GENITOURINARY IMAGING 4 Flashcards

Question

What are the imaging features of this? What is found on Bx? What is the underlying cause?

Answer 1

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

Answer 2

IVP: * little opacification, * prolonged nephrogram, * striated nephrogram (stasis in collecting tubules); * intrarenal collecting system is stretched and compressed by edema

Answer 3

75% of tumors are unilateral.

Answer 4

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.

Answer 5

**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

Answer 6

MAG 3 results in better quality images in transplant patients with renal insufficiency compared with DTPA.

Answer 7

Acute Bacterial Cystitis Pathogens: 1. E. coli 2. Staphylococcus 3. Streptococcus 4. Pseudomonas

Answer 8

* 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

Answer 9

* **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

Answer 10

Common Transplant Complications 1. ATN 2. Rejection 3. Cyclosporine toxicity 4. Arterial or venous occlusion 5. Urinary leak 6. Urinary obstruction

Answer 11

**_Renal Transplant Donor Evaluation_** Transplant donor evaluation is most commonly done by CT or MRI and involves the following steps: 1. **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. 2. **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. 3. **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. 4. **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. 5. **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. 6. **Aberrant renal venous anatomy.** 7. **Collecting system anomalies (duplication).**

Answer 12

**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

Answer 13

**_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/

Answer 14

Cystitis cystica https://www.liebertpub.com/doi/10.1089/cren.2017.0010

Answer 15

Ureteral Diverticulum ( Fig. 4.17 ) Congenital blind-ending ureter. Probably caused by aborted attempt at duplication. https://radiologykey.com/diagnostics-of-ureteral-diverticula/

Answer 16

Causes * Trauma to renal vessels * Embolism * Cardiac causes * atrial fibrillation * endocarditis * Catheter * Thrombosis * Arterial * Venous

Answer 17

* 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 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

Answer 18

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](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.

Answer 19

* Hutch diverticulum: * congenital weakness of musculature near UVJ * Usually associated with reflux https://www.urologyhealth.org/urology-a-z/b/bladder-diverticulum

Answer 20

* Ureterosigmoidostomy * Distal ureter(s) drain into sigmoid colon; ureters are tunneled for antiperistalsis. * Procedure is largely surpassed by ileal conduit nowadays because of complications * (e.g., pyelonephritis, * reflux, * hyperchloremic acidosis, * high risk of colon cancer).

Answer 21

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

Answer 22

* 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

Answer 23

**_4 causes of perirenal fluid collections in Renal transpla_**nts * **Lymphocele:** * **in 10%–20% of transplants at 1–4 months posttransplan**t. * 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

Answer 24

Females: ectopic ureter commonly empties into: 1. postsphincteric urethra, 2. vagina, 3. tubes, 4. perineum

Answer 25

TCC, 90% of bladder malignancy 1. Aniline dyes 2. Phenacetin 3. Pelvic radiation 4. Tobacco 5. Interstitial nephritis

Answer 26

1. Benign prostatic hypertrophy 2. Bladder lesions 3. Tumor 4. Calculus 5. Ureterocele 6. Urethral stricture 7. Postoperative, traumatic 8. Detrusor/sphincter dyssynergy

Answer 27

**_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

Answer 28

* Malignant tumors * Epithelial: * TCC, * SCC, * adenocarcinoma * Mesodermal: * sarcoma, * angiosarcoma, * carcinosarcoma

Answer 29

Ectopic Ureter Ureter does not insert in the normal location in the trigone of the bladder (see Chapter 11 ). Incidence: **male-female ratio 1 : 6.**

Answer 30

**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**

Answer 31

Loopogram 1. Insert 18- to 24-Fr Foley catheter with 5-mL balloon inflated in conduit. 2. 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. 3. Search for drainage, stasis, stenosis, extravasation, calculi, or tumor. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 38261

Answer 32

**Epidemiology** In a large cohort study, the mean age of neurogenic bladder patients was 62.5 years. **Aetiologies included 4:** 1. Multiple sclerosis: ~17% 2. Parkinson disease: ~15% 3. Cauda equina syndrome: ~9% 4. Paralytic syndrome: ~8% 5. 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

Answer 33

Sites of metastatic spread of primary ureteral neoplasm (at autopsy): * **Retroperitoneal lymph nodes, 75%** * **Liver, 60%** * **Lung, 60%** * Bone, 40% * Gastrointestinal tract, 20% * Peritoneum, 20% * Other (\<15%): adrenal glands, ovary, uterus

Answer 34

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

Answer 35

Predisposing Factors * Instrumentation, trauma * Bladder outlet obstruction * neurogenic bladder * Calculus * Cystitis * Tumor

Answer 36

Chronic Cystitis Repeated bacterial infections are usually due to such causes as: * reflux, * diverticulum, or * bladder outlet obstruction.

Answer 37

1. **Intraluminal filling defect** 2. **Goblet sign:** retrograde pyelogram demonstrates dilated ureteral segment distal to obstruction with filling defect and meniscus. 3. **Bergman coiled catheter sign:** on retrograde pyelogram, the catheter is typically coiled in dilated portion of ureter just distal to the lesion.

Answer 38

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

Answer 39

Prognosis • 50% of patients will develop bladder cancer. • 75% of tumors are unilateral. • 5% of patients with bladder cancer will develop ureteral cancer.

Answer 40

• 5% of patients with bladder cancer will develop ureteral cancer.

Answer 41

Painless hematuria

Answer 42

Functional Evaluation of Transplanted Kidney * Normal perfusion and excretion by scintigraphy (MAG 3 , DTPA) * Resistive index (P sys – P diast /P sys ) should be \<0.7 by Doppler US Renal transplant scintigraphy is a non-invasive diagnostic modality, using radioactive isotopes, to assess renal transplant related complications. Renal scintigraphy images are acquired with a dynamic planar procedure using a radioactive isotope visualised on a gamma camera. The final result is a two-dimensional timeframe image. This enables visual inspection of arterial patency, tracer uptake indicating renal perfusion, and tracer excretion to the bladder 1. This diagnostic modality is part of the standard renal transplant follow-up in many transplant centres, however, not included in current guidelines 2. It is considered a sensitive diagnostic tool for the assessment of urological and vascular complications and postoperative fluid collections. Also, early post-transplant procedures are used to assess renal transplant dysfunction, in particular delayed graft function 3-5. The most frequently used radioactive isotope for transplant renal scintigraphy are Tc-99m MAG3 and Tc-99m DTPA. These tracers can be used for qualitative and quantitative assessment of renal transplant perfusion and excretion 6,7. https://radiopaedia.org/articles/renal-transplant-scintigraphy

Answer 43

* Benign tumors * Epithelial: * inverted papilloma, * polyp, * adenoma * Mesodermal: * fibroma, * hemangioma, * myoma, * lymphangioma * Fibroepithelial polyp: * mobile long intraluminal mass, * ureteral intussusception

Answer 44

Chronic thrombosis * Small kidneys * Collateral veins may cause pelvic and ureteral notches by extrinsic compression.

Answer 45

**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

Answer 46

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

Answer 47

Colon Conduit Ureter(s) drain into isolated colon segment. Ureters are tunneled submucosally for antireflux.

Answer 48

Scintigraphy ( 99m Tc DTPA): absent or delayed renal perfusion and excretion, alternatively may be delayed and reveal a large kidney 4. Renal venous thrombosis Although renal vein thrombosis is associated with low mortality, the outcome of renal function is not good [30], so these patients require close clinical follow up with serial sonography and 99mTc-DMSA scan [31]. Also, serial renal scintigraphy using 99mTc-MAG3 can be a sensitive method for the diagnosis and follow-up of these patients since renogram gives additional functional information regarding excretion. Typically, the findings of renal scintigraphy with 99mTc-MAG3 in renal venous thrombosis is presented as decreased perfusion, delayed cortical uptake, retention of radiotracer in the parenchyme, and no excretion.

Answer 49

**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

Answer 50

Associations * 80% have complete ureteral duplication. * 30% have a ureterocele (“cobra head” appearance on IVP)

Answer 51

**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.

Answer 52

Treatment * Nonmuscle invasive * only involvement of mucosa and lamina propria * typically resected endoscopically * Muscle invasive * with extension into detrusor muscle or deeper * radical cystectomy and lymph node dissection

Answer 53

Congenital urachal anomalies are twice as common in **men** as in women.

Answer 54

Cyclosporine toxicity is uncommon within first month after transplant.

Answer 55

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

Answer 56

Radiation cystitis occurs in 15% of patients receiving 6500 rad for pelvic malignancies. https://www.eurorad.org/case/9228

Answer 57

Bladder Injuries Bladder injuries occur in 10% of patients with pelvic fractures; instrumentation and penetrating trauma are less common causes. There are two types of ruptures: extraperitoneal and intraperitoneal. The likelihood of rupture increases with degree of distention of the bladder at time of injury. Intraperitoneal rupture is treated surgically, whereas extraperitoneal rupture is treated conservatively with Foley catheter.

Answer 58

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 [http://www.learningradiology.com/lectures/facultylectures/US%20Renal%20Transplantation%20HTML5/US%20Renal%20Transplantation/US%20Renal%20Transplantation.html](http://www.learningradiology.com/lectures/facultylectures/US%20Renal%20Transplantation%20HTML5/US%20Renal%20Transplantation/US%20Renal%20Transplantation.html)

Answer 59

**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/

Answer 60

**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

Answer 61

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

Answer 62

• Males: ureter inserts ectopically into the: 1. bladder \> 2. prostatic urethra \> 3. SVs, 4. vas deferens, 5. ejaculatory ducts

Answer 63

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***

Answer 64

Types * Spastic bladder: upper motor neuron defect * Atonic bladder: lower motor neuron defect

Answer 65

SCC, 5% 1. Calculi 2. Chronic infection 3. leukoplakia 4. Schistosomiasis

Answer 66

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.

Answer 67

* 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. * 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**

Answer 68

**The likelihood of rupture increases with degree of distention of the bladder at time of injury.** Bladder Injuries Bladder injuries occur in 10% of patients with pelvic fractures; instrumentation and penetrating trauma are less common causes. There are two types of ruptures: extraperitoneal and intraperitoneal.Intraperitoneal rupture is treated surgically, whereas extraperitoneal rupture is treated conservatively with Foley catheter.

Answer 69

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

Answer 70

## Footnote **Hyperacute rejection** has decreased flow but excretion on delayed images **(opposite to ATN).**

Answer 71

**Cyclophosphamide treatment** results in **hemorrhagic cystitis** in **40%** of patients. Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 29842

Answer 72

**_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**

Answer 73

Ileal Loop ( Fig. 4.18 ) * Ureter(s) drain into isolated ileal segment, which serves as an isoperistaltic conduit (not as a reservoir). * May or may not have a surgical “intussusception” of conduit. * **Fifty percent of patients have hydronephrosis immediately postoperatively; the hydronephrosis should resolve by 3 months.** * Common locations of strictures are at the: * ureteroileal anastomosis and where the * left ureter enters the peritoneum.

Answer 74

Neurogenic Bladder The detrusor muscle is innervated by **S2–S4 parasympathetic nerves.**

Answer 75

* 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

GENITOURINARY IMAGING 4 Flashcards

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