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GENITOURINARY RADIOLOGY

Before we begin, here is the anatomy of the kidney, in terms of the vessels found within it:

Here is the sequence from renal artery to renal vein (see figures):

Renal artery

Segmental artery

Lobar artery

Interlobar artery

Arcuate artery

Interlobular artery

Arcuate artery

Interlobular artery

Afferent arteriole

Glomerulus

Efferent arteriole

Interlobular vein

Arcuate vein

Interlobar vein

Segmental vein

Renal vein

this is the Key for the model kidney:

1. Renal Vein 
2. Renal Artery 
3. Renal Calyx 
4. Medullary Pyramid 
5. Renal Cortex 
6. Segmental Artery 
7. Interlobar Artery 
8. Arcuate Artery 
9. Arcuate Vein 
10. Interlobar Vein 
11. Segmental Vein 
12. Renal Column 
13. Renal Papillae 
14. Renal Pelvis 
15. Ureter 

TESTICULAR CA:

germ call tumors: YES CT: yolk sac, embroyonal (2 yo and 2-3rd decade), seminoma, choriocarcinoma, teratoma

Non germ cell: Leydig (3-6 yo, benign>malig by 9:1) and sertoli (1st year, benign >malig by 9:1). Leydig can cause precocious puberty

yolk sac and teratoma are most common tumors in children. Seminoma are also germ cell and are more common in adults

TESTICULAR LYMPHOMA:

child: leukemia>lymphoma

adult: lymphoma>leukemia

TESTICULAR BLOOD SUPPLY:

deferential, cremesteric, testicular

CAUSE OF STRIATED NEPHROGRAM:

renal vein thrombosis, tamm horsfall protein, pyelonephritis, medullary sponge kidney

CAUSE OF NEPHROMEGALY:

Glomerulonephritides, HIV nephropathy, diabetic glomerulosclerosis, amyloidosis, acute tubular and cortical necrosis, leukemia and lymphoma, ADPKD and ARPKD are all causes. Conditions that typically cause enlargement of one kidney, such as acute renal vein thrombosis, can also cause bilateral nephromegaly if the process is present in both sides.

Medullary cystic disease which is inherited causes normal to small kidneys

TESTICULAR CYSTS:

central is rete testes and peripheral is tunica albuginea

ADRENAL METS:

50% of adrenal masses in oncology pts will be mets. A unilateral adrenal met is most likely to be lung.

MALE URETHRA

A little bit of the male urethal anatomy ( i always have trouble remembering this for more than 5 min):

The prostate is a gland situated underneath the bladder (the bladder neck) and is perforated by the first portion of the urethra. The 2 ejaculatory ducts enter the upper part of the prostate from behind, travel through the gland and open into the urethra on a small protuberance (3-4 mm) of the urethral mucosa called the verumontanum ("veru").

This is quoted from an article by Tartufus MD (http://www.prostatitis.org/tarf/p3.htm) which may help to clafify some of the anatomy in this area.

The veru is very critical because of the convergence of several other structures:

Between the 2 openings of the ejaculatory ducts, we find the opening of the utricle, a remnant of our early life as embryo (a small duct representing the rests of the tissue which in the female develops into the uterus). The appearance of the utricle can vary widely from a tiny dimple in the veru to a long narrow duct extending deep into the prostatic tissue parallel to the ejaculatory ducts in the midline. In some individuals, this duct obliterates forming a cyst (utricular cyst) in the prostate, not rarely the cause of symptoms identical to those of "chronic prostatitis".

The prostate is composed of 25-30 small glandular units (acini) located in the periphery of the prostate, and each glandular unit is connected to the outside world by a tiny duct which opens into the urethra at each side in direct proximity to the veru. The prostatic acini produce a fluid that, at orgasm, is expelled from the acini by contraction of the prostatic smooth muscle tissue surrounding these acini. The composition of the prostatic fluid is vital for the well-being of the spermatic cells outside the body and severe alteration, like in certain forms of chronic prostatitis, can degrade fertility.

Other important anatomical structures, mostly neglected in the literature, are the seminal vesicles (SV). These glands reside on the backside of the lower part of the bladder, their body (about 5-8 cm long, .6-1 cm wide) lies alongside the deferent duct (which carries the sperm cells from the testis to the urethra) and empties into this duct before the deferent duct enters the prostate to become the ejaculatory duct. The SVs are structurally hollow organs comparable to the gallbladder, but with multiple small saccular compartments (looking almost like a grape) interconnected with each-other. The wall of the SVs is composed of an internal cellular lining (glandular cells) which produces a fluid necessary for the extracorporeal survival of the sperm cells. This fluid, together with the fluid from the prostatic acini, constitutes a major part of the volume of the spermatic fluid; only a small part comes from the testicles. The outside muscular shell of the SVs contracts and expells the secretion at orgasm.

 

Non atrophy  of Mullerian duct can cause cystic dilation of the vas deferens to the ejaculatory ducts. The utricle cysts can occur close to the prostate in the midline and can cause obstructive symptoms. These cysts lack sperm. They are associated with hypospadias and undescended testicle

PELVIC LIPOMATOSIS:

associated with cystitis glandularis, renal failure, obstruction of the collecting system, no association with obesity, htn is an associated finding as is renal failure and renal stones

PRIMARY MEGAURETER:

more common on the L than the R

GU  INFECTION:

In male<35 y, gonnorhea, clamydia are more common

In male>35 y, main organisma are E coli, staph, proteus

MOST COMMON CAUSE OF RENAL V THROMBOSIS:

nephrotic sydrome

STRICTURE S/P TURP:

most likely place to get a stricture is the bulbous urethra

MOST COMMON CAUSE OF URETERAL OBSTRUCTION:

intrinsic ureteral abnormality

 MOST COMMON CAUSE OF FOCAL SCARRING IN PYELO:

pyelotubular backflow

RENAL MASS WITH A CENTRAL SCAR?

it is most likely RCC, just because RCC's show up  more commonly than the others

PROSTATE CA:

PZ>TZ>CZ

RENINOMAS:

rare tumors but more common in females

REVERSED RENAL VEIN FLOW:

most common cause of reversed renal vein flow in renal transplant is renal vein thrombosis

ECTOPIC URETROCELE IN A CHILD:

can also present as an interlabial mass in addition to sarcom botyroides

RCC:

80-90% are clear cell type

MORE ON HUTCH DIVERTICULUM:

hutch are not associated with hypospadias. They are associated with VUR. Hypospadias are associated with cryptorchidism

PROSTATITIS LOCATION:

usually involves the peripheral zone

BPH:

hypertrophy of the transitional zone is associated with bph

BLADDER CA RISK FACTORS:

TCC: smoking, phenacetin, aniline, XRT, cyclophosphamide

SCC: leukoplakia, stone dz, infected tics, UTI, schistosomiasis (note that it is S hematobium that infects the bladder and not the others)

RENAL STONES:

the most common one is Ca oxalate. #2 is struvite, and #3 is uric acid, 70% of people with renal stones have a metabolic disorder. RTA causes Ca oxalate stones. This is due to hypercalciuria without hypercalcemia. Sarcoid and HPT cause hypercalciuria with hypercalcemia. PCKD also causes an increased incidence of renal stones. Abnormal bowel mucosae from bowel resection or involvement with the terminal ileum with inflammatory bowel disease causes increase in oxalate absorption resulting in increased oxalate stones. Abnormal bowel mucosae also cause increased uric acid stones. The most common cause of uric acid stones is a primary as opposed to a secondary metabolic cause. Note that struvite is often laminated.

Eswl is preferred when stone size is <25mm or when the stone is not branched or made of cystine. Also, it should not be used in cases of obstruction. Other contraindications to eswl are urosepsis, bleeding diathesis, pregnancy, and morbid obesity

TUBULE FUNCTION:

Na reabsorbed: PCT

Acid base balance: DCT and collecting duct

Water reabsorption: PCT and CD

ADH effect: CD

PYELORENAL BACKFLOW:

pyelosinus (fornix rupture)

pyelotubular (fan like streaks)

pyelointerstitial (more amorphous than pyelotubular)

pyelolymphatic (dilated lymphatics)

pyelovenous (rare)

the first 2 are the most common

VICARIOUS EXCRETION:

ARF, ATN is the most common

CYSTITIS GLANDULARIS:

mucin filled mucosal cysts with columnar cells (goblet) which appear as filling defects in the bladder. It is the precursor of adenocarcinoma

CYSTITIS CYSTICA:

can progress to cystitis glandularis. Serous filled cysts. female > male. It is associated with chronic uti. Forms from Brunner nest degeneration in the lamina propria. Radiologyweb.com (Bracco diagnostics sponsored Board review questions) state that cystitis cystica is not a premalignant lesion

PYELOURETERITIS CYSTICA:

Pyeloureteritis cystica is hyperplastic transitional epithelium projecting into the ureteral lumen. It indicates past UTI. It is caused by chronic urinary tract stone or infection resulting in numerous submucosal lined cysts. Diabetics are predisposed. F>M. bladder>>proximal 1/3 of ureter>upj. Unilateral>bilateral. Multiple round small lucent filling defects in the ureter. 1-3 mm in size. Some sources say that there  is an increased incidence of tcc, but the accepted view is that there is no increased incidence of malignancy (unlike in ureteral pseudiverticulitis)

MECKEL GRUBER:

occipital encephalocele, microcephaly, polycystic kidney, post axial polydactyly

ASK UPMARK KIDNEY:

segmental renal hypoplasia. the appearance is the same as unifocal reflux nephropathy

HEMIATROPHY:

assoc with wilms, MSK, congen hepatic fibrosis

URETEROCELES:

orthotopic ureteroceles are frequently bilateral.

MALAKOPLAKIA VS LEUKOPLAKIA:

malakoplakia: bladder > lower 2/3 of ureter > upper ureter > renal pelvis. Multifocal in 75%; bilateral in 50%. female > male for the urinary tract and male > female for other body parts (colon, rectum, etc)

leukoplakia: bladder > renal pelvis > ureter

URETHRAL STRICTURES:

40% of urethral strictures in US are from gonorrea. mostly affects anterior urethra and one sees reflux into the glands of Littre. Foley catheters cause most strictures at the penoscrotal junction. Instrumentation causes most strictures at the external sphincter where it is difficult to pass an instrument through

URETHRAL TUMORS:

most uretrhal tumors are SCC adn arise in the bulbous urethra

HEPATIC FIBROSIS ASSOCIATIONS:

arpkd, adpkd, mdk, caroli, choledochocele

MLCN

has > 10 cm cystic spaces. Young boys and older girls/women. They are taken out as cannot distinguish from Wilms. They can herniate into the renal pelvis. Incidence: F>M

NEPHROBLASTOMATOSIS:

associated with Wilms; 30% unilateral wilms, and 100% bilateral wilms. Precursor to Wilms. The best test for it is contrast enhanced CT

MESOBLASTIC NEPHROMA:

most common solid renal mass in the neonate. It is a hamartoma. it it treated with surgery due to uncertainty that it may contain areas of sarcomatous degeneration.

REFLUX:

5 grades. Grade 1 is reflux to ureter but not to kidney

NEONATAL ADRENAL HEMORRAGE:

R (70%) > L  (20%). Bilateral is 10%

RENAL ARTERY ANEURYSM:

Ca++ 30 to 50% in the wall. They are associated with HTN in 15%. R>L. There is an increased risk of rupture in a pregnant woman. The indications for surgery are: rupture, distal embolization, RAS, causing HTN, woman of child bearing age and >2 cm. If they are not Ca++, then there is a greater risk of rupture.

FRALEY SYDROME:

This is narrowing of  renal pelvis due to crossing vessel

WHAT IS MEGACALICOSIS?

Megacalicosis is nonprogressive caliceal dilatation caused by hypoplastic medullary pyramids. Mosaic-like arrangement of dilated calices (polygonal + faceted appearance, NOT globular as in obstruction)  

SPECTRUM OF URETHRAL INJURIES:

Urethral injury: type 1: stretching of posterior urethra without tear. Type 2: tear above UG diaphragm. Type 3: complete rupture at or below UG diaphragm. Straddle injury involves the anterior urethra in males, especially the bulbous portion where it is caused by compression of the urethra against the pelvis

INTRA VS EXTRAPERITONEAL BLADDER RUPTURE:

extraperitoneal bladder rupture occurs 4 times more common than intraperitoneal rupture

HUTCH DIVERTICULUM

Hutch diverticula are associated with reflux due to their location near the uvj which distorts the anatomy in this region leading to reflux or obstruction

BLADDER CANCER:

Bladder ca arising within a bladder tic usually metastasizes early due to no overlying muscle layer. With bladder outlet obstruction, most bladder tics develop near the base

POLYCYSTIC OVARIAN SYNDROME:

stein leventhal:

increased LH/FSH ratio

DRASH:

male pseudohermaphaditism and progressive nephritis. Like vhl, hemihypertrophy is associated with rcc

BECKWITH WEIDMAN:

EMG OR GOMPE: exomphalos, macroglossia, gigantism, organomegaly, diabetes, increased incidence of wilms

HORSESHOE KIDNEY:

IMA stops kidney form ascending. there is an increased risk of rcc in the isthmus. Horseshoe kidney is 0.01 to 0.25%. It has an increased incidence of UPJ obstruction and increased incidence of infection. The incidence is UPJ obstruction > calculi and UTI's. Associated anomalies include omphalocele, cardiac, skeletal, anorectal, and GU

Here is some other information I ran into:

Pathophysiology: The horseshoe kidney does not by itself produce symptoms. It is however, by virtue of its embryogenesis and anatomy, predisposed to a higher incidence of disease when compared to the normal kidney. The variable blood supply, presence of the isthmus, high insertion and abnormal course of the ureters all contribute to these problems. Because of these embryogenic and anatomical factors there are higher rates of hydronephrosis, stone formation, infection and certain cancers which result in a diseased horseshoe kidney. 

The most common associated finding in horseshoe kidney is ureteropelvic junction obstruction which occurs in up to 35% of patients. It causes the majority of problems. Obstruction is due to the high insertion of the ureter into the renal pelvis. The crossing of the ureter over the isthmus may also contribute to obstruction. Nonobstructive dilatation must be distinguished from obstructive dilatation by diuresis radioisotope renal scans. 

The prevalence of stones in the horseshoe kidney ranges from 20% to 60%. Stone disease is thought to be due to the associated hydronephrosis or ureteropelvic junction obstruction that causes stasis of urine. This hinders stone passage. Metabolic factors as in the normal population have also been suggested as contributing to stone formation in these patients. 

Urinary stasis and stone disease also predispose the horseshoe kidney to infection present in 27% to 41%. Ascending infection from vesicoureteral reflux is another cause of infection in the horseshoe kidney. 

Certain cancers are more frequent in the horseshoe kidney. This is thought to be due to teratogenic factors present at birth as well as the susceptibility of the diseased horseshoe kidney to certain cancers. Renal cell carcinoma is the most common renal cancer in horseshoe kidney, accounting for 45% of tumors. The incidence of renal cell cancer in the horseshoe kidney is no different than that of the normal kidney.


Relevant Anatomy: Horseshoe kidneys may be found at any location along the path of normal renal ascent from the pelvis to the mid abdomen. The kidneys may be lower than normal as the isthmus is tethered during renal ascent by the inferior mesenteric artery. The isthmus usually lies anterior to the great vessels at the level of the 3rd-5th lumbar vertebra. It can rarely be posterior to these vessels or run between them. 

The vascular supply is variable and originates from the aorta, the iliac arteries, and the inferior mesenteric artery. Bilateral single renal hilar arteries occur in 30% of cases, various combinations of single and multiple renal hilar and isthmus vessels are seen in 70%. The isthmus of the kidney may not have a separate blood supply or may be supplied by a single vessel from the aorta in 65% of cases. The blood supply to the isthmus may arise from the common iliac, or inferior mesenteric arteries.

The collecting system has a characteristic appearance on intravenous urogram due to an incomplete inward rotation of the renal pelvis, which faces anterior. The axis of the collecting system is deviated inward at the lower poles because of the lower pole's connection with the isthmus. The ureter may have a high insertion into the renal pelvis and cross anterior over the isthmus as it descends to the bladder.

MOST COMMON GU ABNORMALITY:

duplex collecting system is the most common GU anomaly. There is an associated increased incidence of UPJ obstruction and uterus didelphys. The lower pole refluxes and the upper obstructs, refluxes or both. The associated ectopic ureterocele is secondary to obstruction. It can also cause obstruction of the other side as well

UPJ OBSTRUCITION:

men>women 2:1 and L>R. It is bilateral in 10-30%. It is associated with and increased incidence of contralateral dysplastic kidney and renal agenesis. It does not affect the lower ureter. In the fetus, it is most commonly due to muscular or intrinsic abnormality

RCC ASSOCIATIONS:

aniridia, beckwith weidman, drash, nf, klippel trauneray, vhl, ts.

HYPERTROPHIED COLUMN OF BERTIN:

It is a nl variant. It most commonly occurs at the juction of the upper and middle one third of the kidney

RETROPERITONEAL SPACES (quoted from radiologyweb.com board practice questions):

The scrotum, if the processus vaginalis remains patent, communicates with the peritoneal cavity rather than with the retroperitoneum. The psoas muscle lies posterior to the posterior pararenal space, in what some refer to as the "retrofascial" space. The adrenal gland is in the perirenal space. Part of the lateroconal fascia courses in a plane parallel to the sagittal plane of the body. In patients with ample retroperitoneal fat, this fascia can be seen as a vertical line on x-ray examination of the kidneys, ureter, and bladder.

LIPIDOSIS OF THE ADRENAL GLAND:

Wolman disease is  a lipidosis of the adrenal gland. It is associated with ca++ of the adrenals. The affected infants usually die a few weeks after birth

ADRENAL GLAND SIZE:

The medial limb of the r adrenal is bigger than the lateral limb. With agenesis of the kidney, the adrenal is still present but is cigar shaped

PHEO RULE OF TEN:

Bilateral, multiple, malignant, familial, extraadrenal  

URACHUS:

a bit on the urachus: patent (ie communication) in 50%, urachal cyst in 30%, sinus in 15% and tic in 5%

urachal cysts are susceptible to bleeding, ca, stones and obstruction. Infection with staph aureus is the most common complication of urachal cysts in adults. Bleeding is more common in children

ANORECTAL MALFORMATION:

high (supralevator) anorectal malformation has a high (50%) association with GU and cardiac anomalies while a low malformation does not

ADRENAL CORTICAL HORMONES:

concerning adrenal: cortex: gfr or mga while medulla: norepi, and epi only

RENAL BIOPSY:

Brodels white line is in lateral kidney and is highly vascular. Brodels avascular plane is 1-2 cm posterolateral to the white line

CYSTIC KIDNEY DISEASES::

arpkd  3 types, in the juvenile form, there is bilateral gross renal enlargement and faint nephrogram with blotchy opacification on initial images which then becomes increasingly dense. On US, the kidneys are hyperechoic and the cysts are not resolved.They consist of ectatic dilatation of the collecting tubules. There is a loss of the corticomedullary differentiation. On ob us, there is progressive renal enlargement as early as 17 w with hyperechoic renal parenchyma. There is non visualization of urine in the bladder in severe cases.

adpck mean age at dx is 43y. Assoc with cysts in liver, panc, lung, spleen, thyroid, seminal vesicles etc and cerebral berry aneurysms.There are bilateral large kidneys with multifocal round lesions and unilateral enlargement may be the first manifestation. The cysts may rim calcify. The kidneys shrink after the onset of renal failure. US shows multiple cortical cysts which are not seen prior to the teens. The kidneys are diffusely echogenic when the cysts are small in children. On Ob US, the kidneys can look large and echogenic similar to infantile PCKD usually in the 3rd trimester. The earliest sonographic dx is made at 14 w. It can be unilateral and macroscopic cysts are rare.

posterior urethral valves. Types 1 to 3. Type 1 is membranous, type 2 the folds consist of hypertrophied muscle and type 3 consists of an iris or diaphragm. The folds are wolffian duct remnants. Type 1 is the most common. Discovered in the first year and neonatal period in 70% (about 35% each). There is vur mainly on the L side. US shows oligohydramnios and hypoplastic multcystic dysplastic kidney if early occurrence. The ddx is upj or uvj obstruction or primary megaureter,  megacystis microcolon sydrome, and massive vur

More simply put, Type 1 PUR are slit like and type 3 are pinhole so type 3 are most likely to be associated with renal dysplasia. There is no association of PUV with Prune Belly syndrome

it is interesting to note that primary megaureter is more common on the L

mcdk second most common cause of an abdominal mass in neonate after hydronephrosis and it is the most common cause of an abdominal mass in a healthy neonate.  M>F for unilateral and I believe M=F for bilateral. More common among infants of diabetic mothers. Most common cause of cystic dz in infants. Due to ureteral obstruction. Asymptomatic if unilateral. L>R for unilateral. Unilateral is most common form (80%) which is secondary to pelvoinfundibular atresia. Associated with other GU and ipsilateral anomalies. There are 2 forms. The multicystic kidney (potter 2a) is large kidney with multiple cysts and little visible parenchyma. the potter 2b form is hypoplastic or diminutive form with small echogenic kidney. in relation to site: upj causes large kidney with multiple large cysts. In distal ureter, small or no cysts in small kidney. Also, depending on time of insult, early (8-11w) --> atretic and small with few small cysts. Late causes large central cyst (pelvis) often communicating with small cysts. US shows no central sinus complex and no renal parenchyma.

Medullary cystic dz in adults and juveniles is AD while in children it is AR. Salt wasting uropathy. Medullary striations on ivp.Bilateral small kidneys with smooth contour and thin cortex. US shows increases echogenicity and small medullary cysts. There is loss of CM differentiation.

MSK dysplastic cystic dil of papillary and medullary portion of the collecting ducts. Young to middle aged adults.  May be assoc with Ehlers Dan, hemihypertrophy, arpkd, Caroli dz. Medullary calcinosis may involve one or all pyramids. It is non hereditary.

RENAL CELL CA:

presence of intralesional ca++ of a renal mass favors rcc especially if it is extensive. large solid component to the mass favors carcinoma and herniation of mass into renal pelvis suggests multilocular cystic nephroma

rcc staging: 1: confined to renal capsule. 2: penetrates beyond capsule but remains within gerota fascia. 3a: extends into the renal v or the ivc. 3b: in regional LN's. 3c: both venous extension and LN involvement. 4a: extension thoough Gerota into adjacent organs other than the ipsilateral adrenal. 4b: distant mets.

TS AND AML:

people with TS: 80% have aml. In people with aml, only 20% have TS

BLADDER HYPERACTIVITY:

cerebral lesion, eg parkinsons or stroke

DETRUSOR SPHINCTER DYSYNERGIA:

lesion below pons and above  T5. This results in external sphincter which obstructs emptying and causes thickened trabeculated bladder

FLACCID BLADDER:

disc disease, diabetes, pelvic trauma, surgery disrupts nerves in sacral plexus and causes hyporeflexia of the bladder

SPONTANEOUS RENAL HEMORRAGE:

rcc is the most common cause. for aml there is a much greater chance of bleeding with tumors greater than 4 cm

MORE ON TCC:

trigone of bladder is the most common location and sessile tumors are of a higher grade than papillary tumors. for the bladder: tcc (90%), scc (5%) and adenoca (2%)

RENINOMA:

young women, 2-3 cm at discovery, near poles of the kidneys, subcapsular, hyperechoic

RENAL ANOMALIES

crossed fused ectopia is the second most common fusion anomaly of the kidney after horseshoe. the most common anomaly is partial duplication. in terms of ectopia: l--->r more than r--->l

RENAL AVF VS AVM:

renal AVF is acquired while renal AVM is congenital (aqcuired is more common 75%)

ADRENAL BIOPSY:

right: posterior approach which has risk for ptx

left: anterior which is to avoid spleen, but there is a risk to hit pancreas

complications of adrenal bx are hemorrage and ptx. Some of the recalls say that hemorrage is more common than ptx

FEMALE GU CYSTIC LESIONS:

Gartners cyst is a Wolffian duct remnant in the anterolateral wall of the vagina at the upper end. There is a 6% association with unilateral agenesis of the kidney

Bartolins is in the lower end of the vagina and is associated with adenoca or scc (50/50). Ie it is lower in the vagina than gartners. 

A urethral diverticulum can occur from infected periuretral glands. Skenes are the largest ones and are paired; they are prostatic remnants (ie derived from Wolffian duct). Ureteral tic is more common in females. Skenes are in the distal 1/3 of the urethra

RETROCAVAL URETER:

this occurs between the proximal 1/3 and distal 2/3 and causes proximal ureteral obstrucion adn results in flank pain. The classic sign is the "italic S" on the R

UVJ STONES

the UVJ is the place of hangup of 75% of all stones.

PARAOVARIAN CYSTS:

they often undergo torsion, typically they represent 10% of pelvic masses. They are located in the broad ligament. They are not responsive to hormonal therapy. They are Wolffian duct remnants and can grow to huge size (several liters). The clue to them is that they are in the adnexal region without being clearly connected to the ovary

CAUSE OF PERSISTENTLY DENSE NEPHROGRAM

 (=SAME AS INCREASING NEPHROGRAM):

ras, rvt, atn, hypotension. acute pyelonephritis is not on the differential as 2/3 of pts have a normal nephrogram

CAUSES OF URETHRAL STRICTURES:

Stricture - post trauma #1 cause, develop rapidly at anatomically restricted areas such as the penoscrotal junction and membranous urethra
Congenital Stricture - do occur w short seg involved
Inflam stricture #2 - Gonococcus, TB, Shisto, usually bulbous portion in 70% because of high concn of periurethral glands of littre in this area, beaded long seg strictures
Squamous Cell Ca - rare, most commonly secondary to mult strictures

INCIDENCE OF VARICOCELES:

a possible nutcracker effect of the sma and aorta on the left renal vein may be responsible for increased incidence of varicoceles on the left. Varicoceles occur in 10 to 20% of adult men. The valsalva maneuver increases the size of the varicocele

EMPHYSEMATOUS PYELONEPHRITIS AND CYSTITIS:

emphysematous pyelonephritis and cystitis are more common in diabetic women. E. Coli is the main organism.

PROSTATE CA STAGING (JEWITT):

A: no clinical manifestation

B: palpable, has not invaded through the capsule

C: invaded through the capsule, but assymptomatic

D: distant mets

prostate ca: PZ (75%) > TZ (20%)> CZ (10%)

note that prostate ca is hypointense on T2 relative to the peripheral zone which is bright on T2

GOODPASTURES DISEASE:

these pts have antibasement membrane antibodies

GERM CELL TUMORS OF TESTICLE:

testicular germ cell tumor mets: lung>liver>brain. Seminoma is 40-60% of all germ cell tumors. non seminomatous results in elevation of the HCG in 45% and AFP  in 50%. Pure seminoma does not cause elevation of the HCG or AFP levels

MORE ON ESWL:

in addition to cystine, also Ca oxalate is resistant to eswl

DELAYED CONTRAST RXNS:

these are more common with non ionic than ionic contrast. For renal dysfunction, DM alone: no difference. DM + abnormal renal function: increased risk for contreast nephropathy. Intraarterial contrast shows a lower incidence of contrast nephropathy than intravenous by about 50%

RESPIRATORY DISTRESS:

for expiratory stridor, use beta agonist eg albuterol and for inspirator stridor use epinephrine

SPERM GRANULOMA:

most common cause of epididymal mass

PATENT URACHUS:

patent (50%). urachal cyst 30% and urachal sinus 15%. Urachal tic is only 5%

NEPHROCALCINOSIS:

5% is cortical and 95% is medullary. Of the medullary, 40% is due to primary HPT and 20% is due to RTA. Today, most are due to MSK. Primary hpt causes increased Ca++ and 2ary hpt has less Ca++

URETERAL INJURY:

trauma, R > L

ADRENAL INJURY:

blunt trauma results in more injury to R adrenal ie R>L. This is due to R being connected directly to the IVC with better transmission of intraabdominal pressure to the adenal

SPLENIC CYSTS:

#1 is endothelial and epithelial and #2 is parasitic and pseudocysts

PERINEPHRIC VS SUBCAPSULAR HEMATOMA:

subcap hematoma deforms the kidney while perinephric does not

BLADDER TUMORS:

tcc (90%)> scc (5%) > adenoca (2%)

EAGLE BARETT:

this is synonymous with Prune Belly

EFFECT OF MAI ON THE SPLEEN:

it causes massive splenomegaly

METABOLISM OF VASOPRESSIN:

although it is made mainly in the hypothalamus, it is metabolized largely in the liver and kidney

STRIATED NEPHROGRAM:

acute RVT, acute pyelonephritis, tamm horsfall protein, hypotension, MSK, kidney contusion

AFFECT OF TB ON URETER:

pipestem, beaded, corksrew

ORGANISMS IN EPIDIDYMITIS:

main ones are E coli, and pseudomonas or Staph. These make up 85%. Gonococcus is 12%. TB is 2 %

SPACE OF RETSIUS:

this is located behind the umbilical fascia

PRIMARY MEGAURETER:

this is due to slow emptying of the ureter. It is functional obstruction. It is more common on the L. It is associated with contralateral renal anomalies

RENAL VEIN THROMBOSIS:

most common cause is nephrotic syndrome

ENTEROPATHIC RENAL STONES:

uric acid and oxalate are increased in small bowel resection

UPJ OBSTRUCTION:

L>R. Most are due to an intrinsic abnormality

RENAL TRANSPLANT:

DM is #1 and chronic glomerulonephritis is #2 for renal transplant. #3 is PCKD and #4 is nephroschlerosis

FOCAL RENAL SCARRING:

most common cause of this is pyelotubular backflow

MORE ON ASSOCIATIONS WITH WILMS:

hemihypertrophy, NF, BW, Drash, spontaneous aniridia, cerebral gigantism (soto syndrome), klippel trenaunay

BOTTOM LINE ON BLADDER INSTABILITY:

this is an excerpt from Hovespin which helped me to figure this out a bit better:

there are 2 centers which control micturition, 1 is the pons and 2 is the sacral plexus. The pontine center is under the control of cerebral cortex. CVA, Parkinsonism, NPH etc release control and cause uninhibited bladder contractions. The resultant voiding process occurs as a normal sequence of reflexes and so the urinary tract is often normal radiographically.

With a lesion below the pons, but above the sacrum (especially above T5), there is discoordination between voluntary control of the external sphincter by the CNS and the voiding reflex known as bladder - external sphincter dysynergia. Since the external sphincter obstructs normal emptying of the bladder, the bladder becomes thickened and trabeculated (called christmas tree bladder). The upper tracts suffer from high pressure/reflux. Common etiologies are MS, spinal cord tumors, trauma.

The flaccid or atonic bladder occurs when the lesion involves the conus medullaris or sacral micturition center. Causes include disc dz, diabetic neuropathy, pelvic trauma, surgery. The bladder distends imperceptably until the intravesicular pressure builds up and causes overflow. AGain, the upper tracts may suffer too.

Stress incontinence occurs because of improper vesicourethral angle which produces an incompetent sphicnter.

so in conclusion:

note that there are 2 centers for micturition. One is the sacral micturition center and the other is the pontine micturition center.

above pons: lose volitional control or get hyperreflexia with sphincter synergy

below pons: loss of volitional control or have hyperreflexia with sphincter dysynergia

sacral plexus or conus: get a combo of the above

pelvic nerves: get loss of detrusor contraction ie bladder areflexia leading to a flaccid bladder

NEOPLASMS IN TRANSPLANT:

liver and kidney transplant #1 is skin and #2 is NHL

OVARIAN VEIN SYNDROME:

this is pain and dilatation of the R ureter from pressure due to a dilated ovarian vein

OBSTRETICAL SHOCK:

causes cortical and not medullary necrosis

STRUVITE STONES:

klebsiella, pseudomonas, E coli, Proteus

PROSTATE MR:

homogenous intermediate signal on T1 and uniformly low signal on T2. On T1, the peripheral zone has slightly higher signal than the remainder of the prostate

BLADDER CA

Note that T1 to T3a bladder tumor is confined to the bladder wall. T3b breaches the bladder wall and muscle and enters the pervesicle fat

ABDOMINAL NEUROBLASTOMA:

>2/3 of abdominal neuroblastoma in childhood occur in the adrenals. > 50% of neuroblastomas are calcified on plain film. Ca++ are seen in 25% of childhood RCC on AXR. They are not seen in rhabomyosarcoma on AXR

MORE ON PRUNE BELLY SYNDROME:

the sigmoid ureters, the lower ureters are disproportionately dilated compared with the upper ureters. Also, they have prostate hypoplasia. PBS very rarely occurs in girls

URETEROCELES:

simple are orthotopic and ectopic are not simple

MORE ON MCD:

there is cystic dilatation of the DCT's and not the PCT's. Medullary cystic disease is AR in the juvernile form. The other name for it is juvenile nephronopthasis. The adult form is AD. Both have bilateral echogenic small kidneys with a thin cortex and smooth contour

MEDULLARY NEPHROCALCINOSIS:

medullary nephrocalcinosis results from deposition of calcium salts in the distal collecting tubules near the papilla. In MSK, there are anatomically dilated DCT's causing stasis and resulting in Ca++ deposition, and dilated CD's (green book)

ATN AND CYCLOSPORIN:

atn and cyclosporin toxicity present with preservation of renal perfusion but poor excretion

calcifications in tumors:

Neuroblastoma >50%

rhabdomyosarcoma 0%

renal cell ca 25%

in renal lesions: rcc> wilms>tcc>mlcn>mets

10% of Ca++ renal masses are cystic

SEPTUM OF BERTIN:

upper pole: 90% and bilateral in 60%

DROMEDARY HUMP:

formed from compression of the L kidney due to the spleen

LYMPHOMA OF THE KIDNEY:

incidence is 5%. NHL>HL. It spreads from direct extension from retroperitoneal disease and via hematogenous mets. Primary lymphoma of the kidney is rare as the kidneys do not have primary lymphatic tissue

FILLING DEFECT IN THE BLADDER:

fungas ball (rare), blood clot, stone, ureterocele (rare), prostatic enlargement, cystitis, neoplasm. For neoplasm, the malignant is TCC (90%) and SCC (5%) which are common and adenocarcinoma (rare ie 2 %). The benign ones include leiomyoma, fibroepithelial polyp, hemangioma, pheo, adenoma

SIGNS FOR BLADDER OUTLET OBSTRUCTION AT THE LEVEL OF THE PROSTATE:

bladder trabeculation, prostatic indentation at the base of the bladder, J shaped ureters as they enter the bladder, large PVR

MORE ON CORTICAL AND MEDULLARY CA++:

cortical is tramline, and medullary is stippled. 

cortical Ca++: chronic glomerulonephritis, cortical necrosis, HIV nephropathy, others eg alport

medullary Ca++: medullary sponge kidney, hyperparathyroidism, RTA, papillary necrosis

RENAL PAPILLARY NECROSIS:

lobster claw, clubbed calyxes, sloughed calyxes

INDICATIONS FOR ANGIOGRAPHY IN A PT AFTER TRAUMA:

non visualization of kidneys on IVC, persistent hematuria, hypotension/hypertension or persistent hematuria following an interventional urologic procedure

RVT:

adults: tumor>renal disease>postpartum state, hypercoagulable state

infants: dehydration, shock, trauma, sepsis, SSD

in the transplant situation, it most commonly occurs 3d post transplant

RENAL TRANSPLANT:

resistive index: (Psys - Pdiast)/Psys < 0.7

non specific for rejection if >0.7 ATN is the most common cause of acute renal failure in transplant pts. Persistent dense nephrogram in smooth enlarged kidneys with normal perfusion is suggestive of acute ATN. Note that ATN is the only process with normal flow but decreased excretion

OVARIAN VEIN SYNDROME:

ureteral notching with obstuction on R. The R gonadal vein crosses the ureter to drain into the IVC. The L renal vein drains into the L renal vein

ETIOL OF URETERAL DIVERTUCULUM:

it is an aborted attempt at duplication

URETERAL PSEUDODIVERTICULUM:

outward proliferation of epithelium into the laminal propria. It is premalignant

HUTCH DIVERTICULUM:

congenital weakness of musculature near the UVJ

BENIGN AND MALIGNANT BLADDER TUMORS IN CHILDREN:

malig: rhabdo (sarcoma botyroides projecting into the dome), leukemia/lymphoma mets to the wall

VUR:

primary: congenital, ineffective valve mechanism such as a short tunnel, abnormal insertion angle

secondary: submucosal, valve distorted by adjacent anatomic abnormality eg hutch diverticulum or ureterocele, cystitis

RENAL CALCIFICATIONS:

dystrophic, nephrocalcinosis (cortical and medullary), nephrolithiasis. Dystrophic refers to Ca++ in abnormal tissue such as tumor, vessels, TB etc. If see globular Ca++, than think dystrophic. Medullary nephrocalcinosis is much more common than cortical nephrocalcinosis

CAUSE SOF MEDULLARY NEPHROCALCINOSIS:

hypercalcemic states, hpt, paraneoplastic sydromes, sarcoid, medullary sponge kidney (renal tubular ectasia may be unilateral or focal). RTA is bilateral symmetric because it is metabolic.

OXALOSIS:

primary in children and secondary in adults (eg due to Crohns disease)

BIG FIVE OVARIAN CYSTS:

toa, cystadenoca, adenoca, dermoid, hemorragic cyst, endometrioma, EP, ovarian torsion

PATIENTS AT HIGHER RISK FOR LATEX ALLERGY:

those with myelomeningocele and bladder extrophy

MOST COMMON PLACE FOR EXTRAADRENAL PHEO:

organ of zuckerkandle

MOST COMMON COMPLICATION OF ILEAL CONDUIT:

not stones but pyelonephritis

STONE CHARATERISTICS:

cystine is ground glass, strivits is lucent, matrix is lucent

RETROPERITONEAL FIBROSIS:

may present with renal failure

FUNGAS BALLS IN URINARY TRACT:

usually candida

LASIX TREATMENT:

this can also be a cause of medullary nephrocalcinosis

CONTRAST INFUSION:

causes transient increase in pulmonary arterial pressure but not in systemic arterial pressure

NEUROBLASTOMA VS WILMS:

neuroblastoma is most likely to be bilateral

NEUROBLASTOMA:

associated with opsoclonus, myoclonus, and cerebellar ataxia

IONIC AGENTS SODIUM VS NON SODIUM:

there is a higher urinary flow with sodium agent than with a non sodium agent such as meglutamine. Ionic contrast agents are excreted primarily via glomerular filtration

STAUFFERS SYDROME:

this is a paraneoplastic sydrome consisting of elevated LFT's in a patient with renal cell carcinoma. About 15% of pts with rcc and without mets have elevated lft's

KIDNEY METABOLISM:

insulin, vasopressin, and GH are metabolized by the kidney but renin and erythropoeitin are not