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4. Wilms tumor
B. BENIGN TUMOR
5. Angiomyolipoma
6. Nephroblastomatosis
C. CYSTS
7. Adult polycystic kidney disease
8. Acquired cystic kidney disease
# Unilateral Renal Mass
## Solid Renal Mass
A. TUMORS
(a) primary malignant:
> epithelial tumor of renal parenchyma: adenocarcinoma ( $83 \%$ ), papillary neoplasm ( $14 \%$ ), chromophobe carcinoma ( $4 \%$ ), renal neuroendocrine tumors (carcinoid, small cell carcinoma), Wilms tumor (6\%)
> epithelial tumor of renal pelvis: TCC (8\%), squamous cell carcinoma
> medullary tumor: renal medullary carcinoma, renal collecting duct carcinoma $=$ Bellini duct carcinoma ( $1 \%$ )
> renal sarcoma ( $2 \%$ )
in horseshoe kidney:
adenocarcinoma (45\%), Wilms tumor (28\%), transitional cell carcinoma (20\%)
(b) secondary malignant: malignant lymphoma / Hodgkin disease, metastases, invasive transitional cell carcinoma
(c) benign: adenoma, oncocytoma, hamartoma (mesoblastic nephroma, angiomyolipoma, myolipoma, lipoma, leiomyoma, fibroma), hemangioma
B. INFLAMMATORY MASSES
acute focal pyelonephritis, renal abscess, malakoplakia, xanthogranulomatous
pyelonephritis, tuberculoma
## Fluid-filled Renal Lesion
A. CYSTS
1. Simple renal cyst
$\checkmark$ simple fluid attenuation of $0-20 \mathrm{HU}$
2. Complicated renal cyst
3. Inherited cystic disease:
multicystic dysplastic kidney disease (Potter type II), multilocular cystic nephroma
4. Focal hydronephrosis
B. VASCULAR
5. Arteriovenous malformation
6. Arteriovenous fistula
C. CYSTIC MASS
7. Renal cell carcinoma
$\diamond$ Lesions $<1 \mathrm{~cm}$ often cannot be clearly characterized!
$\diamond$ Lesions $1-1.5 \mathrm{~cm}$ can often be ignored, particularly in elderly / patients with significant
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969 |
other disease
# Calcified Renal Mass
$\diamond$ A calcified renal mass is malignant in $75 \%$ of cases!
$\diamond$ Lesions with
(a) nonperipheral calcifications are malignant in $87 \%$ !
(b) peripheral calcifications are malignant in $20 \%$ !
A. MALIGNANT TUMOR
1. Renal cell carcinoma (calcifies in $8-20 \%$ )
$\checkmark$ calcifications generally nonperipheral, sometimes along fibrous capsule
2. Wilms tumor
3. Transitional cell carcinoma (rare)
4. Osteosarcoma of renal capsule
5. Metastasis
B. INFECTION
6. Abscess
$\diamond$ Tuberculous abscess frequently calcifies!
$\diamond$ Pyogenic abscess rarely calcifies!
7. Echinococcal cyst
$\diamond$ Renal involvement in $3 \%$ of hydatid disease;
$\diamond 50 \%$ of echinococcal cysts calcify
8. Xanthogranulomatous pyelonephritis
$\checkmark$ large obstructive calculus in $>70 \%$
C. CYSTS
$\diamond$ Calcification is related to prior hemorrhage / infection!
9. Simple renal cyst (calcifies in $1-3 \%$ )
$\checkmark$ thin peripheral "eggshell"-like calcification
10. Multicystic dysplastic kidney (in adult)
11. Autosomal dominant polycystic kidney disease
12. Milk of calcium: cyst, caliceal diverticulum, obstructed hydrocalyx
$D D x$ : residual pantopaque used in cyst puncture
D. VASCULAR
13. Subcapsular / perirenal hematoma
14. Renal artery aneurysm
$\checkmark$ circular cracked eggshell appearance
15. Congenital / posttraumatic arteriovenous malformation
16. Arteriosclerosis: in severe atherosclerotic disease, diabetes mellitus, hyperparathyroidism
17. Sloughed papilla: in papillary necrosis
18. Hemangioma
## Avascular Mass in Kidney
mnemonic: CHEAT
Cyst
Hematoma
|
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970 |
Edema
Abscess
Tumor
# Growth Pattern of Renal Lesions
## Renal Lesion with Expansile Growth Pattern
1. Renal cell carcinoma
2. Oncocytoma
3. Angiomyolipoma
4. Juxtaglomerular tumor
5. Metastatic tumor: eg, lymphoma
6. Mesenchymal tumor
## Renal Lesions with Infiltrative Growth Pattern
Imaging hallmarks:
$\checkmark$ growth initially respects renal contour
$\checkmark$ invasion of normal structures
$\checkmark$ poorly defined interface between normal renal parenchyma and lesion
$\checkmark$ enlarged kidney with preservation of reniform shape
IVP:
$\checkmark$ decreased / absent nephrogram
Angio:
$\checkmark$ vascular encasement, pruning, amputation
$\checkmark$ no vascular displacement
CT:
$\checkmark$ poorly marginated area of diminished enhancement
$\checkmark$ encasement of collecting system without displacement
$\checkmark$ replacement of renal sinus fat
US:
$\checkmark$ poorly circumscribed hypo- / hyperechoic regions
A. NEOPLASM
(a) lymphoproliferative
1. Lymphoma / leukemia
2. Extramedullary plasmacytoma
(b) epithelial tumor of renal parenchyma
3. Renal cell carcinoma (unusual)
4. High-grade and sarcomatoid type of RCC
(c) epithelial tumors of the renal pelvis
5. Invasive transitional cell carcinoma
$\checkmark$ mass arises from collecting system
6. Squamous cell carcinoma
(d) medullary tumor of uncertain cell origin
7. Collecting duct carcinoma
8. Renal medullary carcinoma
|
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971 |
(e) metastases: esp. lung cancer
(f) renal sarcomas
(g) pediatric tumor
1. Mesoblastic nephroma
2. Rhabdoid tumor of the kidney
3. Nephroblastomatosis
4. Primitive neuroectodermal tumor
5. Wilms tumor (unusual)
B. INFLAMMATION
6. Bacterial pyelonephritis
7. Xanthogranulomatous pyelonephritis
8. Renal parenchymal malakoplakia
# Local Bulge in Renal Contour
A. CYST
1. Simple renal cyst
B. TUMOR
2. Adenocarcinoma
3. Angiomyolipoma
4. Pseudotumor
C. INFECTION
5. Subcapsular abscess
6. XGP
D. TRAUMA
7. Subcapsular hematoma
E. DILATED COLLECTING SYSTEM
## Hyperechoic Renal Nodule
A. MALIGNANT TUMOR
1. Renal cell carcinoma
2. Angiosarcoma
3. Liposarcoma
4. Undifferentiated sarcoma
5. Lymphoma
B. BENIGN TUMOR
6. Angiomyolipoma
7. Lipoma
8. Oncocytoma
9. Cavernous hemangioma
C. INFARCT
D. HEMATOMA
Focal Area of Increased Renal Echogenicity
A. NONNEOPLASTIC
1. Chronic renal infarction
|
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972 |
2. Acute focal bacterial nephritis
B. BENIGN TUMOR
3. Angiomyolipoma
4. Cavernous renal hemangioma
5. Oncocytoma
C. MALIGNANCY
6. Renal cell carcinoma
7. Angiosarcoma
8. Undifferentiated sarcoma
9. Metastasis
# Hyperattenuating Renal Mass on NECT
$=$ attenuation higher than
(a) renal parenchyma $(>40 \mathrm{HU})$
(b) $>20 \mathrm{HU}$ (more restrictive definition)
## Pathogenesis:
(a) elevated iron content
(b) blood breakdown products, high protein content, colloid formation
(c) infection
(d) transient iodine accumulation in cyst
(e) completely solid mass
(f) diffuse microcalcifications
A. BENIGN
1. Complicated benign cyst: hemorrhagic, protein-rich, gelatinous (most common), eg, in autosomal dominant polycystic kidney disease
2. Hematoma, renal contusion
3. Vascular abnormality: AVM, pseudoaneurysm, aneurysm, thrombosed renal vein
4. Focal inflammation: focal bacterial nephritis
5. Angiomyolipoma ( $4-5 \%$ without fat)
6. Metanephric adenoma
7. Leiomyoma
B. MALIGNANT
8. Malignant multiseptate cyst: multilocular cystic nephroma, cystic renal cell carcinoma
9. Renal cell carcinoma ( $2 \%$ hyperattenuating)
10. Papillary renal cell carcinoma
11. Lymphoma (rare)
12. Oncocytoma (rare)
13. Metastasis from thyroid carcinoma
## Fat-containing Renal Mass
1. Angiomyolipoma
2. Lipoma, liposarcoma
3. Teratoma
4. Wilms tumor
5. Xanthogranulomatous pyelonephritis
|
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973 |
6. Oncocytoma engulfing renal sinus fat
7. Renal cell carcinoma
(a) invasion of perirenal fat
(b) intratumoral metaplasia into fatty marrow (in $32 \%$ of RCCs $<3 \mathrm{~cm}$ in diameter)
$\diamond$ If a lesion contains fat + calcium RCC is likely, NOT angiomyolipoma!
# Renal Pseudotumor
$=$ normal renal tissue mimicking a renal mass
A. PRIMARY / CONGENITAL
1. Large column of Bertin
$=$ LARGE SEPTUM / CLOISON OF BERTIN = LARGE CLOISON = FOCAL CORTICAL HYPERPLASIA = BENIGN CORTICAL REST = FOCAL RENAL HYPERTROPHY
$=$ persistence of normal septal cortex / excessive infolding of cortex usually in the presence of partial or complete duplication
Location: between upper and interpolar portion
$\sqrt{ }$ mass $<3 \mathrm{~cm}$ in largest diameter
$\sqrt{ }$ lateral indentation of renal sinus
$\sqrt{ }$ "deformation" of adjacent calyces + infundibula
$\sqrt{ }$ mass continuous with renal cortex
$\sqrt{ }$ enhancement pattern like renal cortex
$\sqrt{ }$ echogenicity similar to cortex
2. Dromedary hump
$=$ SUBCAPSULAR NODULE $=$ SPLENIC BUMP
Cause: prolonged pressure by spleen during fetal development
Location: in mid portion of lateral border of left kidney
$\sqrt{ }$ triangular contour + elongation of middle calyx
$\sqrt{ }$ enhancement pattern like renal cortex
3. Hilar lip
$=$ SUPRA- / INFRAHILAR BULGE
$=$ medial part of kidney above / below sinus
Location: most frequently medial to left kidney just above renal pelvis (on transaxial scan)
$\sqrt{ }$ enhancement pattern like cortex with medulla
4. Fetal lobation
$=$ PERSISTENT CORTICAL LOBATION = REN LOBATUS
$=14$ individual lobes with centrilobar cortex located around calyces
5. Lobar dysmorphism complete diminutive lobe situated deep within renal substance with its own diminutive calyx in its central portion = calyx of nonresorbed normal junctional parenchyma between upper + lower subkidneys
B. ACQUIRED
6. Nodular compensatory hypertrophy areas of unaffected tissue in the presence of focal renal scarring from chronic atrophic pyelonephritis (= reflux nephropathy), surgery, trauma, infarction
$\sqrt{ }$ hypertrophy usually evident within 2 months; less likely to occur $>$ age 50
|
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974 |
$\sqrt{ }$ "mass" enhances identically to renal parenchyma
$D D x$ : accessory spleen, medial lobule of spleen, splenosis, normal / abnormal bowel, pancreatic disease, gallbladder, adrenal abnormalities
$D x$ : static radionuclide imaging / renal arteriography / CT
# Pseudokidney Sign
= sonographic mass of reniform appearance with a central hyperechoic region surrounded by a hyperechoic region
1. Intussusception
2. Necrotizing enterocolitis
3. Midgut volvulus
4. Sigmoid volvulus
5. Crohn disease
False-positive:
feces in colon, perforated Meckel diverticulum with malrotation + Ladd bands, psoas muscle, hematoma
## RENAL CYSTIC DISEASE
## Potter Classification
$=$ POTTER SYNDROME
$=$ any renal condition associated with severe oligohydramnios
- peculiar facies with wide-set eyes, parrot-beak nose, pliable low-set ears, receding chin
Type I : infantile PCKD
Type II : multicystic dysplastic kidney disease, multilocular cystic nephroma
Ila: kidneys of normal / increased size
IIb : kidneys reduced in size
Type III : adult PCKD, tuberous sclerosis, medullary sponge kidney
Type IV : small cortical cysts / cystic dysplasia $\leftarrow$ ureteropelvic junction obstruction
## Renal Cystic Disease
A. GENETIC CYSTIC DISEASE
1. Autosomal dominant polycystic kidney disease
2. Autosomal recessive polycystic kidney disease
3. Medullary sponge kidney
4. Medullary cystic disease
5. Glomerulocystic kidney disease
B. OBSTRUCTIVE CYSTIC DISEASE
6. Multicystic dysplastic kidney
7. Segmental / focal renal dysplasia
8. Familial renal dysplasia
C. ACQUIRED CYSTIC DISEASE
9. Simple cyst
10. Parapelvic cyst
11. Acquired cystic disease of uremia
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975 |
4. Infectious cysts: TB, Echinococcus, abscess
5. Medullary necrosis
6. Pyelogenic cyst
7. Lithium-induced nephropathy
D. CYSTS ASSOCIATED WITH SYSTEMIC DISEASE
8. Tuberous sclerosis
9. Von Hippel-Lindau disease
E. CYSTIC TUMORS
10. Multilocular cystic nephroma
11. Cystic Wilms tumor
12. Cystic renal cell carcinoma
13. Mixed epithelial and stromal tumor
Focal Renal Cystic Disease
1. Mixed epithelial and stromal tumor
2. Multilocular cystic nephroma
3. Pyelocalyceal diverticulum
Acquired Multifocal Cystic Renal Disease
1. Glomerulocystic kidney disease
2. Lithium-induced nephropathy
3. Acquired cystic kidney disease
4. Multicystic dysplastic kidney
5. Localized cystic renal disease
6. Renal sinus cyst
# Cystic Kidney Infection
1. Renal abscess
2. Renal aspergillosis
3. Renal echinococcosis
## Renal Cystic Disease in Adults
A. HEREDITARY
1. Autosomal dominant polycystic kidney disease
2. Von Hippel-Lindau disease
3. Tuberous sclerosis complex
4. Medullary cystic kidney disease
B. NONHEREDITARY
5. Acquired cystic kidney disease
6. Medullary sponge kidney
7. Multicystic dysplastic kidney
8. Localized renal cystic disease
## Syndromes with Multiple Cortical Renal Cysts
1. Von Hippel-Lindau syndrome
2. Tuberous sclerosis
|
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976 |
3. Meckel-Gruber syndrome
4. Jeune syndrome
5. Zellweger syndrome $=$ cerebrohepatorenal syndrome
6. Conradi syndrome $=$ chondrodysplasia punctata
7. Orofacialdigital syndrome
8. Trisomy 13
9. Turner syndrome
10. Dandy-Walker malformation
# Multiloculated Renal Mass
$=>3-4$ septations
$R x:$ most multiloculated renal masses are treated with excision / nephrectomy
A. NEOPLASTIC DISEASE
1. Cystic renal cell carcinoma
2. Multilocular cystic renal tumor
(a) adult cystic nephroma
(b) cystic partially differentiated nephroblastoma
3. Cystic Wilms tumor
4. Necrotic tumor
(a) mesoblastic nephroma
(b) clear cell sarcoma
B. RENAL CYSTIC DISEASE
5. Localized renal cystic disease
6. Septated cyst
7. Multicystic dysplastic kidney
8. Segmental multicystic dysplasia
9. Complicated cyst
C. INFLAMMATORY DISEASE
10. Echinococcus
11. Segmental XGP
12. Abscess
13. Malakoplakia
D. VASCULAR LESIONS
14. AV fistula
15. Organizing hematoma
## ABNORMAL NEPHROGRAM
## Absence of Nephrogram
## Global Absence of Nephrogram
Pathophysiology: complete renal ischemia $\leftarrow$ occlusion of main renal artery
1. Injury to vascular pedicle during blunt abdominal trauma
2. Thromboembolic disease
3. Renal artery dissection: spontaneous, traumatic, iatrogenic
|
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977 |
# Segmental Absence of Nephrogram
A. SPACE-OCCUPYING PROCESS
1. Neoplasm
2. Cyst
3. Abscess
B. FOCAL RENAL INFARCTION
4. Arterial embolus / thrombosis
5. Vasculitis, collagen-vascular disease
6. Sickle cell anemia
7. Septic shock
8. Renal vein thrombosis
## Rim Nephrogram
$=$ rim of cortex receiving collateral blood flow from capsular, peripelvic, and periureteric vessels
$\diamond$ Most specific indicator of renovascular compromise!
$\sqrt{ } 2-4-\mathrm{mm}$ peripheral band of cortical opacification
Cause: 1. Acute total main renal artery occlusion: in $50 \%$ of cases with renal infarction
2. Renal vein thrombosis
3. Acute tubular necrosis
4. Severe chronic urinary obstruction
$D D x$ : severe hydronephrosis (rim / shell nephrogram surrounding dilated calyces)
## Unilateral Delayed Nephrogram
A. OBSTRUCTIVE UROPATHY
B. REDUCTION IN RENAL blood flow
1. Renal artery stenosis
2. Renal vein thrombosis
## Striated Nephrogram
$=$ streaky linear bands of alternating hyper- and hypoattenuation parallel to axis of tubules + collecting ducts during excretory phase
Cause:
stasis of contrast material in dilated collecting ducts on background of edematous renal parenchyma $\leftarrow$ diminished concentration of contrast material in tubules $\leftarrow$ ischemia + tubular obstruction by inflammatory cells + debris
A. UNILATERAL
1. Acute ureteric obstruction
2. Acute bacterial nephritis / pyelonephritis
3. Renal contusion
4. Renal vein thrombosis
B. BILATERAL
5. Acute pyelonephritis
6. Intratubular obstruction: Tamm-Horsfall proteinuria, rhabdomyolysis with myoglobinuria
|
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978 |
3. Systemic hypotension
4. Autosomal recessive PCKD
5. Medullary sponge kidney
6. Medullary cystic disease
mnemonic: CHOIR BOY
Contusion
Hypotension (systemic)
Obstruction (ureteral)
Intratubular obstruction
Renal vein thrombosis
Bacterial nephritis (acute)
Obstruction (ureteral) — it is so common!
Yes, also cystic diseases: infantile PCKD, medullary cystic disease, medullary sponge kidney
# Persistent Nephrogram
A. BILATERAL GLOBAL
1. Systemic hypotension
2. Intratubular obstruction from protein:
Tamm-Horsfall, Bence-Jones, myoglobin
3. Tubular damage by contrast material
B. UNILATERAL GLOBAL
1. Renal artery stenosis
2. Renal vein thrombosis
3. Urinary tract obstruction
C. SEGMENTAL
4. Obstructed moiety of duplicated collecting system
5. Obstructing renal calculus
6. Obstructing neoplasm
7. Focal stricture
8. Focal parenchymal disease: tubulointerstitial infection
## Abnormal Nephrogram due to Impaired Perfusion
A. SYSTEMIC HYPOTENSIVE REACTION as a reaction to contrast material / cardiac failure / dehydration / shock
Pathophysiology:
drop in perfusion pressure after contrast reaches kidney $\rightarrow$ increased salt + water reabsorption and slowed tubular transit
$\checkmark$ prolonged bilateral dense nephrograms $=$ persistent increasing nephrogram
$\checkmark$ decrease in renal size
$\checkmark$ loss of pyelogram after initial opacification
NUC (use of glomerular filtration agent [eg, ${ }^{99 \mathrm{~m}} \mathrm{Tc}$-DTPA] preferred)
$\checkmark$ prolonged cortical transit + reduced excretion
B. RENAL ARTERY STENOSIS
$\checkmark$ decreased nephrographic opacity + rim nephrogram
|
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979 |
$\checkmark$ hyperconcentration in collecting system
$\checkmark$ ureteral notching
NUC (glomerular filtration agent [eg, ${ }^{99 \mathrm{~m}} \mathrm{Tc}$-DTPA] preferred):
$\checkmark$ decreased perfusion with prolonged excretory phase
C. IMPAIRED PERFUSION OF SMALL ARTERIES
Trueta shunting $=$ transient rerouting of blood flow from cortex to medulla
Cause:
(a) reflex vasospasm during arterial angiography $\leftarrow$ catheter trauma / pressure injection of highly concentrated contrast medium
(b) chronic renal disorders: collagen vascular disease, malignant nephrosclerosis, chronic glomerulonephritis
(c) necrotizing vasculitis (polyarteritis nodosa), scleroderma, hypertensive nephrosclerosis
CT, Angio:
$\checkmark$ inhomogeneous opacification of cortex
$\checkmark$ spotted nephrogram
IVP:
$\checkmark$ irregular cortical nephrogram $=$ spotted nephrogram (DDx: scleroderma, hypertensive nephrosclerosis)
D. ACUTE VENOUS OUTFLOW OBSTRUCTION in renal vein thrombosis
$\checkmark$ obstructive nephrogram
$\checkmark$ progressive increase in opacity of entire kidney
# Abnormal Nephrogram due to Impaired Tubular Transit
NUC: before decrease in renal function $\rightarrow$ use of glomerular filtration agent (eg, 99mTcDTPA); with decrease in renal function $\rightarrow$ use of plasma flow agents (eg, 99 mTc - $\mathrm{MAG}_{3}$ / 123 I-Hippuran ${ }^{\circledR}$ ) is preferred
Cause:
A. EXTRARENAL: ureteric obstruction (eg, stone)
$\checkmark$ obstructive nephrogram
NUC:
$\checkmark$ continuous increase in renal activity
$\checkmark$ dilatation of collecting system
B. INTRARENAL
(a) segmental: limb of duplication system, caliceal obstruction, interstitial edema $\checkmark$ segmental nephrogram
(b) protein precipitation: Tamm-Horsfall protein (a normal mucoprotein product of proximal nephrons), Bence-Jones protein (multiple myeloma), uric acid precipitation (acute urate nephropathy), myoglobulinuria, hyperproteinuric state
$\checkmark$ striated nephrogram
NUC:
$\checkmark$ prolonged cortical transit time + prolonged excretory phase
## Abnormal Nephrogram due to Abnormal Tubular Function
Pathophysiology:
|
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980 |
# A. PROXIMAL TUBULE
Function: reabsorbs almost all of glucose, amino acids, phosphate, bicarbonate
- glycosuria: Toni-Fanconi syndrome
- aminoaciduria: cystinuria
- phosphaturia: phosphate diabetes, thiazides
- HCO3- wasting: proximal renal tubular acidosis
B. DISTALTUBULE
Function: absorbs most of water
- diabetes insipidus, secretes $\mathrm{H}+$
- distal renal tubular acidosis
1. Acute tubular necrosis
$\checkmark$ immediate persistent nephrogram (common)
$\checkmark$ progressive increasing opacity (rare)
2. Contrast-induced renal failure
## Striated Angiographic Nephrogram
$=$ random patchy densities reflecting redistribution of blood flow from the cortical vasculature to vasa recta of medulla
1. Obliterative diseases of renal microvasculature: polyarteritis nodosa, scleroderma, necrotizing angiitis, catheter-induced vasospasm
2. Acute bacterial nephritis
3. Renal vein thrombosis
## Increasingly Dense Nephrogram
$=$ initially faint nephrogram becoming increasingly dense over hours to days
Mechanism:
(a) diminished plasma clearance of contrast material
(b) leakage of contrast material into renal interstitial space
(c) increase in tubular transit time
Cause:
A. VASCULAR = diminished perfusion
1. Systemic arterial hypotension (bilateral)
2. Severe main renal artery stenosis (unilateral)
3. Acute tubular necrosis (in 33\%):
$\leftarrow$ contrast material nephrotoxicity
4. Acute renal vein thrombosis
B. INTRARENAL
5. Acute glomerular disease
C. COLLECTING SYSTEM
6. Intratubular obstruction
(a) uric acid crystals = acute urate nephropathy
(b) precipitation of Bence-Jones protein = myeloma nephropathy
(c) Tamm-Horsfall protein: in severely dehydrated infants / children
7. Acute extrarenal obstruction: ureteral calculus
|
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981 |
# Vicarious Contrast Material Excretion during IVP
$=$ biliary contrast material detected radiographically following intravenous administration of contrast material
Normal contrast excretion:
$<2 \%$ of urographic dose of diatrizoates + iothalamates are handled by hepatobiliary excretion
Pathophysiology: increase in protein binding $\leftarrow$ prolonged intravascular contact + acidosis
Cause:
1. Uremia (reduction in glomerular filtration + uremia-associated acidosis)
2. Acute unilateral obstruction (increase in circulation time + transient intracellular acidosis)
3. Spontaneous urinary extravasation (prolonged vascular contact of contrast material)
## RENAL DOPPLER
A. NORMAL RENAL DOPPLER
$\sqrt{ }$ resistive index (RI) of $0.70=$ upper limit of normal
Elevation of RI:
> significant systemic hypotension
> markedly decreased heart rate
> perinephric / subcapsular fluid collection
> in neonates + infants
B. RENAL MEDICAL DISEASE
Elevation of RI:
more likely with vascular / tubulointerstitial process: less likely with glomerular disease
May be useful in predicting clinical outcome in:
> hemolytic-uremic syndrome
> acute renal failure
> nonazotemic patients with severe liver disease
C. RENAL ARTERY STENOSIS
D. RENAL VEIN THROMBOSIS
## COLLECTING SYSTEM
## Spontaneous Urinary Contrast Extravasation
$=$ SPONTANEOUS PYELORENAL BACKFLOW
Etiology: physiologic "safety valve" for obstructed urinary tract with pressures of 80-100 mmHg in collecting system $\leftarrow$ ipsilateral ureteral obstruction $\leftarrow$ distal stone impaction; pressure is proportional to degree + duration of acute obstruction + dose of contrast material
Prevalence: $0.1-18 \% ; \mathrm{M}>\mathrm{F}$ (male ureter less compliant)
Criteria: absence of
(a) recent ureteral instrumentation
(b) previous renal / ureteral surgery
(c) destructive urinary tract lesion
|
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982 |
(d) external trauma
(e) external compression
(f) pressure necrosis due to stone
Types:
1. Pyelotubular backflow
$=$ opacification of terminal portions of collecting ducts ( $=$ papillary ducts $=$ ducts of Bellini) as a physiologic phenomenon (in $13 \%$ with low osmolality + in $0.4 \%$ with high osmolality contrast media), wrongly termed "backflow"
$\sqrt{ }$ wedge-shaped brushlike lines from calyx toward periphery
2. Pyelosinus backflow
$=$ contrast extravasation from ruptured fornices along infundibula, renal pelvis, proximal ureter; most common form
Cx: urinoma, retroperitoneal fibrosis
3. Pyelointerstitial backflow
$=$ contrast flow from pyramids into subcapsular tubules
4. Pyelolymphatic backflow
$=$ contrast extravasation into periforniceal + peripelvic lymphatics
$\sqrt{ }$ visualization of small lymphatics draining medially
5. Pyelovenous backflow
$=$ forniceal rupture into interlobar / arcuate veins; rare
# Widened Collecting System \& Ureter
## Fetal pyelectasis:
AP diameter of renal pelvis $<5 \mathrm{~mm}<20$ weeks MA
$<8 \mathrm{~mm} 20-30$ weeks MA
$<10 \mathrm{~mm}>30$ weeks MA
A. OBSTRUCTIVE UROPATHY
B. NONOBSTRUCTIVE WIDENING
(a) congenital
1. Megacalycosis
= underdevelopment of papillae; usually unilateral
2. Congenital primary megaureter
$=$ widened ureter with normally tapered distal end
3. Megacystis-megaureter syndrome
4. Prune-belly syndrome
5. Bardet-Biedl syndrome
6. Beckwith-Wiedemann syndrome
7. Megalourethra
(b) increased urine volume
8. High-flow states: diabetes insipidus, osmotic diuresis, dehydrated patient undergoing rehydration, unilateral kidney
9. Vesicoureteral reflux
(c) atony of renal collecting system
10. Infection: ie, acute pyelonephritis
|
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983 |
2. Pregnancy
3. Retroperitoneal fibrosis
(d) overdistended urinary bladder
(e) previous long-standing significant obstruction: dilatation remains in spite of relief of obstruction
# Caliceal Abnormalities
A. OPACIFICATION OF COLLECTING TUBULES
1. Pyelorenal backflow
2. Medullary sponge kidney
B. PAPILLARY CAVITY
3. Papillary necrosis
4. Caliceal diverticulum
5. Tuberculosis / brucellosis
C. LOCALIZED CALIECTASIS
6. Reflux nephropathy = chronic atrophic pyelonephritis
7. Compound calyx
8. Hydrocalyx
9. Congenital megacalyx
10. Localized postobstructive caliectasis
11. Localized tuberculosis / papillary necrosis
D. GENERALIZED CALIECTASIS
12. Postobstructive atrophy
13. Congenital megacalices
14. Obstructive uropathy (hydronephrosis)
15. Nonobstructive hydronephrosis
16. Diabetes insipidus
## Filling Defect in Collecting System
mnemonic: 6 C"'s \& 2 P's
Clot
Cancer
Cyst
Calculus
Candida + other fungi
Cystitis cystica
Polyp
Papilla (sloughed)
## Nonopaque Intraluminal Mass in Collecting System
A. NONOPAQUE CALCULUS uric acid, xanthine, matrix $\sqrt{ }$ smooth, rounded, not attached
B. TISSUE SLOUGH
1. Papillary necrosis
2. Cholesteatoma
|
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984 |
3. Fungus ball = conglomeration of fibrillar hyphae
4. Inspissated debris ("mucopus")
C. VASCULAR
5. Blood clot: history of hematuria
$\checkmark$ change in appearance over time
D. FOREIGN MATERIAL
6. Air from bladder via reverse peristalsis, direct trauma, renoalimentary fistula
7. Foreign matter
# Mucosal Mass in Collecting System
A. NEOPLASTIC
(a) benign tumor
1. Aberrant papilla = papilla without calyx protruding into major infundibulum
2. Endometriosis
3. Fibroepithelial polyp
(b) malignant tumor
> uroepithelial tumors
4. Transitional cell carcinoma ( $85-91 \%$ )
5. Squamous cell carcinoma ( $7-10-15 \%$ )
Predisposing factors: calculi (50-60\%), chronic infection, leukoplakia, phenacetin abuse
$\checkmark$ infiltrating / superficially spreading
3. Mucinous adenocarcinoma
$=$ metaplastic transformation
4. Sarcoma (extremely rare)
> metastases: breast (most common), melanoma, stomach, lung, cervix, colon, prostate
B. INFLAMMATION / INFECTION
1. Tuberculosis
2. Candidiasis
3. Schistosomiasis
4. Pyeloureteritis cystica
5. Leukoplakia
6. Malakoplakia
7. Xanthogranulomatous pyelonephritis
C. VASCULAR
(a) submucosal hemorrhage
8. Trauma
9. Anticoagulant therapy
10. Acquired circulating anticoagulants
11. Complication of crystalluria / microlithiasis
$\checkmark$ thumbprinting with progressive improvement
(b) vascular notching
12. Ureteropelvic varices
13. Renal vein occlusion
|
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985 |
3. IVC occlusion
4. Vascular malformation
5. Retroaortic left renal vein
6. "Nutcracker" effect on left renal vein between aorta and SMA
7. Polyarteritis nodosa
D. PROMINENT MUCOSAL FOLDS
8. Redundant longitudinal mucosal folds of intermittent hydronephrosis: UPJ obstruction, vesicoureteral reflux / after relief of obstruction
9. Chemical / mechanical irritation
10. Urticaria: Stevens-Johnson syndrome $=$ erythema multiforme bullosa
11. Leukoplakia $=$ squamous metaplasia
12. Ureteral diverticulosis $=$ rupture of the roofs of cysts in ureteritis cystica
# Effaced Collecting System
A. EXTRINSIC COMPRESSION
(a) Uni- / bilateral global enlargement of renal parenchyma
(b) Renal sinus masses
1. Hemorrhage
2. Parapelvic cyst
3. Sinus lipomatosis
B. SPASM / INFLAMMATION
(a) infection
4. Acute pyelonephritis
5. Acute bacterial nephritis
6. Acute tuberculosis
(b) hematuria
C. INFILTRATION
7. Malignant uroepithelial tumors
D. OLIGURIA
8. Antidiuretic state
9. Renal ischemia
10. Oliguric renal failure
|
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986 |
# RENAL SINUS
## Renal Sinus Mass
A. TUMOR
(a) renal pelvis
1. Transitional cell carcinoma $(90 \%)$
2. Squamous cell carcinoma $(9 \%)$
3. Mucinous adenocarcinoma $(1 \%)$
(b) renal parenchyma
4. Renal cell carcinoma
5. Multilocular cystic nephroma
6. Plasmacytoma
(c) mesenchymal tumor (rare): hemangioma, lipoma, angiomyolipoma, fibroma, leiomyoma, neurogenic tumor, teratoma; sarcomas (eg, leiomyosarcoma)
(d) retroperitoneal
7. Lymphoma
8. Metastasis to sinus lymph nodes
9. Myeloid metaplasia
B. NONTUMOROUS CONDITION
(a) fat
10. Sinus lipomatosis
(b) fluid
11. Renal sinus cyst
12. Urinoma
(c) vessels
13. Renal artery aneurysm
$\checkmark$ annular calcifications in $>50 \%$
$D D x$ : renal calculus
14. Arteriovenous communication
15. Renal varix
## Hypoechoic Renal Sinus
A. SOLID
1. Fibrolipomatosis
2. Column of Bertin
3. Duplex kidney
4. TCC / RCC
B. CYSTIC
5. Renal sinus cysts
6. Caliectasis
7. Dilated veins, varix
8. Aneurysm, arteriovenous malformation
## RENAL CALCIFICATION
|
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987 |
# Retroperitoneal Calcification
A. NEOPLASM
1. Wilms tumor (in $10 \%$ )
2. Neuroblastoma (in 50\%): fine granular / stippled / amorphous
3. Teratoma: cartilage / bone / teeth, pseudodigits, pseudolimbs
4. Cavernous hemangioma: phleboliths
B. INFECTION
5. Tuberculous psoas abscess
6. Hydatid cyst
7. Alkaline-encrusted cystitis and pyelitis
C. TRAUMA
8. Old hematoma
## Nephrocalcinosis
$=$ diffuse fine radiologically demonstrable calcifications deposited as calcium salts in renal parenchyma
$D D x$ : Nephrolithiasis (= "kidney stones" = renal calculi = radiopaque / nonradiopaque hard crystalline minerals formed within lumen of the urinary tract (renal collecting system, ureter, bladder $=$ urolithiasis)
nephros, Greek = kidney; lithos, Greek = stone; calx, Latin = lime; calculus, Latin = pebble; osis, Greek = abnormal condition = "full of"
Prevalence: $0.1-6 \% ; \mathrm{M}>\mathrm{F}$
Cause:
mnemonic: MARC
Medullary sponge kidney
Alkali excess
Renal medullary / cortical necrosis, RTA
Chronic glomerulonephritis
Hyperoxaluria, Hypercalcemia, Hypercalciuria
## Medullary Nephrocalcinosis ( $95 \%$ )
$=$ calcifications involving the distal convoluted tubules in the loops of Henle
Frequency: $95 \%$ of all nephrocalcinoses
Cause:
A. HYPERCALCIURIA
(a) endocrine
1. Hyperparathyroidism in $5 \%\left(1^{\circ}>>2^{\circ}\right)$
2. Paraneoplastic syndrome of lung + kidney $\leftarrow$ ectopic parathormone production
3. Cushing syndrome
4. Diabetes insipidus
5. Hyperthyroidism / hypothyroidism
6. Glycogen storage disease Type I
(b) alimentary
7. Absorptive hypercalcemia
|
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988 |
2. Milk-alkali syndrome $=$ excess calcium + alkali $\leftarrow$ milk + antacids
3. Hypervitaminosis D
4. Beryllium poisoning
(c) osseous
5. Osseous metastases, multiple myeloma
6. Prolonged immobilization
7. Progressive senile osteoporosis
(d) renal
8. Medullary sponge kidney
9. Distal renal tubular acidosis (in $73 \%$ of primary RTA)
10. Chronic glomerulonephritis
11. Bartter syndrome tubular disorder with potassium + sodium wasting, hyperplasia of juxtaglomerular apparatus, hyperaldosteronism, hypokalemic alkalosis, and normal blood pressure
(e) drug therapy
12. Furosemide (in infants)
13. Prolonged ACTH therapy
14. Vitamin E (orally)
15. Vitamin D excess
16. Calcium (orally)
17. Nephrotoxic drugs: outdated tetracycline, amphotericin B
(f) miscellaneous
18. Sarcoidosis
19. Idiopathic hypercalciuria
20. Idiopathic hypercalcemia
21. Sjögren syndrome (distal RTA)
(g) genetic
22. Williams syndrome
23. Kenny-Caffey syndrome
B. HYPEROXALURIA $=$ OXALOSIS
C. HYPERURICOSURIA = urate crystal deposition
24. Gouty kidney (adult)
25. Lesch-Nyhan syndrome (child)
D. URINARY STASIS
26. Milk-of-calcium in pyelocaliceal diverticulum
27. Medullary sponge kidney
E. DYSTROPHIC CALCIFICATION
28. Renal papillary necrosis $\leftarrow$ especially analgesic nephropathy
29. Chronic pyelonephritis
30. Sickle cell disease
31. Renal tuberculosis
# mnemonic: HAM HOP
Hyperparathyroidism
Acidosis (renal tubular)
Medullary sponge kidney
|
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989 |
Hypercalcemia / hypercalciuria (sarcoidosis, milk-alkali syndrome, hypervitaminosis D)
Oxalosis
Papillary necrosis
$\sqrt{ }$ normal-sized / occasionally enlarged kidneys (medullary sponge kidney)
$\sqrt{ }$ small poorly defined / large coarse granular calcifications in renal pyramids:
$\checkmark$ uniform deposition: hyperparathyroidism / distal renal tubular acidosis (type 1)
$\checkmark$ asymmetric deposition in dilated collecting ducts within papillary tips: medullary sponge kidney
US:
$\checkmark$ absence of hypoechoic papillary structures (earliest sign)
$\checkmark$ hyperechoic rim at corticomedullary junction + around tip and sides of pyramids
$\checkmark$ solitary focus of hyperechogenicity at tip of pyramid near fornix
$\checkmark$ increased echogenicity of renal pyramids $\pm$ shadowing (no acoustic shadowing with small + light calcifications)
DDx of hyperechoic medulla in newborns:
oliguria with transient tubular blockage by Tamm-Horsfall proteinuria
$C x$ : often followed by urolithiasis
# Medullary Nephrocalcinosis in Children
- Normocalcemia + Hypercalciuria
(a) iatrogenic
1. Furosemide
2. Corticotropin therapy
(b) noniatrogenic
3. Distal renal tubular acidosis
4. Idiopathic hypercalciuria
5. Bartter syndrome
6. Hyperprostaglandin E syndrome
7. Hypomagnesemia
8. Cushing syndrome
9. Cystinosis
10. Glycogen storage disease Type 1
11. Tyrosinemia
12. Beckwith-Wiedemann syndrome
13. Hypothyroidism
- Hypercalcemia + Hypercalciuria
1. X-linked hypophospatemic rickets
2. Hyperparathyroidism
3. Hypophosphatasia
4. Sarcoidosis
5. Vitamin D intoxication
6. Williams syndrome
7. Subcutaneous fat necrosis
8. Idiopathic infantile hypercalcemia
|
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990 |
- Normocalcemia + Normocalciuria
1. Acetazolamide
2. Hyperoxaluria
# Cortical Nephrocalcinosis (5\%)
= calcium deposition in renal cortex
Frequency: $5 \%$ of all nephrocalcinoses
Cause:
1. Acute cortical necrosis
2. Chronic glomerulonephritis
3. Alport syndrome
4. Congenital oxalosis, primary hyperoxaluria
5. Chronic paraneoplastic hypercalcemia
6. Toxic: ethylene glycol, methoxyflurane
7. Sickle cell disease
8. Rejected renal transplant
mnemonic: COAG
Cortical necrosis (acute)
Oxalosis
Alport syndrome
Glomerulonephritis (chronic)
$\sqrt{ }$ thin rim of calcification with a "tramline" appearance
$\sqrt{ }$ spotty appearance (= preferential deposition in necrotic glomeruli)
US:
$\checkmark$ homogeneously increased echogenicity of renal parenchyma $>$ liver echogenicity
## Calcification of Pyelocaliceal System
1. Staghorn calculus
2. Nephrolithiasis
3. Papillary necrosis
4. Renal tuberculosis
5. Leukoplakia
6. Alkaline-encrusted pyelitis
7. Primary carcinoma of renal pelvis
8. Renal pelvic argyrosis $\leftarrow$ contact with silver nitrate
9. Amyloidosis
## Spontaneous Retroperitoneal Hemorrhage
A. RENAL TUMOR (57-63\%)
(a) malignant tumor (30-33\%)
1. $\operatorname{RCC}(33 \%)$
2. TCC of renal pelvis
3. Wilms tumor
4. Lipo-, fibro-, angiosarcoma
(b) benign tumor ( $24-33 \%)$
|
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991 |
1. Angiomyolipoma (16-24\%)
2. Lipoma
3. Adenoma
4. Fibromyoma
5. Ruptured hemorrhagic cyst
B. VASCULAR DISEASE (18-26\%)
6. Ruptured renal artery aneurysm
7. Vasculitis: eg, polyarteritis nodosa in $13 \%$
8. Arteriovenous malformation
9. Segmental renal infarction
C. INFLAMMATION / INFECTION (7-10\%)
10. Abscess (in $50 \%$ of infections)
11. Acute / chronic nephritis
D. COAGULOPATHY
12. Anticoagulant therapy (in 4.3-6.6\% of IV heparin, in $01 .-0.6 \%$ of oral anticoagulants)
Source: idiopathic ( $42 \%$ ), tumor ( $21 \%$ ), stone disease ( $17 \%$ ), hemorrhagic cystitis
2. Bleeding diathesis
3. Long-term hemodialysis
E. PRIMARY ADRENAL CYST / TUMOR
1. Pheochromocytoma
$\diamond$ Massive bleed $\leftarrow$ an undiagnosed pheochromocytoma has been lethal in $50 \%$ !
2. Pseudocyst
3. Myelolipoma
4. Hemangioma
5. Adrenocortical adenoma / carcinoma
6. Metastasis
- flank pain of sudden onset
$\diamond$ Follow-up CT may be indicated at 3 and 6 months if the source of blood remains indeterminate!
$\diamond$ Surgical exploration must be considered to uncover a small renal tumor if the cause of hemorrhage is not determined radiologically!
# Subcapsular Hematoma
$\checkmark$ subcapsular mass with flattening of renal parenchyma
$\checkmark$ total resorption / formation of pseudocapsule with calcification
Angio:
$\checkmark$ avascular mass
Cx: Page kidney (ischemia, release of renin, HTN)
## URETER
## Congenital Ureteral Abnormalities
A. URETERAL DUPLICATION (most common)
1. Complete ureteral duplication
2. Partial ureteral duplication
|
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992 |
# B. SMOOTH MUSCLE DYSFUNCTION
1. UPJ obstruction
2. Primary megaureter
C. ABNORMAL TERMINATION OF SINGLE URETER
3. Ectopic ureter
4. Ureterocele
5. Vesicoureteral reflux
## Ureteral Deviation in Course
A. LUMBAR URETER
(a) lateral deviation (common)
1. Hypertrophy of psoas muscle
2. Enlargement of paracaval / para-aortic lymph nodes
3. Aneurysmal dilatation of aorta
4. Neurogenic tumors
5. Fluid collections: abscess, urinoma, lymphocele, hematoma
(b) medial deviation
6. Retrocaval ureter (on right side only)
7. Circumcaval ureter
8. Retroperitoneal fibrosis
9. Inflammatory aortic aneurysm
B. PELVIC URETER
(a) medial deviation
10. Hypertrophy of iliopsoas muscle
11. Enlargement of iliac lymph nodes
12. Aneurysmal dilatation of iliac vessels
13. Bladder diverticulum at UVJ (= Hutch diverticulum)
14. Following abdominoperineal surgery + retroperitoneal lymph node dissection
15. Pelvic lipomatosis
(b) lateral deviation with extrinsic compression
16. Pelvic mass: eg, fibroids, ovarian tumor
17. Herniated ureter through inguinal canal
C. INTENTIONAL SURGICAL DIVERSION
ileal conduit, continent cutaneous diversion, orthotopic neobladder
## Ureteral Dilatation / Hydroureter
A dilated ureter is not necessarily obstructed; an obstructed ureter is not always dilated.
Size of ureter: $>3 \mathrm{~mm}$
A. OBSTRUCTION
1. Ureterolithiasis
B. CONGENITAL
2. Chronic vesicoureteral reflux
3. Posterior urethral valves
4. Megaloureter
|
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993 |
4. Prune-belly syndrome
5. Ectopic ureter
6. Ureterocele
C. INFECTION / INFLAMMATION impairing ureteral peristalsis
7. UTI: eg, E. coli, Pseudomonas, Citrobacter
8. Appendicitis
9. Diverticulitis
D. COMPRESSION
10. Pelvic / abdominal mass
11. Vessel:
> retroiliac / retrocaval course of ureter
> ovarian vein syndrome
# Unilateral Hydroureter
(a) obstruction: calculus, tumor, clot, sloughed papilla, stricture, extrinsic compression, mass effect
(b) resolved obstruction (if distension was severe)
## Bilateral Hydroureter
1. Polyuria / diuresis
2. Bladder outlet obstruction
3. Neurogenic bladder
4. Pregnancy: $\mathrm{R}>\mathrm{L}$
## Megaureter
A. VESICOURETERAL REFLUX
(a) primary vesicoureteral reflux
1. Primary reflux megaureter
Cause: abnormal ureteral tunnel at UVJ
2. Prune belly syndrome
(b) secondary vesicoureteral reflux
1. Hypertonic neurogenic bladder
2. Bladder outlet obstruction
3. Posterior urethral valves
B. OBSTRUCTION
(a) primary obstruction
4. Intrinsic ureteral obstruction: stone, stricture, tumor
5. Ectopic ureter
6. Ureterocele
7. Ureteral duplication
$\sqrt{ }$ tortuous dilated ureter of upper moiety
(b) secondary obstruction
8. Retroperitoneal obstruction: tumor, fibrosis, aortic aneurysm
9. Bladder wall mass
10. Bladder outlet obstruction: eg, prostatic enlargement
|
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994 |
C. nonreflux-nonobstructed MEGAURETER
1. Congenital primary megaureter $=$ megaloureter
2. Polyuria: eg, diabetes insipidus, acute diuresis
3. Infection
4. Ureter remaining wide after relief of obstruction
mnemonic: DiaPOUR
Diabetes insipidus
Primary megaureter
Obstruction (recent / old)
UVJ obstruction
Reflux
# Ureteral Stricture
A stricture is a fixed narrowing with proximal dilatation.
A. INTRINSIC CAUSE
(a) mucosal
1. Primary ureteral tumors
2. Inflammation $\leftarrow$ stone passage
(b) mural
3. Endometriosis
common disorder in menstruating women ( $15 \%$ ); ureteral involvement is rare and indicates widespread pelvic disease
$\checkmark$ abrupt smooth stricture of $0.5-2.5 \mathrm{~cm}$ length
$\checkmark$ rectosigmoid involvement on BE
4. Infection: tuberculosis, schistosomiasis
5. Traumatic / iatrogenic
ureterolithotomy, endoscopic stone extraction, gynecologic procedures (esp. hysterectomy), ureteral anastomosis (urinary diversion)
6. Amyloidosis
$\checkmark$ distal stricture with submucosal calcification
7. Nonspecific (rare)
B. EXTRINSIC CAUSE
8. Endometriosis: extrinsic form $\div$ intrinsic form $=4 \div 1$
9. Abscess: tuboovarian, appendiceal, perisigmoidal
10. Inflammatory bowel disease: eg, Crohn disease, diverticulitis
11. Radiation fibrosis
12. Tumor encasement / metastasis: cervix, endometrium, ovary, rectum, prostate, breast, lymphoma
13. Iliac artery aneurysm $\rightarrow$ perianeurysmal fibrosis
mnemonic: MISTER
Metastasis (extrinsic / intrinsic)
Inflammation from calculus
Schistosomiasis
Tuberculosis, Transitional cell carcinoma, Trauma
|
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995 |
Endometriosis + other periureteral inflammatory process
Radiation therapy, Retroperitoneal fibrosis
Physiologic narrowing is common and characterized by absence of proximal dilatation and rapid changeability.
$D D x$ : Physiologic narrowing
1. Ongoing peristalsis $\rightarrow$ incomplete opacification resolved on delayed images
2. Anatomic: UPJ, pelvic brim, UVJ, abrupt turn / kink
# Ureteral Filling Defect
A. FIXED
(a) neoplasm
1. Urothelial neoplasm
2. Metastasis
3. Fibroepithelial polyp
(b) inflammation / infection
4. Polyureteritis cystica
5. Tuberculosis
6. Fungus: Candida, Aspergillus
7. Schistosomiasis
8. Endometriosis
B. MOBILE
9. Stone $=$ urolithiasis
10. Sloughed papilla
11. Blood clot
Cause: trauma, stone, malignancy, anticoagulation
$\sqrt{ }$ NO enhancement
$\sqrt{ }$ density of $>50 \mathrm{HU}$ relative to urine and surrounding soft tissues on NECT
$\sqrt{ }$ clot resolution at follow-up imaging studies
C. MULTIPLE
1. Polyureteritis cystica
2. Malakoplakia
3. Multifocal urothelial cell cancer
Any ureteral filling defect of soft-tissue attenuation must be considered malignant and requires ureteroscopic assessment, biopsy, and cytologic analysis.
## Ureteral Calcification
A. URETERAL LUMEN
1. Stone: migrated from kidney
2. Stone: in ureteral diverticulum / ureterocele
3. Stone street = "Steinstrasse" = collection of stone fragments in distal ureter following lithotripsy
B. URETERAL WALL
4. Schistosomiasis
5. Tuberculosis
|
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996 |
3. Amyloid infiltration
4. Ureteral tumor
DDx: (1) Phlebolith in gonadal vein (multiple, not along course of ureter, centrally radiolucent)
(2) Orally administered contrast material trapped in appendix / diverticulum
(3) Dermoid cyst with calcification
(4) Silastic fallopian tube band
(5) Radiation seeds used for prostate cancer
# URINARY BLADDER
## Bilateral Narrowing of Urinary Bladder
A. WITH ELEVATION OF BLADDER FLOOR
1. Pelvic lipomatosis
2. Pelvic hematoma
Cause: trauma, anticoagulant therapy, spontaneous rupture of blood vessels, blood dyscrasia (rare), bleeding neoplasm (rare)
3. Chronic cystitis
B. WITH SUPERIOR COMPRESSION OF BLADDER
1. Thrombosis of IVC
Cause: trauma, hypercoagulability state (oral contra-ceptives), extension of thrombi from lower extremity, abdominal sepsis, Budd-Chiari syndrome, compression of IVC by neoplasm
$\sqrt{ }$ collaterals: $\leftarrow$ gonadal veins, ascending lumbar veins, vertebral plexus, retroperitoneal veins, portal vein (via hemorrhoidal veins)
$\sqrt{ }$ notching of distal ureter by ureteral veins
2. Pelvic lymphadenopathy
Cause: lymphoma (most often), prostatic carcinoma
$\checkmark$ polycyclic asymmetric compression of bladder
$\checkmark$ medial displacement of pelvic segment of ureters
$\checkmark$ lateral displacement of upper ureters
3. Hypertrophy of iliopsoas muscles
4. Bilateral pelvic masses
(a) bilateral lymphocysts (after radical pelvic surgery)
(b) bilateral urinomas
(c) bilateral pelvic abscesses
5. Retroperitoneal fibrosis
6. Large iliac artery aneurysms
## Inverted Pear / Teardrop-shaped Urinary Bladder
mnemonic: PHALL
Psoas hypertrophy
Hematoma (pelvic)
Aneurysm (bilateral common / external iliac artery)
|
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997 |
Lipomatosis, pelvic
Lymphadenopathy (pelvic)
# Small Bladder Capacity
## Cause:
A. THICKENED / FIBROTIC BLADDER WALL
1. Interstitial cystitis
2. Tuberculous cystitis
3. Cystitis cystica
4. Schistosomiasis
5. Trauma: surgical resection, radiation therapy
B. DISUSE OF BLADDER
- urinary frequency
- progressive rise in bladder pressure during filling
$\checkmark$ reduced bladder compliance
$\checkmark$ thickened bladder wall + decreased bladder volume
$\checkmark$ vesicoureteral reflux
## Bladder Wall Thickening
Normal bladder wall thickness (regardless of age + gender):
$<5 \mathrm{~mm}$ in nondistended bladders
$<3 \mathrm{~mm}$ in well-distended bladders
A. TUMOR
1. Neurofibromatosis
B. INFECTION / INFLAMMATION
2. Cystitis
C. MUSCULAR HYPERTROPHY
3. Neurogenic bladder
4. Bladder outlet obstruction (eg, posterior urethral valves)
D. UNDERDISTENDED BLADDER
## Urinary Bladder Wall Masses
A. CONGENITAL
1. Congenital septum
2. Simple ureterocele
3. Ectopic ureterocele
B. BLADDER TUMOR
C. INFLAMMATION / INFECTION
4. Cystitis: hemorrhagic cystitis, abacterial cystitis, bullous cystitis, edematous cystitis, interstitial cystitis, cystitis cystica, eosinophilic cystitis, granulomatous cystitis, emphysematous cystitis, cyclophosphamide cystitis, cystitis glandularis (premalignant lesion with villous lesions in bladder dome from proliferation of "intestinelike" glands in submucosa)
5. Tuberculosis
6. Schistosomiasis
|
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998 |
4. Malakoplakia
5. Extravesical inflammation:
(a) Diverticulitis
(b) Crohn disease
(c) endometriosis
D. HEMATOMA
after instrumentation, surgery, trauma
# Bladder Tumor
Frequency: $2-6 \%$ of all tumors
A. EPITHELIAL TUMORS ( $95 \%$ )
1. Urothelial carcinoma $=$ transitional cell carcinoma $(90 \%)$
2. Squamous cell carcinoma ( $4 \%$ in USA) worst prognosis; $\leftarrow$ chronic disorders (chronic irritation from indwelling catheters, infection, stricture, calculi), cyclophosphamide, smoking, intravesical bacillus Calmette-Guérin, bladder diverticula, schistosomiasis (> $50 \%$ of bladder tumors in countries with endemic bilharziasis)
3. Adenocarcinoma ( $1 \%$ ) most common in bladder exstrophy, less common in cystitis glandularis + urachal carcinoma
$\diamond$ Metastatic adenocarcinoma ( $\leftarrow$ colon, prostate, rectum) more common than primary
4. Small cell / neuroendocrine carcinoma $(<0.5 \%)$
$=$ highly aggressive tumor with invasive disease in $94 \%$ at presentation
Age: $20-91$ years; $\mathrm{M}+\mathrm{F}=3 \div 1$ to $5 \div 1$
- hematuria ( $88 \%$ )
Size: $3-8 \mathrm{~cm}$
$\sqrt{ }$ large polypoid / nodular tumor
Prognosis: $16 \% 5$-year survival rate
5. Carcinoid
Mean size: 6 mm
6. Melanoma (extremely rare)
B. NONEPITHELIAL/ MESENCHYMAL TUMORS
(a) primary benign bladder tumor originating from
> muscle
1. Leiomyoma $(0.43 \%)$
$\diamond$ Most common nonepithelial tumor
Age: $22-78$ years; $\mathrm{M}+\mathrm{F}=1 \div 1$
- hematuria $\leftarrow$ ulceration
Location: arise in submucosa
Site: submucosal (7\%) / intravesical (63\%) / extravesical (30\%)
$\checkmark$ solid homogeneous mass
$\checkmark$ smooth indentation of bladder wall
$\checkmark$ intraluminal mass $\pm$ degeneration
2. Rhabdomyoma (rare)
> nerve
1. Neurofibroma / NF1 in $60 \%$
$\checkmark$ typically of low attenuation on CT
|
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999 |
$\sqrt{ }$ hypointense mass on T1WI
$\sqrt{ }$ "target" sign on T2WI in plexiform neurofibroma= central hypointense fibrosis surrounded by hyperintense myxoid stroma
2. Paraganglioma $=$ pheochromocytoma $(0.1 \%)$
$\diamond 1 \%$ of all pheochromocytomas
Age: $10-78$ years; $\mathrm{M}<\mathrm{F}$
Origin: paraganglia of bladder wall
- adrenergic attack in $50 \%$ during micturition ("micturition attack") or bladder filling (headaches, weakness)
- intermittent hypertension
- elevated catecholamine levels
$\sqrt{ }$ submucosal mass
$\sqrt{ }$ ring calcification around circumference
$\sqrt{ }$ marked enhancement (KEY FEATURE)
N.B.: biopsy may incite hypertensive crisis!
Prognosis: $7 \%$ are malignant
> fat
1. Lipoma
fibrous tissue
2. Fibroma
3. Solitary fibrous tumor
blood vessels
4. Hemangioma
Age: 58 (range, 19-76) years during adulthood; $50 \%$ during childhood
Median size: 7 (range, 2-30) mm
2. Plasmacytoma
3. Nephrogenic adenoma
Associated with: cystitis cystica / cystitis glandularis
(b) primary malignant bladder tumor
1. Primary lymphoma
$\diamond 2^{\text {nd }}$ most common nonepithelial tumor of bladder
Age: 40 years; $\mathrm{M}+\mathrm{F}=1 \div 3$
Histo: low-grade B-cell mucosa-associated lymphoid tissue (MALT) / diffuse large B-cell type
Location: submucosa; at base + trigone of bladder
2. Rhabdomyosarcoma
Age: $1^{\text {st }}$ and $2^{\text {nd }}$ decades of life
$\diamond$ Most common bladder tumor in patients $<10$ years
3. Leiomyosarcoma
$\diamond$ Most common nonepithelial malignant bladder tumor
Age: mainly $>40$ (range, $25-88$ ) years; $\mathrm{M}+\mathrm{F}=3 \div 1$
Location: rarely at trigone
Mean size: 7 cm
$\checkmark$ poorly circumscribed invasive mass
|
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