Congenital

• Prune Belly Syndrome

  • GU anomalies

    • Dilated ureters and bladder

    • Dilated prostatic urethra due to prostatic hypoplasia

  • Deficient abdominal musculature

  • Cryptorchidism

• Undescended testicle

Kidneys

• Congenital

  • Megacalyces

    • Calyces are enlarged

    • Renal pelvis and ureter are normal in size

  • UPJ

    • Deficiency of smooth muscle

  • Duplex collecting system

    • Lower pole refluxes

    • Upper pole obstructs

      • Ectopic insertion (medial and inferior or outside the bladder)

      • Ureterocele

• Pyelonephritis

  • Acute pyelonephritis

    • Striated nephrogram on CT

    • Gallium 67 can be used but is normally excreted by the kidneys during first 24 hours

    • In 111 WBCs can also be used

  • Xantogranulamatous pyelonephritis

    • Usually in a setting of chronic obstruction with infection in a diabetic female patient.

    • Renal parenchyma is replaced by lipid laden macrophages

    • Classic triad

      • Poorly defined renal mass

      • Staghorn calculus

      • Absent or diminished excretion of contrast medium

  • Emphysematous pyelonephritis

    • E. Coli, Klebsiella, Aerobacter, Proteus

  • Chronic pyelonephritis

    • Parenchymal scars from urine reflux usually located in the upper pole of the kidneys

  • Renal TB

    • Moth-eaten papilla

    • Papillary necrosis

    • Parenchymal calcifications

    • Parenchymal scarring

    • Irregular infundibular stenosis - hallmark of renal TB

    • Hydrocalycosis

    • Ureteral strictures

  • Candidiasis

    • Multiple filling defects from fungus balls

  • Brucellosis

    • Similar to TB

  • Opportunistic infections

    • Punctate renal calcifications

      • PCP

      • MAI

      • CMV

• Bilateral large kidneys (LG-P)

  • Leukemia/lymphoma

  • Glycogen storage disease

  • Polycystic kidney disease

• Renal cortical calcifications (COCA)

  • Cortical necrosis

    • Methoxyflurane anesthesia or ethylene glycol

    • Vascular insult

  • Oxalosis

  • Chronic glomerulonephritis

  • Alport syndrome

• Renal medullary calcifications (HMMMR)

  • Hyperparathyroidism

  • Medullary sponge kidney

  • Milk alkali syndrome

  • Medications

  • RTA

• Calcified calyces

  • Hyperparathyroidism

  • DM

  • Renal hypertension

  • Amyloidosis

• Amyloidosis

• Leucoplakia

  • Squamous metaplasia with keratinization

• Malakoplakia

  • Histiocytes contain Michaelis-Gutmann bodies (phagocytized bacteria is destroyed, but not completely digested)

  • Bladder>Ureter>Renal Pelvis>Urethra

• Cystic disease

  • Simple cysts

  • Compliacted cysts

    • Septations, calcifications, thick walls, increased density

  • Milk of calcium cysts

  • Medullary cystic disease

    • Juvenile nephronopthisis

    • Retinal renal dysplasia

  • ARPKD

    • Enlarged kidneys

  • ADPKD

  • Multicystic dysplastic kidney

    • Collection of irregularly sized cysts and fibrous tissue

    • No functioning renal parenchyma

  • Multilocular cystic nephroma

    • Well-circumscribed lesion surrounded by thick fibrous capsule

  • TS

    • Angiomyolipomas and cysts

  • vHL

    • Type 1 => retinal and CNS hemagioblastomas, renal cysts and cancers and pancreatic cysts

    • Type 2A => retinal and CNS hemagioblastomas, pheochromocytomas and islet cell tumors of the pancreas

    • Type 2B => retinal and CNS hemagioblastomas, pheochromocytomas and renal and pancreatic disease

  • Renal cysts related to dialysis

  • Orofaciodigital syndrome

    • X-linked

    • May mimick polycystic kidney disease

  • Hydatid disease

  • Renal sinus cysts

    • Parapelvic => arise from renal parenchyma

    • Peripelvic cysts => develop from sinus lymphatics

  • Perinephric cysts

    • Presumably develops from extravasation of urine which is trapped beneath the renal capsule

  • Page kidney => compression of renal parenchyma by large cyst results in hypertension

• Renal lymphangiomatosis

  • Lymphatic tissue fails to develop normal communications which results in cystic masses at the periphery of the kidneys

• Middle aortic syndrome

  • Diffuse narrowing of abdominal aorta, which involves visceral and renal arteries

• Neoplasms

  • RCC (Adenocarcinoma)

    • Staging

      • Stage 1 => confined to renal capsule

      • Stage 2 => within Gerota's fascia, ipsilateral adrenal may be involved

      • Stage 3

        • Stage 3A => renal vein, IVC

        • Stage 3B => regional lymph nodes

        • Stage 3C => venous and lymph node involvement

      • Stage 4

        • Stage 4A => through Gerota's fascia and into adjacent tissues

        • Stage 4B => distant metastases

    • Bellini duct carcinoma is a variant of RCC, which arises in the collecting duct of Bellini

  • Renal medullary carcinoma

    • Occurs in young patients with sickle cell trait

  • Oncocytoma

    • Most are well differentiated

    • Angiography demonstrates spoke wheel pattern of vessels

  • Multilocular cystic nephroma

    • Bimodal distribution

      • 3 mos to 2 yrs males

      • Middle age females

  • Wilm's tumor (nephroblastoma)

    • Associations

      • Sporadic aniridia

      • Hemihypertrophy

      • Beckwieth-Wiedemann

        • Macroglossia

        • Omphalocele

        • Adrenal cytomegaly

        • Visceromegaly

  • Nephroblastomatosis

    • Subcapsular location

    • Hypovascular

  • Mesoblastic nephroma

    • Usually detected at birth to few months of age.

  • Angiomyolipoma

    • Hypervascular on angiograms

  • Fibrous tumors

  • Osteosarcoma

  • Lipoma

  • Leiomyoma/leiomyosarcoma

  • Malignant fibrous histiocytoma

  • Hemangioma

  • Reninoma

    • Hypovascular

  • Lymphoma

  • Multiple myeloma

  • Metastases

  • Uroepithelial tumors

    • TCC

    • SCC

  • Follow-up of small lesions (from Dunnick 2nd edition)

    • <1 cm => no further follow up

    • 1-3 cm => second modality if can't establish diagnosis

    • More recent literature suggests correlation with age, clinical status and possibly biopsy or surgery

• Pyelitis cystica

  • Smooth filling defects protruding into the pelvis

• Renal transplants

  • ATN

    • Related to ischemia in donor or during period from harvesting to anastomosis in recepient

  • Cyclosporine toxicity (1-3 months)

  • Rejection

    • Hyperacute

    • Accelerated acute (1st week)

    • Acute (1-4 weeks)

      • RI > 0.9

      • PI > 1.5

    • Chronic (1-3 months)

  • Thrombosis

    • Renal artery

    • Renal vein

      • Elevated RI

    • Renal artery stenosis

  • Fluid around transplant

    • Hematoma

    • Urinoma

    • Lymphocele

    • Abscess

Ureters

• Congenital

  • Congenital megaureter

    • Definciency of smooth muscle in distal ureter near UVJ

    • The dilatation is more severe in the distal part of the ureter

  • Circumcaval ureter

• VUR

• Pseudodiverticulosis

  • Associated with malignancy (usually TCC)

• Ureterocele

  • Congenital dilatation of the intramural segment of intravesical ureter

• Pseudoureterocele

  • Edema from stone impaction

  • Bladder malignancy

  • Radiation cystitis

• Procidentia

  • Uterine prolapse in elderly females with bilateral ureteral obstruction

• Retroperitoneal fibrosis

• Ovarian vein syndrome

  • Right ovarian vein crosses the ureter at L3.

  • If thrombosed, may cause obstruction

• Dilatation of pregnancy

• Infectious

  • Schistosomiasis

    • Calcifications, dilatations and stenosis

  • TB

    • Multiple strictures

    • Calcifications

      • More focal compared to amyloidosis

• Malakoplakia – scalloping of ureters

  • Malakoplakia => ureter and bladder

  • Leucoplakia => kidneys and bladder

• Ureteritis cystica

  • Subepithelial fluid filled cysts

• Amyloidosis

  • Linear calcifications

• Endometriosis

• Benign fibroepithelial polyp

• Secondary malignancies

• Hematogenous metastases

• TCC

  • Champagne glass (goblet) sign

Bladder

• Congenital

  • Congenital bladder diverticulum

    • Hutch diverticulum

      • Close to ureteral orifice (above and lateral)

  • Bladder extrophy

    • Associated with epispadias

• Normal urothelium

  • Squamous metaplasia

    • Squamous Cancer

    • Or, Leukoplakia => Cholesteatoma

• Bladder diverticula

  • Hutch diverticulum

    • Congenital deficiency of bladder musculature near ureterovesical junction

  • Acquired diverticula

• Prune Belly Syndrome

  • Abnormal bladder development - mass effect =>

    • Triad =>

      • GU malformations

      • Cryptorchidism

      • Thinning of the abdominal musculature

• Urachus (Radiographics 2001)

  • Four types => patent urachus is the only communicating type

    • Patent urachus

    • Umbilical-urachal sinus => dilatation at the umbilicus

    • Vesicourethral diverticulum

    • Urachal cyst => umbilical and vesical ends are closed

  • Calcifications in the midline supravesical mass are considered nearly diagnostic of urachal carcinoma

• Infection/inflammation

  • Bacterial cystitis

  • Emphysematous cystitis

    • Gas formed by E. coli in the wall, which transgresses into the lumen

  • Schistosomiasis

  • Candidiasis

  • Radiation cystitis

  • Cyclophosphamide cystitis

  • Eosinophilic cystitis

    • Usually occurs in patients with severe allergic conditions

  • Alkaline encrustation cystitis

  • Interstitial cystitis

    • Results in fibrosis and very small bladder

  • Malacoplakia

    • Maybe associated with long standing malignant disease, pulmonary TB or chronic osteomyelitis

    • Rounded contour defects predominantly in the region of trigone

• Response to infection

  • Cystitis cystica

    • Degeneration of subepithelial clusters of transitional cells (von Brunn's nests) in women from recurrent or chronic cystitis secondary to E. coli infection

    • Dome like lesions on trigone

  • Cystitis glandularis

    • Further metaplasia of von Brunn nests

    • Considered premalignant

    • Irregular mucosal lesions that resemble bladder cancer

  • Nephrogenic adenoma

    • Mucosal irregularities or large masses

• Calcifications (SCATA)

  • Schistosomiasis

  • Cancer

  • Alkalotic cystitis

  • TB

  • Amyloidosis

• Masses

  • Carcinomas

    • TCC

      • Risk factors: tobacco, aniline dyes

      • Surface calcifications

      • Maybe polypoid or infiltrative

    • SCC

      • Risk factors: stones and chronic inflammation

    • Adenocarcinoma

      • Urachal remnants

  • Leiomyoma

    • Well circumscribed mass

  • Pheochromocytoma

    • Fainting episodes during urination

• Trauma

  • Contusion

  • Interstitial bladder rupture => bleeding into the wall results in thickened wall

  • Intraperitoneal bladder rupture => contrast in the peritoneal spaces

    • Cloud-like contrast

    • Require emergent surgery

  • Extraperitoneal bladder rupture => contrast fills prevesical space (space of Retzius),

    • Most common type of bladder injury

    • Molar tooth or flame-shaped appearance.

    • Simple extraperitoneal bladder rupture is confined to perivesical space

    • Complex extraperitoneal bladder rupture results in constrast extension into a variety of fascial planes and spaces

    • Can be treated conservatively

  • Combined rupture

• Urinary diversion

  • Terminal ileum

    • Kock pouch

  • Cecum and terminal ileum

    • Indiana pouch

      • Continent stoma constructed with plicated segment of terminal ileum

    • King pouch

      • Continent stoma constructed with intussuscepted ileocecal valve

• Neurogenic bladder

  • Uninhibited bladder

    • Lesion is in the cortex

    • Pontine micturition center and sacral pathways are intact

    • Uninhibited bladder contractions are not senses and are not interrupted

    • Can be evaluated with voiding cystourethrography

  • Detrusor hyperrflexia (Detrusor External Sphincter Dyssynergia - DESD)

    • Spinal cord lesion, which interupts pathway between pontine micturition center and sacral micturition center

    • Bladder is vertically oriented and trabeculated

  • Detrusor areflexia

    • Lesion is in the sacral micturition center

    • Large bladder

      • Bladder fills until pressure overcomes sphincter mechanisms

      • If leak point pressure is >40 cm of  H₂O, hydronephrosis will result with or without VUR

• Signs

  • Tear drop or vertical bladder

    • Hematoma

    • Lymphadenopathy

    • Pelvic lipomatosis

    • Collateral veins secondary to IVC obstruction

  • Elevated bladder with no mass impression

    • Thickened wall (base thickens more)

    • Retroperitoneal fibrosis (pelvic fibrilipomatosis)

    • Fluid

  • "Female prostate"

    • Impression on the base of bladder in females from urethral diverticulum

Prostate

• BPH

  • "J-ing" of ureters from gland enlargement

• Prostatitis

  • Non-specific heterogenous appearance of the gland

• Prostatic abscesses

• Carcinoma

  • Usually in peripheral zone

  • Usually hypoechoic on ultrasound, but maybe hyperechoic

  • Low signal intensity lesions on the background of high signal intensity of peripheral zone on T2

• Calcifications

  • Calcifications are a non-specific finding, which can be seen in infection, carcinoma, or may be idiopathic

Urethra

• Congenital

  • Dilated utricle

    • Associated with hypospadias

  • Posterior urethral valves

    • Type 1: Lealets extend from distal verumontanum to distal walls

    • Type 2: Probably acquired (not congenital) mucosal redundancy

    • Type 3: Distal iris like membrane

  • Fibroepithelial polyp

    • Originates in the prostate and projects into urethra

  • Meatal stenosis

  • Hypospadias

  • Epispadias

    • Associated with bladder extrophy

  • Anterior urethral diverticulum

    • Anterior urethral valve may represent a diverticulum rather than a separate entity

  • Cowper duct cyst

    • May cause mass effect on urethra

• Trauma

  • Type I: urethra is stretched

  • Type II: rupture above the urogenital diaphragm (contrast in the retropubic space).

  • Type III: complete rupture above and below the urogenital diaphragm (extravasation into the perineum and scrotum)

Female pelvis

• Congenital

  • Mullerian agenesis or hypoplasia

    • Mayer-Rokitansky-Kuster-Hauser syndrome

      • Absence of uterus, cervix and vagina

      • Ovarian and renal anomalies may or may not be present

  • Unilateral mullerian duct anomaly

    • Unicornuate uterus

  • Uterus didelphus

    • Two cervices

    • Cleft > 1 cm

    • Duplication of upper third of vagina

  • Bicornuate uterus

    • Cleft > 1 cm

    • Arcuate uterus

      • Shallow cleft < 1 cm

  • Septate uterus

    • No cleft

  • DES exposure

    • T-shaped uterus

• Uterus

  • Fibroids

    • Hypointense on T1 and T2

    • + enhancement

  • Sarcoma

  • Adenomyosis

    • Proliferation of endometrium within the myometrium

    • Junctional zone > 11 mm

    • Glands demonstrate increased T2 signal in hypointense junctional zone

  • Endometrial hyperplasia

    • Premenopausal should be < 14 mm

    • Postmenopausal should be < 8 mm (<4-5 mm normal)

  • Endometrial carcinoma

    • Extension to deep myometrium requires lymph node dissection

  • Gestational trophoblastic disease

  • Asherman syndrome

• Cervix

  • Cervical carcinoma

    • Need to evaluate for parametrial extension

    • Hydronephrosis => stage III b

  • Adenoma malignum

    • Distended vagina due to watery discharge.

• PID

• Ovaries

  • Ovarian neoplasms

    • C CFM LDS G

      • Cystadenoma

      • Cystadenocarcinoma

      • Fibroma

      • Metastases

      • Lymphoma

      • Dysgerminoma

      • Sertoli-Leydig cell tumors

      • Granulosa cell tumor

  • Krukenberg tumor

    • Metastases to ovaries

  • Cysts

    • Corpus luteum cysts

      • Crenulated walls

    • Theca lutein cysts

      • Large multilocular cysts

    • Peritoneal inclusion cysts => ovarian fluid entraped by adhesions

      • Ovary within a cyst appearance

  • Polycystic ovarian syndrome

  • Ovarian torsion

• Ectopic pregnancy

• Endometriosis

  • Hyperintense on T1, variable on T2

Retroperitoneum

• Fluid (HULA)

  • Hemorrhage

  • Urinoma

  • Lymphocele

  • Abscess

• Chyluria

• Retroperitoneal fibrosis

• Masses (LMLMLT)

  • Lymphoma/leukemia

  • Metastases

  • Liposarcoma

  • Malignant fibrous histiocytoma

  • Leiomyosarcoma

  • Teratoma

Adrenals

• Adrenals

  • Adrenal hyperplasia

  • Adrenal adenoma

    • < 3cm

    • Well-defined, smooth contour

    • Uniform density (-20 HU to + 30 HU), if <10 HU → 95% sensitivity

    • Minimal contrast enhancement

    • 60% washout on 15 min scans

    • 50% washout on 10 min scans

  • Calcification rare

  • Adrenal carcinoma

  • Pheochromocytoma

    • VHL

    • NF

    • MEN

  • Adrenal metastases

    • Lung, breast, lymphoma, melanoma

    • Collision tumor: met to adenoma

  • Adrenal cyst

  • Adrenal myelolipoma

  • Adrenal hemorrhage

• Masses: Benign

  Adenoma	<3cm	<15HU	iso or hypo to liver
  Pheochrom	3-4cm, large		homogenous, necrosis, cystic appearing
  Myelolipoma	<5cm		heterogenous
  Hemangioma	large		thick irreg wall, hypodense center

  • Lymphangiomas are water density

• Masses: Malignant