Urologic Radiology

Published by Springer Verlag
Print ISSN: 0171-1091
Publications
A urographic pattern of renal clubbing and scarring was found in 182 scarred kidneys of 110 adult patients. Homolateral vesicoureteric reflux was demonstrated by reliable techniques in 90/135 scarred kidneys. Urinary tract infections occurred in 75 patients. Hypertension developed in 20 patients with normal renal function and was not related to the extent of scarring. Chronic renal failure occurred in 30 patients with diffuse bilateral scarring. Four patients showed histologic changes of chronic pyelonephritis. Two hypertensive patients had a typical histologic pattern of Ask-Upmark kidney (segmental hypoplasia). Development of renal scars in adulthood was demonstrated in 2 cases.
 
Siblings of patients with vesicoureteral reflux (VUR) are reported to have an increased incidence of reflux. We present 16 families with 33 affected children out of a total of 493 patients with VUR. Twenty-seven had urinary tract infection and 6 were asymptomatic and were examined because a sibling had VUR. Renal scarring was present in 19 cases; reflux was more marked and more often bilateral in the siblings than in sporadically affected children. In view of our findings we suggest that siblings of patients with VUR be screened early for reflux to prevent renal damage from untreated VUR.
 
Palliative renal artery embolization (without subsequent nephrectomy) was performed in 19 patients with renal carcinoma, and the follow-up is presented. Seventeen of the patients had metastatic disease at the time of embolization. Three patients were alive 11, 52, and 56 months after embolization. Gross hematuria was eliminated in 5 patients. Temporary remission of suspected pulmonary metastases was seen in 2 patients. It is concluded that transcatheter embolization alone is not curable and in this series did not affect the overall survival rate; however, local tumor symptoms may be palliated by this method.
 
Renal adenocarcinoma is rare before age 20. Clinically and radiographically, it presents similarly in adults and children. Prognosis is related to the clinical stage of the tumor at surgery. Treatment methods are still under investigation.
 
We performed a retrospective study of patients who had urinary tract stones and were seen at our hospital from 1985-1990. The study was intended to determine the prevalence of urolithiasis and optimal approaches to imaging. Clinical data and imaging studies of 87 patients were reviewed. The mean age was 15.7 years with a range of 3 months to 44 years. Fifty-four percent of patients were male. Most patients had a known predisposing cause for urolithiasis; patients with myelodysplasia and structural urologic problems predominated. Plain films were performed in 77 patients; 57% showed stones. Ultrasonograms were performed in 71 patients; 77% showed stones. Excretory urograms (EU) were performed in 49 patients; 84% showed either stones or their effect on the urinary tract. Computed tomographic (CT) scan was performed in 25 patients; all showed stones.
 
The first 500 patients who underwent percutaneous stone removal at our hospital and who have been evaluated for at least 8 months were reviewed. Comparison of the first 100 patients with the entire series showed a sharp improvement in the success rate as the radiologic and urologic team gained experience. The success rate for simple pelvicaliceal stones was 98% in the entire series (vs. 89% in the first 100 cases) and 87% for staghorn calculi. The most common complication was bleeding, with 12% of the patients requiring transfusion. Other complications include infection (0.6%), retained stone fragments (4%), and ureteropelvic junction stricture (1%). There was 1 death, an obese diabetic woman who suffered a myocardial infarction. Successful stone extraction requires a properly placed nephrostomy tract, and radiologic and urologic expertise. The advent of extracorporeal shock-wave lithotripsy will not abolish the need for nephrostolithotomy.
 
Sixty-one cases of diverticulum of the male urethra were reviewed. This group included 10 patients with congenital and 51 with acquired diverticula. The etiology of the acquired variety, the radiological findings, and the frequency of appearance in both congenital and acquired diverticula of the urethra during a 30-year period are described.
 
The role of gallium-67 is limited in the genitourinary tract [1]. The rare occurrence of increased67Ga uptake in renal carcinoma and other tumors is notable because of a lack of documentation in the literature [2]. This report is of such cases found in the last year. Gallium-67 scanning has been performed at our institution since 1972 with an average of 200 cases per year.
 
Percutaneous transluminal angioplasty (PTA) was performed on 94 patients with hypertension due to renovascular stenosis. In 76 cases PTA was successful. Even in the presence of severe arteriosclerosis the balloon catheter technique was successful and resulted in few complications. Recording intraluminal blood pressure is the best parameter to predict a successful outcome. Nuclear studies are helpful in the follow-up of patients. The principal aim of PTA is to lower the blood pressure and to salvage the diseased kidney.
 
A case of nontraumatic rupture of the ureter secondary to a nonopaque calculus is presented. Because of the inherent high image contrast caused by the leak of technetium 99m-DTPA-labeled urine, the technetium 99m-DTPA excretory urogram is seen as an alternative to the intravenous urogram or contrast-enhanced computed tomography in selected cases of suspected ureteral rupture.
 
99mTc-DTPA renal scanning offers a method for demonstrating adrenal hemorrhage as a cause of flank mass in the neonate and for assessing renal function. The hemorrhagic adrenal appears as a tracer-free area over the flattened and displaced kidney. The method is low in radiation and is not hampered by obscuring bowel contents.
 
A 99mTc penile scan was performed in 9 patients with priapism. The technique of the procedure is described. Penile scan is an easily obtainable modality that can differentiate between high- and low-flow forms of priapism. We believe that these scintigraphic findings facilitate management of priapism.
 
Computed tomographic (CT) evaluation of an abdominal mass diagnosed a huge 2-L congenital bladder diverticulum that caused urinary retention and ureteral compression leading to renal failure. The patient's renal failure resolved with decompression. His voiding dysfunction and retention resolved following diverticulectomy.
 
A case of bladder herniation through the abdominal wall as a late complication of retropubic prostatic adenomectomy is reported. The computed tomographic scan gave the diagnosis and a complete recovery was obtained with herniorraphy.
 
Intraabdominal neuroblastomas were evaluated by sonography in 30 children, 18 of whom underwent 2-5 studies, for a total of 63 examinations. All tumors had a variable and inhomogeneous echo pattern, but the level of echogenicity and changes in echo texture with therapy were of no value in predicting the course of disease. Sonography was limited in delineating the extent of tumor and in following response to therapy. Total resolution of abdominal disease could not always be accurately diagnosed with sonography. Computed tomography is recommended to evaluate further those children in whom abdominal disease is thought to have resolved, since heavily calcified, residual neuroblastoma may be mistaken for bowel gas on sonography.
 
Abdominal neuroblastoma is reviewed in terms of its diagnosis, including in utero, at birth, and through infancy into childhood. Age at diagnosis remains the best predictor of survival, with infants under 1 year of age having almost 100% cure. Ultrasonography and magnetic resonance imaging (MRI) are the recommended diagnostic modalities to stage the abdominal primary, although computed tomography (CT) (including myelography) is still widely and efficiently used. Examples are given of each stage.
 
Retrograde flow in the left gonadal vein may be visualized in the venous phase of aortography or renal arteriography. In none of 13 cases was this due to a mass lesion at the renal hilum. Although the Valsalva maneuver may cause this flow reversal in some, in most cases it is due to anatomical structures or variants compressing the renal vein. These are detailed. Left gonadal vein reflux incidentally detected on the aortogram may thus indicate impaired left renal venous drainage and its consequences. There are also clinical and urographic constellations which merit aortography to detect left gonadal vein reflux for their elucidation.
 
Computed tomography (CT) after abdominoperineal (AP) resection for rectal carcinoma is a routine procedure for the detection of recurrent tumor and distal metastases. We reviewed sequential CT scans after AP resection in 52 patients in order to see whether the urinary tract as a neighboring organ is involved in recurrent malignancy. Bladder displacement in itself was not associated with hydronephrosis. Such hydronephrosis developed, however, in 14 patients--13 with a presacral mass, and one with retroperitoneal lymphadenopathy. In 23 of the 52 patients a presacral mass appeared, either fibrosis, infection, or recurrence. Severe hydronephrosis was found only with malignancy. We suggest that marked hydronephrosis associated with a presacral mass after AP resection is an indirect sign of malignancy.
 
Partial renal ablation was produced in 15/17 swine kidneys after segmental intraarterial injection of 1-2 ml of 95% ethanol. Complications were seen in 3 kidneys, including reflux of ethanol into nontarget vessels with subsequent total infarction of 2 kidneys, and the development of hydronephrosis in 1 kidney. Strictly selective catheterization and a very slow injection of ethanol are essential to avoid complications. This technique may find clinical application and the possible indications are discussed.
 
Imaging of the pediatric pelvis has proven of great use in defining the normal and abnormal genital tracts. Sonography is the key screening tool and often the only tool necessary for the diagnosis of problems related to ambiguous genitalia, ovarian and uterine masses, amenorrhea, and abdominal and pelvic pain. Computed tomography (CT) and magnetic resonance imaging (MRI) have key roles in the global assessment of the pelvis particularly with regard to the assessment of tumor spread.
 
Sonographic examinations of 17 patients revealed 21 kidneys with anechoic sonolucent areas within the renal sinus. Computerized tomography was obtained in 3 patients and the mass effects were proven to be multilocular parapelvic cysts. These parapelvic cysts simulated renal sinus lipomatosis.
 
A case of a perinephric abscess invading the spleen in a 25-year-old woman with bladder exstrophy is reported. Treatment utilized both percutaneous drainage and open surgery. Perinephric abscesses have not been previously reported to extend into the spleen.
 
A patient with acquired immune deficiency syndrome (AIDS) who presented with right testicular swelling is described. Sonography demonstrated diffuse enlargement and inhomogeneity of the testicle with central hypoechoic areas. Testicular abscesses were seen at surgery and Mycobacterium tuberculosis was cultured from the surgical specimen. Tuberculosis should be considered in the differential diagnosis of testicular enlargement or abscess formation in AIDS.
 
Prostatic abscess appears on computed tomography (CT) as multiple, well-demarcated fluid collections within the prostate gland and/or periprostatic tissues. Since prostatic abscess may not be differentiated from other prostatic disease on the basis of history and physical examination alone, CT can contribute significantly to establishing this diagnosis. Prostatic abscess can be an aggressive lesion within the pelvis and may rupture into the urethra, peritoneum, prevesical space, rectum, perineum, and ischiorectal fossa. By defining the extent of the disease, CT can guide selection of an optimal surgical drainage procedure. CT can be used effectively to monitor the treatment of prostatic abscess.
 
A unique case of a hypernephroma complicated by a left perinephric abscess and descending colon perforation is presented. Appropriate surgical management was guided by the use of abdominal CT scanning, barium enema, and renal arteriography.
 
A case of a perinephric abscess complicated by a fistulous tract leading to the pericardium is presented. We report herein on the conventional radiological findings.
 
Pelvic abscesses and fluid collections are relatively common complications of major pelvic surgery. When a radical cystectomy has been performed, the ultrasonic acoustic window to normal anatomic landmarks is lost and bowel loops prolapse into the anatomic pelvis. This makes standard suprapubic ultrasonography (US) either difficult or nondiagnostic and often obscures significant pathology. The current use of high-frequency endocavitary US transducers permits an alternate view of the remaining pelvic structures. Coronal transgluteal scans also permit a limited view of the presacral area. These approaches were used in drainage of pelvic abscesses after cystectomy using the transrectal, transurethral, transperineal, and transabdominal routes under US guidance.
 
A case of acute focal bacterial nephritis (lobar nephronia) which evolved into a renal abscess is reported. This case is unusual for 2 reasons: the focal nephritis was isoechoic (not previously reported), and it progressed to an abscess despite antibiotic therapy. Ultrasound initially detected the focal nephritis and later confirmed its progression to an abscess. Successful treatment was obtained with sonographically guided percutaneous catheter drainage in conjunction with systemic antibiotics.
 
Computed tomography and ultrasonography are effective methods for diagnosis and localization of renal and perinephric abscesses. In patients with clinical suspicion of sepsis, diagnostic needle aspiration of these lesions can be safely performed extraperitoneally by using sectional imaging for guidance. When an abscess is confirmed, small catheters can be introduced percutaneously via the diagnostic aspiration route to provide immediate decompression as well as continuous and definitive drainage without need for surgery. In 8 cases so treated, there were no major complications, deaths, or recurrences. These results, obtainable without the risks of surgery, indicate that patients with renal or perinephric abscesses should be offered a trial of percutaneous drainage as a definitive method of therapy. Those cases not amenable to percutaneous drainage, or those in which the procedure has failed, can then be drained surgically. Percutaneous abscess drainage is widely applicable because it can be performed in any uroradiologic facility with access to sectional imaging.
 
A case of perinephric abscess with renal cell carcinoma is presented. Hematuria is uncommon in cases of perinephric abscess. When hematuria is present in a patient with perinephric abscess further evaluation is necessary to rule out an associated malignant process.
 
The computed tomographic (CT) findings in four cases of seminal vesicle abscess are presented. The predominant infectious organism in two cases was Escherichia coli, one case was probably caused by Mycobacterium tuberculosis, and another by atypical mycobacterium. The CT findings included unilateral (three cases) or bilateral involvement (one case), seminal vesicle enlargement with hypodense areas within the gland (three cases), adjacent perivesicle inflammation (three cases), and associated bladder wall thickening (three cases). Although the diagnosis of seminal vesicle abscess is often overlooked clinically, CT may help suggest the correct diagnosis early thereby helping to initiate therapy.
 
A case of myelolipoma arising from an accessory adrenal gland is reported. The accessory adrenal gland is a developmental anomaly, recognized often in the periadrenal fatty tissue at post-mortem examination. Myelolipoma of accessory adrenal gland should be considered when a suprarenal fat-containing tumor is seen separately from a normal-shaped adrenal gland.
 
Computed tomography (CT) was performed on four patients in whom excretory urograms revealed marked displacement of the kidneys and/or ureters. CT in each case was remarkable for the presence of excessive accumulation of normal retroperitoneal fat and failed to document the existence of a retroperitoneal neoplasm, lymphadenopathy, or other pathological mass.
 
Fifty-one percutaneous renal needle biopsies were performed on 46 patients. Initial biopsy was adequate for diagnosis in 89% of patients. When a second biopsy was performed, this accuracy increased to 98%. Thirty-four of 51 (67%) biopsies were for renal masses and 17 (33%) for medical indications. Computed tomographic guidance was utilized in 94% of cases. Biopsies of renal masses were performed with 18-21-gauge needles, while biopsies for medical indications were performed with an 18-gauge cutting needle or 14-gauge Trucut. A rate of serious complications of 6% was noted.
 
Our previous research showed that radiologists could interpret digital urograms with sensitivity, specificity, and receiver operating characteristic (ROC) curve performance similar to their interpretations of conventional urograms. To evaluate further the suitability of digital radiology for performing excretory urography, we investigated relationships among image quality, radiologists' certainty of diagnostic decisions, and diagnostic accuracy for digital and conventional urograms. We examined data from a study of 100 excretory urograms performed using matched film-screen and digital exposures. Three radiologists rated the quality of digital urographic images compared to film-screen images. Image quality did not correlate well with diagnostic accuracy for either modality, perhaps because of the overall high level of quality of the exposures. Radiologists' level of certainty in their diagnostic decisions decreased with poorer image quality for both modalities. The similarities of the tested relationships provides further evidence that digital technology is suitable for use in urography.
 
Screening for hydronephrosis continues to be an essential part of the evaluation of patients with azotemia of unknown cause. To determine whether sonography is as reliable as nephrotomography for screening purposes, we carried out a prospective, comparative study. Sixty-two patients were evaluated. Mean serum creatinine was 4.3 mg/dl. Of 116 kidneys, 45 were obstructed according to urographic criteria and 42 of these were correctly called hydronephrotic by sonography. The 3 false negative sonographic studies occurred in 2 patients. All 3 kidneys contained radiopaque calculi visible on the plain abdominal film. Of the 71 nonobstructed kidneys, 5 were mistakenly called hydronephrotic by ultrasound, giving a false positive rate of 7%. We believe it is appropriate to use gray-scale ultrasound as a screening test for urinary obstruction in azotemic patients providing the plain abdominal radiograph shows no calcifications.
 
The findings of computed tomography (CT), magnetic resonance imaging (MRI), and angiography were correlated with the histopathological findings in a patient with acquired renal cystic disease (ARCD) and bilateral multiple renal adenocarcinomas. Hemodialysis patients, especially with ARCD, should have a follow-up imaging study for an early detection of renal adenocarcinomas because multiple renal adenocarcinomas would arise frequently and simultaneusly from ARCD.
 
Patients with end-stage kidney disease, particularly those treated with dialysis, have an increased risk of renal cell carcinoma. Renal cell carcinoma may also develop in the native kidneys of renal transplant recipients with good graft function many years after transplantation. Recent studies suggest that the incidence of renal carcinoma among dialysis patients is 3-6 times greater than in the general population. However, annual imaging of the native kidneys of all dialysis patients is not justified because it has not been shown to have a significant effect on patient outcome. Screening may, however, be useful in selected patients with good general medical conditions and who have known risk factors for renal carcinoma.
 
Noninvasive imaging studies were performed on 26 patients undergoing chronic hemodialysis. We found cysts in 46% of patients and neoplasms in 7.7%. The cysts were relatively easy to detect. However, the neoplasms were very difficult to detect; this problem has been described before in the literature. The natural history of acquired cystic disease and neoplasms in hemodialysis patients is largely unknown. A review of the problems associated with the imaging and management of these patients is included.
 
Five different benign causes of ureteropelvic junction obstruction in adults without prior obstructive history are presented: aortic aneurysm, renal cyst, xanthogranulomatous pyelonephritis, eosinophilic ureteritis, and a crossing blood vessel. Although uncommon, these etiologies warrant consideration when an adult patient presents with ureteropelvic junction obstruction without a prior history of obstruction.
 
Acquired obstructions of the lower urinary tract in children are uncommon. They can be divided into intrinsic and extrinsic lesions, and have a very varied etiology. Several illustrative cases are reported, such as traumatic and infectious strictures, meatal stenosis, benign and malignant tumors, fused labia, and epidermolysis bullosa. Many of these lesions have distinct radiographical features, best demonstrated by micturating cystourethrograms.
 
A 6-year-old girl with meningomyelocele and a neurogenic bladder was managed with clean intermittent catheterization. After 3 months she developed a vesicocolonic fistula, demonstrated on cystography. This is the first such complication reported since this type of management was popularized.
 
Intraurethral Condylomata acuminata can present as a serious problem. Prior to endoscopy, retrograde urethrography can help in diagnosing and determining the extent of the disease.
 
Top-cited authors
John Cronan
  • Alpert Medical School - Brown University
Nicholas Papanicolaou
  • University of Pennsylvania
Christian G Chaussy
  • Universität Regensburg
Marjorie Hertz
  • Sheba Medical Center
Peggie Jonas
  • University of Greenwich