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  • 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

Neuroblast.



mottled Ca++

Metastasis

variable

>15HU

hyper to liver (melanoma is cystic)

Cortical Carcinoma

>6cm


heterogenous with Ca++

Lymphoma


40-60 HU

may be complex cystic



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