29 DAVID SUTTON PICTURES THE UROGENITAL TRACT ANATOMY AND INVESTIGATION

29
THE UROGENITAL TRACT: ANATOMY
AND INVESTIGATIONS
DAVID SUTTON

DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

• Fig. 29.1 Structure of the kidney. 1, Cortex; 2,
compound calyx 3, minor calyx; 4, medullary
pyramid; 5, papilla; 6, renal sinus; 7, renal
pelvis; 8, infundibulum of major calyx; 9,
ureter.

• Fig. 29.3 Anterior relations of (A) the right
kidney, and (B) the left kidney. 1, Hepatic flexure;
2, small intestine; 3, right adrenal gland; 4, liver;
5, duodenum; 6, left adrenal gland; 7, spleen; 8,
stomach; 9, pancreas; 10, splenic flexure.

• Fig. 29.5 The relationships of the prostate.

• Fig. 29.6 The KUB. (A) Full length and (B) cross kidney
films from a KUB examination. Several phleboliths are
seen in the pelvis. They are characteristically smooth
small rounded calcific areas with a tiny central
radiolucency.

• Fig. 29.7 Postcontrast IVU films. (A) Immediate,
(B) 5 min, (C) 15 min film with compression
producing calyceal distension; (D) full length
release; (E) full length postmicturition. The
phleboliths noted on the plain films (Fig. 29.6A)
are nicely shown to lie outside the urinary tract.

• Fig. 29.7 Postcontrast IVU films. (A) Immediate, (B) 5 min,
(C) 15 min film with compression producing calyceal
distension; (D) full length release; (E) full length
postmicturition. The phleboliths noted on the plain films
(Fig. 29.6A) are nicely shown to lie outside the urinary tract.

• Fig. 29.8 Normal renal ultrasound; note the
relatively hypoechoic pyramids and markedly
hyperechoic fat containing sinus (centrally)
compared to the cortex.

• Fig. 29.9 Normal bladder ultrasound; note
the thin smooth wall and the shape
approximating to a rounded-off square in the
transverse view (A) and a rounded-off triangle
in the sagittal view (B).

• Fig. 29.10 Scrotal ultrasound. (A) Longitudinal image showing the
intermediate slightly speckled appearance of the normal testicle.
The thin echogenic line represents the mediastinum of the
testicle. (B) Longitudinal view showing a prominent vascular
channel (linear echopoor structure)-normal variant. (C)
Longitudinal view showing the body of the epididymis as a thin
echo-poor line posterior to the testicle. Transverse view of the
testicle through the mid (D) and upper (E) parts, the latter
showing the bead of the epididymis as a small area of soft tissue
adjacent to the upper pole of the testicle.

• Fig. 29.10 Scrotal ultrasound. (A) Longitudinal image
showing the intermediate slightly speckled appearance of
the normal testicle. The thin echogenic line represents the
mediastinum of the testicle. (B) Longitudinal view
showing a prominent vascular channel (linear echopoor
structure)-normal variant. (C) Longitudinal view showing
the body of the epididymis as a thin echo-poor line
posterior to the testicle. Transverse view of the testicle
through the mid (D) and upper (E) parts, the latter
showing the bead of the epididymis as a small area of soft
tissue adjacent to the upper pole of the testicle.

• Fig. 29.11 Transrectal ultrasound of the
prostate. (A-C) Young adult prostate. (A)
Transverse section. There is a little
calcification appearing as speckled
echogenicity in the periurethral area,
presumed to be related to previous
prostatitis and urethritis. The prostate at
this age shows poor zonal anatomy. (B)
Transverse view of the normal paired
echo-poor seminal vesicles. (C)
Longitudinal view showing the subjacent
puborectalis sling as a laminated,
relatively echo-poor structure. (D, E)
Transverse and longitudinal views of the
prostate around middle to old age. The
zonal anatomy is clearly seen with a
relatively hyperechoic peripheral gland
compared to the hypoechoic central
gland.

• Fig. 29.11 Transrectal ultrasound of the prostate. (A-C) Young
adult prostate. (A) Transverse section. There is a little
calcification appearing as speckled echogenicity in the
periurethral area, presumed to be related to previous
prostatitis and urethritis. The prostate at this age shows poor
zonal anatomy. (B) Transverse view of the normal paired echo-
poor seminal vesicles. (C) Longitudinal view showing the
subjacent puborectalis sling as a laminated, relatively echo-
poor structure. (D, E) Transverse and longitudinal views of the
prostate around middle to old age. The zonal anatomy is clearly
seen with a relatively hyperechoic peripheral gland compared
to the hypoechoic central gland.

• Fig. 29.12 Retrograde pyelogram
demonstrating the pelvicalyceal system and
ureter down to the vesicoureteric junction.

• Fig. 29.13 Retrograde pyelogram with
pyelosinus extravasation due to
overdistension of the collecting system.

• Fig. 29.14 Normal loopogram (conduitogram).
Contrast outlines the ileal loop (which still
demonstrates the typical small-bowel mucosal
pattern) and freely refluxes into both ureters.

• Fig. 29.15 Normal stentogram demonstrating
intact anastamosis between the ureters and
the afferent loop of small bowel leading to the
reconstructed neobladder.

• Fig. 29.17 Normal female micturating
cystourethrogram showing the typical short
open-necked female urethra.

• Fig. 29.16 Post prostatectomy cystogram.
Supine (A), oblique (B) and lateral (C) views
demonstrate a substantial extravasation
arising from the right posterolateral aspect of
the vesicourethral anastamosis.

• Fig. 29.18 Descending urethrogram in a male.
The entire length of the urethra is demonstrated
as the bladder empties. A post-operative
urethrorectal fistula is present with contrast
tracking posteriorly from the prostatic beds.

• Fig. 29.19 The normal male ascending urethrogram
usually shows contrast flowing retrogradely as far as
the junction of the bulbar and membranous urethra
(A). Sometimes contrast will flow into the bladder and
demonstrate the prostatic urethra (B). Note the
smooth filling defect of the verumontanum within the
prostatic urethra.

• Fig. 29.20 Ascending urethrogram. A vigorous
infusion of 150 strength contrast has been
performed. The external sphincter has not
relaxed (as is usually the case) and the anterior
urethra is therefore overdistended with contrast
extravasating and entering the corpora
cavernosa.

• Fig. 29.21 Antegrade pyelography. The dilated pelvicalyceal
system has been cannulated with a 22 gauge needle and
opacified with 1 50 strength contrast (A). The ureter is
dilated, shows marked medial displacement distally and
tapers to a complete occlusion (B).

• Fig. 29.22 Nephrostomy procedure using fluoroscopy and dual puncture
technique. Having opacified the system through a fine-gauge needle a
second puncture is made with a sheathed needle (A). A guide-wire is
advanced through this into the pelvicalyceal system (and ideally for
stability into the ureter) (B). The fine needle is removed and the sheathed
needle exchanged for a dilator over the wire (C). The calibre of the dilator
depends on the nephrostomy drain to be positioned and often comes as
part of a nephrostomy set. For an 8F drain a dilator of 8 or 9F is usually
employed. The dilator is exchanged for the drain, which is positioned,
coiled up, in the renal pelvis (D).

• Fig. 29.23 Antegrade stent positioning. A guide-wire has been manipulated down the
right ureter to the level of the obstruction (A). Note the distal end of a previously
postioned left-sided stent is visible within the bladder. The guide-wire is advanced across
the obstruction into the bladder. Following a dilatation step with a long 9F dilator the
stent has been advanced along the wire so its distal end lies within the bladder (B). Once
the wire is removed the distal end of the stent will adopt a pigtail configuration within
the bladder. The upper end will behave similarly within the renal pelvis, provided care
has been taken to ensure the upper end has been advanced sufficiently and does not lie
within renal parenchyma.

• Fig. 29.24 Percutaneous nephrolithotomy. A faintly opacified staghorn calculus is
present (A). A retrograde catheter is in position. After the system is opacified and
dilated via the retrograde catheter a sheathed needle is used to cannulate one of
the calyces (B). A guide-wire is advanced through the sheath into the calyx and
manipulated into the renal pelvis adjacent to the calculus (C). An initial dilatation
step is performed with an 8F dilator over the wire (D). A high-pressure balloon is
positioned with its distal end in the collecting system. As it is inflated a waist at the
level of the renal capsule is often the last part to dilate (E). Following inflation an
Amplatz sheath is positioned over the balloon (F-example from a second patient).
The balloon is deflated and removed, allowing the urologist access to the calculus.
After the procedure fluoroscopy demonstrates adequate clearance of the stone
(G).

• Fig. 29.25 Percutaneous cyst aspiration. A 22
gauge needle has been postioned within a
heavily calcified cyst under CT guidance for
diagnostic aspiration.

• Fig. 29.26 CT-guided biopsy. An 18 gauge
cutting needle has been positioned in a solid
mass in the right renal bed under CT guidance.
The core of tissue obtained confirmed
recurrent renal cell carcinoma.

• Fig. 29.27 Right renal angiogram showing a small upper pole accessory artery (A).
Selective cannulation of the dominant renal artery demonstrates a small
peripherally placed renal cell carcinoma (B). A larger renal cell carcinoma is shown
on this left renal angiogram (C) with a characteristic malignant circulation
(irregular disorganised vessels). Selective embolisation of part of the renal cell
carcinoma has been performed (D).

• Fig 29.28 Pelvic angiography and tumour embolisation. The left internal iliac
artery has been cannulated, by manipulating a catheter from the right femoral
artery across the bifurcation, and its two major divisions (anterior and posterior)
demonstrated (A). The patient is suffering severe immediate postprostatectomy
haemorrhage. A coil has been positioned in the anterior divison (B) and the
subsequent angiogram demonstrates successful obstruction of flow in this vessel
(C). It is rare actually to demonstrate the bleeding point and, given the life
threatening situation, it is often worth embolising both sides. Consequently in this
case the right internal iliac artery has also been cannulated from the same femoral
artery (D) and the anterior division of the internal iliac selectively cannulated (E).
This injection shows the inferior vesical artery from which most of the bleeding is
probably occurring and therefore this has also been occluded with a coil (F) (see
over)

• Fig. 29.28 (F) with satisfactory clinical
response.

• Fig. 29.29 Testicular vein embolisation. The left renal vein has been cannulated via the
inferior vena cava (A). A testicular phlebogram performed once the catheter has been
advanced down the testicular vein reveals a double testicular vein with multiple origins
unprotected by valves, one of a number of variants associated with varicocele formation
(B). The upper end of the varicocele is just visible once the catheter has been advanced to
the inguinal ring (the varicocele itself should not be screened, to avoid irradiating the
testicles) (C). The main testicular vein is occluded with multiple (2-4) coils along its length.
Two are illustrated here (D). The most important is the distal one that also occludes the
entry of the accessory testicular vein.

• Fig. 29.29 Testicular vein embolisation. The left renal vein has been
cannulated via the inferior vena cava (A). A testicular phlebogram
performed once the catheter has been advanced down the testicular vein
reveals a double testicular vein with multiple origins unprotected by
valves, one of a number of variants associated with varicocele formation
(B). The upper end of the varicocele is just visible once the catheter has
been advanced to the inguinal ring (the varicocele itself should not be
screened, to avoid irradiating the testicles) (C). The main testicular vein is
occluded with multiple (2-4) coils along its length. Two are illustrated here
(D). The most important is the distal one that also occludes the entry of
the accessory testicular vein.

• Fig. 29.30 Transverse CT through the midpart
of the kidneys. Prior to contrast the kidneys
are of intermediate density (A), similar to liver,
spleen and blood vessels. During the
nephrogram phase the cortex is seen to
enhance earlier than the medullary pyramids
(B).

• Fig. 29.31 Contrast-filled ureters entering the
pelvis at the level of the iliac crest, running
along the anterior aspect of the psoas muscles
(A) and then around mid sacral level crossing
the iliac vessels and beginning to turn
anteriorly (B).

• Fig. 29.32 CT of the pelvis showing the distal
ureters just above the vesicoureteric junctions
lying anterior to the seminal vesicles (A). The
right ureter happens to contain a bolus of
contrast at the time of the scan. (B) shows the
ureters at the vesicoureteric junctions with a jet
of opacified urine projecting from the right ureter
into the bladder. Further interiorly the prostate is
seen just projecting into the bladder base (C).

• Fig. 29.32 CT of the pelvis showing the distal ureters
just above the vesicoureteric junctions lying anterior
to the seminal vesicles (A). The right ureter happens to
contain a bolus of contrast at the time of the scan. (B)
shows the ureters at the vesicoureteric junctions with a
jet of opacified urine projecting from the right ureter
into the bladder. Further interiorly the prostate is seen
just projecting into the bladder base (C).

• Fig. 29.33 Transverse CT of the prostate with
focal calcification. The puborectalis sling is
well demonstrated as a thin intermediate-
density line encircling the anorectal junction
and the prostate.

• Fig. 29.34 MRI scan of the normal kidneys. On the T,-
weighted sequence A) the renal cortex is seen to be of
higher signal than the medulla. The reverse is seen on
the T2 -weighted (B) and STIR (C) sequences, with the
medulla being of higher signal than the cortex
(although both are relatively high signal).

• Fig. 29.34 MRI scan of the normal kidneys. On the T,-
weighted sequence A) the renal cortex is seen to be of
higher signal than the medulla. The reverse is seen on the
T2 -weighted (B) and STIR (C) sequences, with the medulla
being of higher signal than the cortex (although both are
relatively high signal).

• Fig. 29.35 MRI scan of the kidneys 30 s (A)
and 90 s (B) following intravenous gadolinium
showing the intense enhancement of the
cortex and then both the cortex and the
medulla.

• Fig. 29.36 MRI of the pelvis on the T,-weighted
sequence at the level of the bladder (A) and the
prostate (B). The same levels (on a different
patient) are seen on the T 2 - weighted sequence
(C,D) demonstrating the increased conspicuity of
the bladder wall and the zonal anatomy of the
prostate. Both sequences show the puborectalis
sling well. The same levels are also shown on the
STIR sequences (E, F).

• Fig. 29.37 Normal 99 '°Tc-DMSA study. LPO =
left posterior oblique; POST = posterior; RPO =
right posterior oblique.

• Fig. 29.38 Horseshoe kidney. 99"'Tc-DMSA
showing bridging renal tissue between the
lower poles of both kidneys.

• Fig. 29.39 Ectopic kidney. 99mTc-DMSA study
showing right kidney in normal position; left
kidney lying in the midline of the pelvis
superior to the bladder.

• Fig. 29.40 Bilateral Wilms' tumours. 99 mTc-
DMSA study showing extensive replacement
of the left kidney; smaller tumour at the hilum
of the right kidney.

• Fig. 29.41 Post infective scarring. 99mTc-
DMSA study showing normal left kidney;
scarred right upper pole (arrows).

• Fig. 29.42 Normal 99mTc-MAG3 dynamic renal study: (A)
Part of the first-pass acquisition showing perfusion of
aorta and both kidneys; (B) selected images from the
excretion series with symmetrical uptake and clearance
from both kidneys; (C) renogram curves from the perfusion
sequence in the first 30 s (left) and the excretion curves up
to 30 min (right). LK = left kidney; RK = right kidney; Ao =
aorta.

• Fig. 29.43 Unilateral PUJ obstruction. 99 mTc-
MAG3 images at 1 min (A), 5 min (B) and 15 min
(C), showing typical left hydronephrosis with
normal clearance from the right kidney.
Renogram curves (bottom right) show normal
clearance on the right and an obstructed left side.
LK = left kidney; RK = right kidney; B = bladder.

• Fig. 29.44 Dilated but unobstructed renal pelvis. 99 mTc
images at 5, 10 and 15 min show rapid uptake and
clearance from the left kidney; slower clearance from the
right kidney. Renogram curves (bottom right) show normal
left side and delayed peak on the right with rapid washout
following furosemide (frusemide) injection. LK = left kidney;
RK = right kidney; B = bladder.

• Fig. 29.45 Low-grade obstruction. 99 nTc-MAG3 diuretic study
images at 1,5 and 20 min show normal uptake and clearance on
the right; normal uptake on the left but incomplete clearance.
Renogram curves (bottom right) show normal right side and
normal uptake on the left but after an initial fall the excretion
curve rises again (Homsy's sign). LK = left kidney; RK = right
kidney; B = bladder.

• Fig. 29.46 Right renal artery stenosis. 99m -Tc-
MAG3 dynamic study shows reduced blood flow
to the smaller right kidney on the perfusion
series (A), delayed excretion on the 15 min image
(B), and the renogram curve (C) shows reduced
uptake, delayed T max and slower clearance from
the right kidney. LK = left kidney; RK = right
kidney.

• Fig. 29.47 Acute tubular necrosis. 99mTc-MAG3 study
shows perfusion of both kidneys is reduced (A) and
excretion images at 1 min (B) and 20 min (C) show
persistent retention of the tracer in the kidney with no
excretion. Renogram curves (D) show immediate uptake
but no clearance. LK = left kidney; RK = right kidney.

• Fig. 29.48 Acute oliguria after renal
transplantation. Anterior perfusion phase
images from 99mTc-DTPA study show that
blood flow to the transplanted kidney in the
right iliac fossa is well maintained. Diagnosis:
acute tubular necrosis.

• Fig. 29.49 Acute oliguria after renal
transplantation. Anterior view dynamic
images 2, 5 and 10 minutes after injection of
99mTc-DTPA show a photon deficient area
which represents the totally ischaemic graft in
the left iliac fossa; diagnosis: renal vein
thrombosis.

• Fig. 29.50 Acute oliguria after renal transplantation. Anterior view
perfusion images (A) and excretion images at 1 min (B) and 20 min
(C) show severely impaired perfusion of the transplant kidney in the
right iliac fossa with slowly increasing uptake but hardly any
excretion to the bladder. Renogram curve (D) shows the typical flat
curve of a badly-functioning kidney but without the initial vascular
spike usually seen with acute tubular necrosis. Diagnosis: severe
rejection.

• Fig. 29.51 Suspected obstruction in renal
transplant. 99mTc-DTPA study shows good
uptake at 2 min (left) with activity reaching the
bladder via a distended ureter and collecting
system at 20 min (right). Diagnosis: obstruction
confirmed.

• Fig. 29.52 Sudden deterioration in renal
transplant function.m9Tc-DT9PA study shows
normal uptake at 2 min (left); at 20 min (right)
some activity is draining via a bladder catheter (C)
but much of the activity is leaking into the
peritoneal cavity (L). Diagnosis: ureteric leak.

• Fig. 29.53 Radionuclide cystography showing
reflux. Selected images from the dynamic
sequence obtained during micturition (left) show
tracer appearing in the right kidney and ureter as
the bladder empties (arrows). Time-activity
curves over left and right ureters (right) show no
reflux on the left and mild but prolonged episodic
reflux on the right.

• Fig. 29.54 Set-up for lower urinary tract
urodynamics.

• Fig. 29.55 Renal ultrasound. Corona) (A) and
transverse (B) images of a neonatal kidney
demonstrating prominent hypoechoic
medullary pyramids and no renal sinus fat.

• Fig. 29.56 Renal ultrasound. Coronal (A) and
transverse (B) images of the kidney of a 10-
year-old child. The medullary pyramids are
less conspicuous than in the neonatal period
and there is now some echogenicity around
the renal hilum.

• Fig. 29.57 Micturating cystourethrogram-
male. An oblique voiding image demonstrates
the whole urethra with no foreshortening. The
filling defect in the posterior urethra
represents the verumontanum.

• Fig. 29.58 Micturating cystourethrogram-
female. A supine voiding image in a female
child. The urethra is shorter than the male
and is straight.

• Fig. 29.59 Computed tomography. Axial
image through renal hilum shows clearly the
left renal vein and right renal artery. There is
prominent fetal lobulation and
corticomedullary differentiation.

• Fig. 29.60 Molecular structure of the building
block for water-soluble contrast media.

29 DAVID SUTTON PICTURES THE UROGENITAL TRACT ANATOMY AND INVESTIGATION

29 DAVID SUTTON PICTURES THE UROGENITAL TRACT ANATOMY AND INVESTIGATION

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29 DAVID SUTTON PICTURES THE UROGENITAL TRACT ANATOMY AND INVESTIGATION