Urinary Flashcards
general outline of kidney
- pericapsular fat continuous w/ renal sinus
- thick capsule
column of bertin
cortex extending btw pyramids
variant kidney anatomy
- fetal lobulation
- Dromedary hump (left kidney via adaptation to adj spleen)
- prominent/Htr column of Bertin (most likely to be shown on US)
fetal lobulation vs scar
- lobulation: indentation overlie space BTW pyramids
- scar: indentation over pyramid. LOSS OF CORTEX
UL renal agenesis associations
- F-unicornuate uterus
- M-ø IL epididymis & vd OR IL seminal vesicle cyst
- add: ø IL ureter, hemitrigone
Mayer-Rokitansky-Kuster-Hauster
Mullerian duct anomalies ass w/ UL renal agen
basic breakdown renal phases
- cortical- characterizing tumor enh, staging/treatment
- nephrographic -tumors
- excretory-papilla morphology, urothelial cell/TCC lesions
RFs RCC
- tobacco
- syndromes-VHL
- dialysis >3 yrs
- family hx
RCC subtypes
- clear cell-general pop, VHL
- papillary-hereditary papillary renal Ca, Tx
- medullary-SCD
- chromophobe-Birt Hogg Dube
- translocation-kids s/p cytotoxic chemo
T2 dark kidney lesions
- papillary
- lipid poor AML
- hemorrhagic cyst
RCC staging
1) kidney, <7cm
2) kidney, >7cm
3) Gerota’s fascia- A) renal vein invasion B) IVC above diaphragm C) IVC below diaphragm
renal leukemia
- MC visceral orgn envolved
- smooth, enlarged
- cortically based hypodense lesions
Bourneville disease aka
Tuberous Sclerosis
what % AMLs are lipid poor, for TS?
5%
30% for TS
MC tumor to met to kidney
lymphoma
“protrudes into renal pelvis”
multilocular cystic nephroma
BL oncocytomas and chromophobe RCC
Birt Hogg Dube
kidney benign tumors to consider
a) AML (MC)
b) oncocytome (2nd MC)
ways to show oncocytoma
1) solid mass + central scar
2) spoke wheel on US
3) HOT on pet
mx oncocytoma
resect (indist from RCC)
img multilocular cystic nephroma
“non-communicating, fluid filled locules surr by thick fibrous capsule”
-“protrude into renal pelvis”
what abd organs are part peritoneal and RP?
pancreas
duo
rectum
what % of 1˚ retroperitoneal neoplasms are mal?
75%
RP lesions
- lipomatosis
- liposarcoma
- RMS-kids
- EMH
- RP hem
- lymphoma
- RP fibrosis-uncommon above renal a’s
- Erdheim Chester
lipomatosis
- fat person w/ “incomplete bladder emptying”
- overgrowth benign fat in pelvis (perirectal, per vesicular)
- anterosup bladder displ. Pear/tear drop shaped.
liposarcoma-how many recurr, when is it bad, MC loc
- 2/3 local recurrence
- looks bad=bad
- deeper=bad
- MC loc is actually the thigh
MC 1˚ RP malignancy
liposarcoma
MC RP malignancy
lymphoma
MCC’s RP hem
1) anticoag
2) rupture/leaking aorta
3) bleeding RCC or AML
(A’s)
NHL vs HL RP lymphoma
NHL-nodes larger, involve mesentery, non continuous
-HL nodes para-aortic early, more continuous
risk of malignancy based on Bosniak
1) 0%
2) 0%
2F) <5%
3) 50%
4) 100% (ie: RCC)
Bosniak 1
- simple anechoic
- hairline thin wall
Bosniak 2
- hyper dense, <3 cm
- thin Ca, sept
- no ST
Bosniak 2F
- hyperdense >3cm
- minimally thickened Ca, wall or septa
- no ST
- totally intrarenal
bosniak 3
- measureable enhancement
- thick/irreg or smooth wall/septa
Bosniak 4
same as 3 + distinct enhancing ST components
what is always present in ARPKD
congenital hepatic fibrosis
Tuberous sclerosis and kidneys
- AML
- RCC (younger pts)
ADPKD findings-where are the cysts, ass?
- cysts: kidneys, liver, seminal vesicle
- berry aneurysms
what happens to dialysis related kidney cysts?
regress s/p tx
parapelvis vs peripelvic cyst
para (beside)-simple renal cysts that plunge into the renal sinus from the adjacent renal parenchyma. Org from parenchyma, may compress collecting system. look like cortical cyst but bulge in (instead of out)
-peri-from renal sinus, mimic hydro
renal abscess cutoff for drainage
3cm
striated nephrogram ddx
- acute ureteral obstruction
- acute pyelonephritis
- hypoTN (BL)
- acute renal v thrombosis
- renal contusion
- radiation nephritis
- medullary sponge kidney
- infantile polycystic kidney (BL)
findings chronic pyelo
- thinning, atrophy, scarring
- HTr of normal residual tissue!
mx emphysematous pyelonephritis vs pyelitis
kid-Abx + nephrectomy
who gets emphysematous pyelonephritis vs pyelitis
- kid-DM
- CS-women, DM, urinary obstruction
img pyonephrosis
- US > CT (has trouble distinguishing pyonephrosis from hydronephrosis
- F/F level
papillary necrosis causes
- DM (mc)
- pyelonephritis
- SCD (50% of SC pts dev PN!)
- Tb
- analgesia
img papillary necrosis
- filling defects in calyx
- lobster claw-linear streek in calyx
MC extra pulmonary site Tb
-urinary tract
Tb renal disease img/progression
- earliest- pap necrosis/ “moth eaten calyces-deep cups/w-shaped central necrosis (pelvis remains symmetrical)
- progressed necrosis –> cavity (MOST CHAR)
- phantom calyx-focal stenosis of infundibulum
- diffuse infundibulum stenosis–> caliectasis
- ureteral stenosis –> Kerr kink-scarring of pelvis –> uplifted appearance at renal pelvis
- putt kidney-Ca autonephrectomized end stage Tb kidney
- Ca mesenteric nodes
HIV nephropathy
- MCC renal fx in this population
- enlarged, echogenic, loss of fat (edema in fat)
disseminated PCP-renal disease
punctate (cortical) Ca
who’s at risk for CIN?
- pre-existing renal dx (+DM w/ renal disease)
- CHF
- dehydration
- myeloma
Stone compositions
- Ca-oxalate-75%
- struvite-women + UTI
- uric acid-Unseen on xray
- cystine-rare, cong disorders of metabolism
- indinavir-HIV. only stone not seen on CT
Rx nephrolithiasis-size cut off.
- 5mm cut off
- uric acid-change acidic diet/mediacl (Kcitrate, NaBicarb)
appearance of stones on dual E CT
- non-uric acid stones-higher HUat 80kEv
- UA-same at 80 and 140
cortical nephrocalcinosis mimic
disseminated PCP
Medullary sponge kidney MOA and ass
- UL cystic dilation of CTs
- Ehlers-Danlos, Caroli’s, BW
in which organs is RI useful?
those with a capsule
delayed vs persistent nephrogram
UL vs BL
cortical rim sign
perfusion of cortex (8hrs-days later) via dual bs
flip flop enh
region of hypo density/hypoenh bc hyperdense on delayed
renal v thrombosis causes
- nephrotic MC in adults
- dehydration
- indwelling umbilical venous catheter
RI calculation
(peak systolic-ED)/Peak Systolic
flavors of kidney tx compl
1) urologic-MC
2) vascular-2nd MC
3) cancer-3rd MC
4) AVN-steroids (- now w/ cyclosporine use)
5) trauma (more superficial, less rib protection)
urologic compls s/p kidney tx
- fluid collections
- hyperacute rejection
- acute rejection
- ATN
- cyclosporin toxicity
- Chronic rejection
“delayed graft function” (DGF)
-transplant requiring dialysis in 1st wks. Amount of cold ischemia is best predictor
img urologic compls kid tx (minus fluid colls)
- hyperacute rejection-immediate, not imaged.
- acute-swelling, RI+, MAG3 3pt crappy
- ATN-MAG3 N perfusion w/ retained tracer
- chronic rejection-same as acute
- cyclosporin tox-ATN but months later
how many kid tx pts wind up with acute rejection?
20%
how to differentiate acute rejection vs ATN?
- MAG3
* bx (despite Nucs)
what cancers are renal tx pts at risk for
- 100x at risk via immunosuppresion
- nonmelanomatous skin cancer (annual skin exams), lymphoma, colon cancer
- RCC-native kidney
- PTLD-EBV, B cell proliferation, 1st yr, mult organs, mass encasing/replasing hilum. rx=(-) imm supp
- urothelial-BK in donor kidney. cyclophosphamide
kidney fx vs shattered
- fx-2+ fragms, lac goes full depth connecting 2 cortical surfs
- shatter-3+ fragms
renal trauma: wedge shaped perfusion abN vs diffuse non perfusion vs persistent nephrogram
- segm a
- devascularized
- renal v thrombosis
mx renal trauma
- grades 1-3 conservative
- 4, 5-surgery
renal trauma grades
1) subcap hem
2) <1cm lac
3) >1cm lac, active bleed into perirenal space
4) fractured, blood outside perirenal space, segm infarcts
5) shattered, hilar injury, devasc
ureteral wall Ca
Tb
schisto
ureteritis cystica
chronic inflamm (DM, recurr UTI)
- tiny subep cysts
- ?(+) risk cancer
ureteral pseudodiverticulosis
small outpouching
BL 75%
-upper/middle 3rd
-maligancy
malakoplakia-pathophys, who, orgm
chronic granulomatous condition–> ST nodularity/plaques in bladder and ureters (bladder MC)
- imm supp F w/ chr UTI
- E. Coli
-BW: Michaelis-Gutmann bodies
malakoplakia
malakoplakia vs leukoplakia
M-not mal
L-mal
leukoplakia
squamous MP 2/2 chronic irritation
- bladder > ureter
- mural filling defects
- risk SCC
RP fibrosis-causes
- iso-75%
- radiation, mx (methyldopa, ergotamine, methysergide), inflamm (pancreatitis, pyelonephritis, inflamm aneurysm), mal (desmoplastic rxn, Lymphoma)
- mal=10% (PET to find 1˚?)
RP fibrosis-aka
Ormond dx
RP fibrosis-nukes
gallium+
PET HOT in active phase
RP fibrosis-MOA, ass
fibro-inflamm proliferation
-ass w/ IgG4
medial vs lateral deviation of ureters
- Lat-RP LAD, aortic aneurysms, psoas HTr (proximal)
- med (“waisting”)-RPF, retrocaval ureter, pelvic lipomatosis, psoas HTr (distal)
sub epithelial renal pelvis hematoma
- long term anticoag
- hemophilia
- thickening upper tract wall w/o enh (vs TCC)
TCC/urothelial CA RFs
- smoking
- azo
- cyclophosph
- aristolochic acid
- horseshoe
- stones
- ureteral pseudodiverticulosis
- hereditary non-polyposis colon cancer (II)
Balkan nephropathy
degenerative nephropathy endemic to Balkan States
- high rate renal pelvis and upper ureter TCCs
- 2/2 eating aristolocholic acid (AA) seeds in Aristolochia clematis plant
mets to ureters
GI, Prostate, renal, breast
ureteral fibroepithelial polyp
upper tract/pelvis
- younger pt
- smooth/oblong and mobile
- vs tcc
bladder diverticula-who
- boys
- chronic BOO
- ehler danlos
bladder ears-when is it seen, in whom (why), vs diverticulum
-transitory extraperitoneal herniation of bladder into ing canal
- in the infant, lies in a relatively high position in the pelvis and is proportionately large in relation to the abdominal cavity (1, 15). This position places the lateral base closer to the internal inguinal ring than in the adult. With increasing age, the bladder becomes almost completely a true pelvic structure except when distended (5). It is covered by peritoneum in its superior and posterior portions, while laterally and anteriorly it consists of only loose areolar tissue.
- bladder ears: in young infants, NORMAL (?) protrusion of the lateral aspect of the bladder into the inguinal canal
-vs diverticulum: herniation has smooth wall, wide neck
what’s more likely cancer? macro vs micro hematuria
macro
wall thickening of bl cancer
nodular and asymm
bl cancer enh
“hypovasc” but do enh (often arterial)
squamous bladder cancer
- recurr UTIs & stone dx
- schisto
- suprapubic cath
bladder leiomyoma
benign tumor (mc) at trigone -BW: unary hesitancy, drippling
TCC subtypes
- papillary (frond like, low grade)
- nonpapillary (aggressive)
location of bladder tumors
- TCC-base (infest
- squamous-trigone, lat
- adeno-midline
- rhabdo-paratesticular
Bladder cancer RFs
- smoking
- poison-arsenic, aniline, benzidine
- diverticulu-2-10% via stasis. quick to spread (less m)
Ca rate in bladder adeno
75%
urinary diversion surgeries
- bowel made into conduit or reservoir –> ureters att to it
1) incontinent
2) continent - compl: early (bowel function, leakage, fistula) & late (inf, stone, herniation, strictures, recurr)
early urinary diversion sx compls
1) bowel function-dynamic ileus (MC, 25%), SBO (3%, entero-entero)
2) urinary leakage-ureteral-reservoir anastomosis –> urinoma, 5%
3) fistula-mc in pts w/ pelvic radiation
late urinary diversion sx compls
- inf
- stones
- parastomal herniation-15% w/ ileal conduits. 10% need sx. obesity :(
- urinary stricture- L>R (L is brought under mesentery)
- recurr-adv org disease, 3-15%
psoas hitch
- aunt minni
- removal of long-segm distal ureter –> stretch IL bladder toward short ureter and sew to psoas m
pear shaped bladder
1) hematoma
2) pelvic lipomatosis
bladder infections
- emphysematous-E coil, DM
- Tb (from upper)
- schisto-ENTIRE BLADDER will Ca
ddx bladder diverticulum
- colovesicular-diverticular
- ileovesical-crohns
- rectovesical-Neo or trauma
neurogenic bladder-types
1) small contracted (pinecone/christmas tree)-spinal lesions above T12
2) atonic-sacral lesions and peripheral neuropathy
3) suprapontine lesions-spastic bladder w/ normal sphincters
Sensory neurogenic bladder
Inability to sense bladder fullness results in a large rounded and smooth bladder. Voiding is often preserved.
Motor paralytic bladder
Atonic large bladder with the inability of detrusor contraction during voiding.
Uninhibited neurogenic bladder
Rounded bladder with a trabeculated appearance to the mucosa above the trigone from detrusor contractions. On voiding large interureteric ridge is noted
Reflex neurogenic bladder
Results from detrusor hyperreflexia with a dyssynergic sphincter. This leads to contrast extension to the posterior urethra and an elongated pointed urthera with pseudodiverticula.
Autonomous neurogenic bladder
Intermediate between detrusor hyperreflexia (contracted) and dysreflexia (atonic).
bladder diverticula-mc loc
uvj
bladder stones-how
1) drop from above
2) form 2/2 stasis
* known RF for TCC and SCC
role of cystography (via fluoro or CT)
100% sensitive when filled w/ 300-400 mL
pseudoazotemia aka pseudo renal failure
bladder rupture–> Cr abs by peritoneal lining–> elevation of blood Cr –> pseudo renal fx
appearance extraperitoneal vs intraperitoneal bladder rupture
- extra-molar tooth
- intra-bowel loops
which type of bladder rupture is MC?
extra
extraperitoneal bladder rupture ass
pelvic fx (almost 100% -10% with pelvic fx have bladder rupture
male urethra parts
- ant (penile, bulbous)
- pst (membranous, prostatic)
vocab: fossa navicularis, verumontanum, prostatic utricle
- FN: most ant portion of urethra
- V: ovoid mound in pst prostatic urethra.
- PU: center of V. embryologic mullein remnant
how to differentiate bulbous vs membranous urthera
1) conus configuration
2) inf margin obturator foramina
MOA urethral trauma
- ant: straddle
- pst-car accident
urethral trauma types
1) stretched, ie: in tact
2) membranous
3) membranous + bulbar- UGS ruptured, perineal/scrotal contrast. MC
4) bladder base –> prostatic urethra
5) bulbous
retrograde vs antegrade urethral studies
retrograde-ant part fills
antegrade (voiding urethrogrphay)-pst pt fills
-dynamic urethrography=using both
MC urethral trauma type
3
which urethral trauma types are ass w/ incontinence
2-4
urethral strictures
- bulbous trauma (MC)-short segm
- GN-long/irregular
effect of pancreatic tx on urethra
- old form of surgery connecting pancr tx to bladder
- pancreatic enzymes jack up urethra –> extrav
condyloma acuminatum
small filling defects on RUG
-should not instrumentize (even RUG)-seeding
urethrorectal fistula cause
radiation (classically brachytherapy, 1%)
urethral diverticulum
-long term foley
urethral cancer-bd of subtypes
- rare
- 80% SCC
- prostatic urethra TCC 90%
- diverticulum-adeno
female urethral diverticulum
- way more common than in men!
- middle 1/3, pstlat wall
- stress urinary incontinent (60%), UTI
- BW=saddle bag
- adeno
normal kidney echogenicity
Antenatally, fetal kidneys show varying texture depending on gestational age. It is echogenic in the first trimester, with decreasing echogenicity as the pregnancy progresses. Corticomedullary differentiation can be appreciated after 15 weeks of gestation but clear demarcation between cortex and medulla can be seen at 20 weeks. Renal echogenicity decreases compared to liver and spleen after 17 weeks 12.
Normal kidney appearance in adult:
cortex is less echogenic than the liver
medullary pyramids are slightly less echogenic than the cortex
cortex thickness equals/is more than 6 mm 14
if the pyramids are difficult to differentiate, the parenchymal thickness can be measured instead and should be 15-20 mm 11
central renal sinus, consisting of the calyces, renal pelvis and fat, is more echogenic than the cortex
renal pelvis may appear as a central slit of anechoic fluid at the hilum
normal ureters are generally not well seen on ultrasound
infiltrative kidney lesions
- lymphoma
- tcc
- medullary cystic nephroma/medullary rcc
mx multilocular cystic nephroma
resection (indist from cystic rcc)
low attenuation LAD
whipples
testicular neo
tb
atypical mycobacterium
upper tcc îs found-likelihood of CL and lower tract?
CL 3-5%
Bladder: 30-50%
mcc renal scarring
reflux nephropathy
sign of fat and Ca in a renal mass
fat containing rcc
scarring with dilated calyces
reflex nephropathy
what makes upper pole moiety reflux?
shorter intramural course
significance of sudden disappearing excreted contrast
-developing hypotension
chance of obstructed labor in setting of UL vs BL pelvic kidneys
UL-none
BL-100%
christmas tree bladder
spastic detrusor against spastic sphincter
retraction of urinary bladder wall
m invasive bladder cancer (rx=radical cystectomy s/p TURBT)
oncocytoma-path, img
- Path: Benign renal tumor composed of eosinophilic epithelial cells arising from intercalated cells of collecting ducts
- img:
- Solid renal cortical mass lesion with central stellate scar
- Encapsulated, well marginated, smooth contour
- large mass with renal contour abnormality and compression of collecting system
- lacks mal features
- Ca/hem/necr rare
- Degree and timing of enhancement are variable due to variable cellularity
-CT: Isodense or slightly hyperdense relative to kidney
-MR T1WI Isointense to low signal T2WI Intermediate signal: Highly cellular components ↑ signal: Edematous stroma, central scar, cystic areas DWI ↑ signal in highly cellular components ↑ ADC values Not useful to differentiate from RCC T1WI C+ Dynamic postcontrast findings are similar to CECT
-Grayscale ultrasound
Well-defined, homogeneous, hypo-/isoechoic mass
Central scar: Usually echogenic
Color Doppler
Internal flow ± central radiating vessels
bladder hernia types
1) extraperitoneal- bladder protrudes through the inguinal ring, remaining entirely outside the peritoneum
2) paraperitoneal- also extraperitoneal protrusion with an adjacent peritoneal hernia
3) intraperitoneal, in which a more superior portion of the bladder carries its peritoneal covering into the inguinal ring
*paraperitoneal type is twice as common as the intraperitoneal and that extraperitoneal hernias are rare
