diaphragm (curved arrows) marked by the tip of the cone on the RUG and the slight narrowing of urethral caliber on the VCUG.
The posterior urethra consists
of the membranous urethra and the prostatic urethra. The membranous urethra (curved arrows) is only 1 cm in length and is entirely within the muscle of the urogenital diaphragm. On a RUG, the membranous urethra extends between the tip of cone and the verumontanum. The verumontanum
(arrowheads) is a nodular structure that produces a
fi lling defect on the urethrograms by bulging into the prostatic urethra. The prostatic urethra extends from the inferior aspect of the verumontanum to the base of the bladder (B).
IDENTIFY THIS NORMAL STRUCTURE [FIGURE 33.30].
COWPER GLANDS
Radiograph from a voiding cystourethrogram shows filling of the ducts to Cowper glands. The glands (skinny arrow) are in the urogenital diaphragm and their ducts (fat arrow) drain into the _bulbous urethra (BU)_. The _verumontanum_ (arrowhead) produces its usual filling defect in the contrast column.
IDENTIFY THIS NORMAL FEMALE STRUCTURE.
[FIGURE 33.31]
NORMAL FEMALE URETHRA
T2-weighted MR demonstrates
the zonal anatomy of the female urethra ( arrow ) in the anterior
wall of the vagina ( arrowhead ). The outer smooth layer is low signal
( dark ), the submucosal layer is moderately bright, and the central
mucosa is dark. The rectum ( R ) is seen posteriorly.
This patient had a history of multiple episodes of gonorrhea. Identify the pathology and specify its exact location. [FIGURE 33.32]
URETHRAL STRICTURES, GLANDS OF LITTRE
Retrograde urethrogram demonstrates multiple strictures in the penile urethra and the bulbous urethra.
Filling of the glands of Littre (arrow) is evidence of
urethritis.
DIAGNOSIS (INCLUDE SPECIFIC LOCATION)?
[FIGURE 33.33]
CARCINOMA OF THE PENILE URETHRA
Sagittal plane MR
image shows recurrent squamous cell carcinoma as abnormal low signal (arrow) fi lling and distending the penile urethra within the corpus spongiosum.
This patient has already experienced partial resection of the tip of his penis for carcinoma. One of the corpora cavernosa (CC) is seen anteriorly.
A normal testis (T) is also shown.
DIAGNOSIS? [FIGURE 33.34]
A. Voiding cystourethrogram in a woman with recurrent urinary tract infections
B.Coronal T2-weighted MR image of a different woman
DIVERTICULUM OF THE FEMALE URETHRA
A. Voiding cystourethrogram in a woman with recurrent urinary tract infections fills a urethral diverticulum (D).
B, bladder; U, female urethra. B. Coronal T2-weighted MR image of a different woman shows a l_arge diverticulum (arrow) of the urethra_ beneath the bladder (B) and posterior to the symphysis pubis.
DIAGNOSIS? [FIGURE 33.35]
Radiograph from a retrograde urethrogram shows transection of the urethra at the level of the urogenital diaphragm (arrow).
TRAUMATIC URETHRAL TRANSECTION
Contrast extravasates into adjacent
tissues and intravasates into pelvic veins.
