Imaging in Genitourinary System dr Harry Galuh Nugraha

Imaging in Genitourinary System dr. Harry Galuh Nugraha, Sp. Rad

ANATOMY Genitourinary System • Urinary System – Kidney – Ureter – Bladder – Urethra

ANATOMY

ANATOMY Genitourinary System • Genital/Reproductive – Male • • Testis Epidydimis Vas deferen Ejaculatory duct Prostate Seminal vesicle Penis – Female • • • Uterus Salphynx Ovaries Cervix Vagina

ANATOMY Male Reproductive System

ANATOMY Female Reproductive System

ANATOMY KIDNEY • Bean shaped (convex laterally & concave medially) • Length: ± 11, 5 cm or 31/2 vertebral body) • Width: ± 5 -8 cm • Thickness: ± 3 cm • Retroperitoneal • Between Th 12 - L 3 • Right kidney is lower ± 1 cm than left kidney

ANATOMY KIDNEY

ANATOMY KIDNEY

ANATOMY URETER • Diameter 1 mm-1 cm • Length: 25 -30 cm • Retroperitoneal • Three normal narrowing area – Pelvoureter junction (PUJ) – Pelvic brim where the iliac vessels cross the ureter – Vesicoureter junction (VUJ)

ANATOMY URETER

ANATOMY BLADDER • Urine reservoir • Posterosuperior to the pubic bone • Position: – Empty: In the pelvic cavity – Full: Extend to the abdominal cavity • Capacity – Adult: 350 -500 cc – Children: (Age [in year] + 2) x 30 cc

ANATOMY BLADDER

ANATOMY URETHRA • Length: – Male: 17, 5 -20 cm – Female: 4 cm • Male urethra divided by inferior aspect of urogenital diaphragm into: – Anterior part • Cavernous/Penile part • Bulbar part – Posterior part • Membranous part • Prostatic part

ANATOMY URETHRA

ANATOMY

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Voiding Cystourethrography – Ultrasonography – CT Scan – MRI – Nuclear Imaging – Hysterosalphingography

PLAIN ABDOMINAL X-RAY • Routine • Good quality films will show the kidney outlines – Enlargement (mass/hydronephrosis) can be recognized • Calcification – Opaque calculi in the kidney, ureter or bladder – Nephrocalcinosis : calcification in the renal parenchym. • Air distribution in the bowel – Sentinel loop

NORMAL

KIDNEY STONE

KIDNEY STONE

URETERAL STONE

BLADDER STONE

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Voiding Cystourethrography – Ultrasonography – CT Scan – MRI – Nuclear Imaging – Hysterosalphingography

BNO-IVP • Blass = Urinary bladder, Nier = Kidney, Overzicht = Examination • Synonim: – Intravenous urography – Excretory urography – Intravenous pyelography

BNO-IVP • Use contrast media intravenously • Anatomic function: – Depict the minor calyx, major calyx, renal pelvis, ureter, urinary bladder. • Physiologic function: – Assess the kidney function in contrast media filtration and excretion.

BNO-IVP • Indication – Evaluate mass or cyst – Urolithiasis (calculi in the kidney or urinary tract) – Pyelonephritis – Glomerulonephritis – Hydronephrosis – Trauma – Renal hypertension

BNO-IVP • Contraindication – – – Allergy Asthma Anuria Renal failure Cardiovascular disease Severe liver function abnormality Diabetes mellitus Sickle cell disease Multiple myeloma Pheochromocytoma Pregnancy

BNO-IVP • Contraindication – – – Allergy Asthma Anuria Renal failure Cardiovascular disease Severe liver function abnormality Diabetes mellitus Sickle cell disease Multiple myeloma Pheochromocytoma Pregnancy

BNO-IVP Procedure • 1 -3 minute : Nephrogram phase • Ureteral compression • 5 minute : Excretory function • 15 minute : Pelvocalyceal system • Compression can be released if the pelvocalyceal system has been seen adequately • 30 minute : After the compression was released to see the urinary tract from the kidney to the bladder • 45 -60 minute : fullbladder • Post voiding : passage of contrast agent

BNO-IVP Contraindication of compression : • Suspected stone • Acute abdomen • Following abdominal surgery • Large abdominal mass • Aortic aneurysm Use trendelenburg position instead

BNO IVP

1 -3 Minute

5 Minute

15 Minute

30 Minute

Full Blast

Post Voiding

HYDRONEPHROSIS CAUSED BY URETERIC STONE (Black arrow

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Voiding Cystourethrography – Ultrasonography – CT Scan – MRI – Hysterosalphingography

Retrograde Urethrography • To assess the urethra • The contrast media is injected from the distal to the proximal part of the urethra (retrograde or ascending)

Retrograde Urethrography Indication • Urethral rupture • Urethral stricture • Congenital anomaly • Urethral fistule • Urethral diverticle • Urethral obstruction • Hematuria • Recurrent urinary tract infection • Slow urinary flow • Urinary mass

Retrograde Urethrography Contraindication • Acute urinary tract infection

Retrograde Urethrography

Retrograde Urethrography Urethral rupture

Retrograde Urethrography Urethral stricture with periurethral abscess

Retrograde Cystography • To assess the urinary bladder • The contrast media is injected through the urinary catheter into the urinary bladder • Retrograde to the urinary flow

Retrograde Cystography Indication • Recurrent urinary tract infection • Suspicion of urinary bladder rupture • Stone • Mass • Inflammation • Diverticle • Fistule • Incontinentia • Hematuria • Measure the urinary volume post micturition • Assess the integrity of the anastomosis or suture post operative

Retrograde Cystography Contraindication • Pregnancy • Urethral rupture (contraindication to the urinary catheter insertion)

Retrograde Cystography

Retrograde Urethrocystography • To assess the urinary bladder and the urethra. • Combination of the retrograde urethrography and cystography. • The contrast media is injected through the external urethral orificium to fill the urethra and then the urinary bladder.

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde & antegrade pyelography – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Voiding Cystourethrography – Ultrasonography – CT Scan – MRI – Hysterosalphingography

Bipolar Urethrocystography • To assess the urethra from the proximal and distal aspects. • Retrograde from the distal urethra • Antegrade from the cystostomy catheter • Patient is asked to void so that the contrast media will fill the proximal part of the urethra.

Bipolar Urethrocystography Indication • Assess the proximal and distal margin of obstruction (stricture, stone, mass) in the urethra Contraindication • Allergy to contrast media

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde & antegrade pyelography – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Ultrasonography – CT Scan – MRI – Hysterosalphingography

Ultrasonography • The kidneys are well shown by ultrasound – Mass – Cyst (simple or polycystic) – Hydronephrosis – Stone – Nephrostomy guiding

Ultrasonography Renal Mass

Ultrasonography Simple cyst

Ultrasonography Hydronephrosis

Ultrasonography Kidney stone

Ultrasonography • The distended urinary bladder is also well shown by abdominal ultrasound – Mass – Stone – Inflammation – Infection – Diverticle

Ultrasonography Urinary Bladder Mass

Ultrasonography Urinary bladder stone

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde & antegrade pyelography – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Ultrasonography – CT Scan – MRI – Hysterosalphingography

CT scan • Mass, cyst and various lesion of the kidneys are all well shown • Gold standard in urinary tract stone • Staging in tumour

CT scan Ureteric stone with hydronephrosis

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde & antegrade pyelography – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Ultrasonography – CT Scan – MRI – Hysterosalphingography

MRI • Staging in tumour • Superior to CT in staging the bladder and prostatic tumour • Good contrast resolution

MRI Renal mass

IMAGING MODALITIES – Plain abdominal x ray – BNO-IVP – Retrograde & antegrade pyelography – Retrograde uretrography/cystography/urethrocystography – Bipolar Urethrocystography – Ultrasonography – CT Scan – MRI – Hysterosalphingography

Hysterosalpingography • Primarily demonstrate the uterus and the salpynx (fallopian tube)

Hysterosalpingography Indication • Infertility assessment – Obstruction (can be therapeutic) – Anatomic anomaly (e. g. uterine bicornis) • Intrauterine pathology – Endometrial polyps – Uterine fibroids – Intrauterine adhesion • Post operative assessment after tubal ligation or reconstructive surgery

Hysterosalpingography Contraindication • Pregnancy (performed 7 -10 days after the onset of menstruation) • Acute pelvic inflammatory disease • Active uterine bleeding

Hysterosalpingography

Left Hydrosalpynx

Uterus bicornis

Thank you for your attention