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The urinary piece of land dwelling of kidneys, ureter and vesica is prone to many diseases runing from congenital to neoplastic. The patients may be symptomless in which instances it would be an incidental determination or he/she may show with symptoms declarative of urinary piece of land pathology i.e. wing hurting, haematuria, febrility, firing urination or tangible mass lesion.

Normally employed radiological probes include X-ray, IVP, ultrasound, CT scan and MRI. Each has its ain advantages and restrictions.

Measuring by echography ( USG ) has an border over other conventional modes as It is economical, easy available, non invasive with no radiation jeopardies, supply existent clip imaging and can be repeated as and when required. However the major restricting factor is insufficiency of informations obtained in overly corpulent patients and those with gaseous prominence in venters due to laden colon.

Using multidetector computed imaging ( MDCT ) scanner, different protocols for scanning can be applied which can be tailored harmonizing to patient ‘s ailments and the suspected pathology and the obtained volumetric informations reduces the misregistration artefacts and respiratory artefacts.

It is unsurpassed in measuring lesions incorporating fat and Ca.

The commonly used technique consists of – non enhanced or kick stage followed by cortico-medullary, nephrographic and excretory stages.

Among the different station processing technique, Maximum strength projection ( MIP ) is peculiarly utile to expose vascular construction ; volume rendered images are disposed to picture both vass and soft tissue.

AIM AND OBJECTIVES

This survey aims to set up the function of MDCT in rating of urinary piece of land pathologies.

AIMS & A ; OBJECTIVES:

To observe urinary piece of land pathologies.

To determine assorted radiological characteristics and categorise lesions in congenital, morbific, vascular, clogging or neoplastic conditions.

To measure the extent of disease procedure.

To find the truth of the MDCT in diagnosing of urinary piece of land pathologies and measure the extra information provided by the mode over other probes.

MATERIALS AND METHODS

During the period from May 2010 TO October 2012, 50 patients with suspected urinary piece of land disease were examined utilizing MDCT scan as premier diagnostic mode at our establishment.

Each patient was studied in item with relevancy to clinical history, scrutiny and laboratory probe.

USG was done in bulk patients prior to CT scan.

INCLUSION CRITERIA

Patients with age runing from five to seventy five old ages were included in the survey.

Patients showing with either of the undermentioned ailments: abdominal hurting, febrility, haematuria, abdominal ball, firing urination.

Laboratory findings like urine scrutiny declarative mood of urinary piece of land pathology.

EXCLUSION CRITERIA

Patients with lone urinary piece of land concretion.

Patients with history of injury.

Scanning AND METHODS USED

Scaning was done with 64 SLICE MULTIDETECTOR CT SCAN MACHINE.

Volumetric informations from stop to rectum were acquired with pitch kept normally at 1 with immediate 1 millimeter pieces with axial, coronal and sagittal Reconstruction.

Images were acquired after

Oral H2O soluble contrast or unwritten H2O.

Rectal contrast when indicated. ( In suspected vesica mass or pelvic pathology ) .

Intravenous iodinated contrast agent, volume of 80-100ml injected at 2-3 ml/sec and different CT scan stages acquired viz. apparent ( or non- enhanced ) followed by cortico-medullary, nephrographic and excretory stages.

REVIEW OF LITERATURE

A ) Evaluation of Upper Urinary Tract Tumors with Portal Venous Phase MDCT: A Case-Control Study

Study was performed by Max Kupershmidt, A Myles Margolis, A Hyun-Jung Jang etal in the Mount Sinai Hospital and Women ‘s College Hospital, Toronto, Canada to measure the sensing and negative anticipation rate of upper urinary piece of land tumours on portal venous stage MDCT.

This retrospective case-control survey included 20 patients with upper urinary piece of land tumours and 40 age- and sex-matched control topics. All surveies were assessed independently by two referees.

It was found that the sensing rate of the proximal two upper urinary piece of land sections was significantly higher than that for the distal sections ( pA & lt ; 0.001 ) . The sensitiveness, specificity, and negative prognostic value of portal venous stage MDCT for observing tumours were 95 % , 97 % , and 100 % , respectively.Top of Form

Bottom of Form

B ) Role of non- contrast CT in rating of wing hurting and comparing with IV Urography

In 1995 Smith et Al. reported on the usage of non-contrast CT for rating of acute wing hurting and compared it straight with IV Urography in 20 patients.

In that series 12 patients had CT and IVU findings consistent with obstructor while 8 had normal surveies. Of the 12 patients with obstructor, 5 have a ureteric rocks seen on both surveies but 6 had a rock seen merely on CT.

This led the writers to reason that “ Non-contrast enhanced CT is more effectual than IVU in exactly placing ureteric rocks and is every bit effectual as IVU in the finding of the presence or absence of ureteric obstructor. ”

C ) Arteriographic correlativity in 30 patients with nephritic vascular disease diagnosed with multislice CT.

This survey was performed by AU Echevarria JJ, Miguelez JL, Lopez-Romero et Al: Medline. Pubmed 2008 ; 50 ( 5 ) :393.

30 patients with arterial high blood pressure and/or kidney failure underwent MSCT to govern out a vascular cause and DSA to corroborate a vascular cause suspected at MSCT.

The findings at MSCT and DSA were indistinguishable in 56 ( 78.8 % ) nephritic arterias ; MSCT overestimated the grade of stricture in 13 ( 18.3 % ) instances.

In the diagnosing of hemodynamically important stricture, MSCT had a sensitiveness of 96.5 % , specificity 78.5 % , accuracy 85.9 % , positive prognostic value 75.6 % , and negative prognostic value 97 % .

MSCT is a good noninvasive imagination technique for the rating of nephritic vass ; it is utile for testing patients with kidney disease to govern out potentially treatable vascular causes.

D ) Multislice computed imaging urography in the diagnosing of urinary piece of land diseases.

Performed by Volumen 68, Broj 5 by- Olivera NikoliA‡ , Clinical Center of Vojvodina, Center of Radiology, Novi Sad, Serbia.

It was observed that compared with IVU, MSCTU is more specific for nephritic parenchymal abnormalcies, tumours of the excretory system, urolithiasis, vesica tumours, fibrosis and excess urinary diseases.

MSCTU is every bit sensitive, but more specific for hydronephrosis compared to MSCT. The diagnosing made by the usage of MSCTU in patients with macroscopic and microscopic haematurias and with obstructor non caused by rocks, absolutely complies with operative findings and histological diagnosing.

The lone staying function for IVU is imaging of the upper urinary piece of land in patients with haematurias under the age of 40.

Tocopherol ) Role of MDCT in the rating of patients with Hematuria –

Study undertaken by Sameh Hanna, S.Abdel Rahman, N.Barsoum, HM.El Gammal ; Cairo, EG. EUROPEAN SOCIETY OF URORADIOLOGY.

Fifty nine patients showing with haematurias were diagnosed utilizing different techniques of MDCT, over a period of 2 old ages. Harmonizing to the patient ‘s status & A ; suspected lesion, the protocol of the survey was tailored. The cause of haematurias were divided into nephritic ( n=36 ) , ureteric ( n=6 ) , vesical ( n=4 ) and urethral ( n=13 ) pathologies.

It was concluded that contrast-enhanced multiphasic MDCT urography can show a broad spectrum of disease in haematuria patients. Virtual cystoscopy can be good in instances with vesica pathologies and urethral lesions can be decently assessed by CT urethrography.

F ) Congenital nephritic anomalousnesss detected in maturity

Performed by – Muttarak M, Sriburi T Department of Radiology, Chiang Mai University, Chiang Mai, Thailand. – Biomedical Imaging and Intervention Journal. December 2011.

Between January 2007 and January 2011, the clinical informations and imaging surveies of 28 patients older than 18 old ages diagnosed with nephritic anomalousnesss were retrospectively reviewed.

Of these 28 patients, 22 underwent imaging surveies and their consequences constituted the stuff of this survey.

Of the 22 patients, 14 had horseshoe kidneys ( HSK ) , four had crossed nephritic ectopia and four had malrotation.

Abdominal radiogram suggested nephritic anomalousnesss in nine out of 15 surveies. IVP, RP, US and CT suggested anomalousnesss in all patients who had these surveies performed.

CT was the best imagination mode to measure anatomy, map and complications of patients with nephritic anomalousnesss.

( G ) CT urography: definition, indicants and techniques. A guideline for clinical pattern

Aart J. Van Der Molen, Nigel C. Cowan, Ullrich G. Mueller-Lisse Claus C. A. Nolte-Ernsting et Al ; CT Urography Working Group of the ESUR ; Eur Radiol DOI 10.1007/s00330-007-0792-x

They proposed to specify CTU as a “ diagnostic scrutiny optimized for imaging the kidneys, ureter and vesica ” .

The scrutiny involves the usage of multidetector CT with thin-slice imagination, endovenous disposal of a contrast medium, and imaging in the excretory stage. Imaging in the excretory stage, either early or delayed is therefore a compulsory portion of any CTU protocol.

The purpose was to develop clinical guidelines for CTU by a group of experts from the European Society of Urogenital Radiology ( ESUR ) .Expert guidelines on indicants and CTU scrutiny technique was produced.

CTU is justified as a first-line trial for patients with macroscopic haematurias, at high-risk for urothelial malignant neoplastic disease.

Otherwise, CTU may be used as a problem-solving scrutiny. A differential attack utilizing a one- , two- or three-phase protocol is proposed, whereby the clinical indicant and the patient population will find which CTU protocol is employed.

Lower dosage ( CTDIvol 5-6 mGy ) is used for benign conditions and normal dosage ( CTDIvol 9-12 mGy ) for possible malignant disease A low-dose ( CTDIvol 2-3 mGy ) unenhanced series can be added on indicant.

The expert-based CTU guidelines provide recommendations to optimise techniques and to unite the radiotherapist ‘s attack to CTU.

RADIOLOGICAL ANATOMY OF KIDNEY, URETER AND BLADDER

KIDNEYS

Gross anatomy

Lie in the superior portion of the retroperitoneum on either side of the vertebral column about at the degree of L1-L4.

Right kidney normally lies somewhat lower than the left.

Bipolar length of the kidney is normally about 11 centimeter. Discrepancy between right and left nephritic length of up to 1.5-2 centimeter is within normal bounds.

Structure

Cortex forms the outer 3rd ; myelin forms the interior two tierces of kidney.

Columns of Bertini extend medially into the myelin between the pyramids.

Pyramids are conic, with the vertex ( the papilla ) indicating into the nephritic hilus.

Each papilla undertakings into the cup of a nephritic calyx, which drains via an infundibulum into the nephritic pelvic girdle.

Pelvis is a funnel-shaped construction at the upper terminal of the ureter. It usually divides into two or three major calyces.

Each major calyx so divides into two or three minor calyces, which have a cup-shape, indented by the vertex of the attach toing nephritic pyramid.

The nephritic hilus contains the nephritic pelvic girdle, the nephritic arteria, the nephritic vena and lymphatics, all of which are surrounded by nephritic fistula fat.

Nephritic arterias, venas and lymphatic drainage

Arise from the abdominal aorta, at the degree of the superior border of L2, instantly caudal to the beginning of the SMA.

It divides at the nephritic hilus into three subdivisions. Two subdivisions run anteriorly, providing the anterior upper pole and full lower pole, and one runs posteriorly providing the posterior upper pole and mid pole.

The right renal vena has a short class, running straight into the IVC. The left nephritic vena runs anterior to the abdominal aorta and so drains into the IVC. It receives feeders from the left inferior phrenic vena, the left gonadal and the left adrenal vena.

Lymphatic drainage follows the nephritic arterias to nodes situated at the beginning of the nephritic arterias in the para-aortic part.

Nerve supply

The sympathetic nervousnesss providing the kidney arise in the nephritic sympathetic rete and run along the nephritic vass.

Afferent fibres travel with the sympathetic fibres through the visceral nervousnesss and fall in the dorsal roots of the 11th and 12th thoracic and the 1st and 2nd lumbar degrees.

Fascial infinites around the kidney

The kidney is surrounded by perirenal fat, which is wholly encircled by a Gerota ‘s facia anteriorly and Zuckerkandl ‘s facia posteriorly which meet on sidelong facet to organize the sidelong conal facia.

Relationss of the right kidney

Superior: right suprarenal secretory organ, liver.

Anterior: 2nd portion of the duodenum, right colic flection.

Posterior ( same on both sides ) : stop, costodiaphragmatic deferral of the pleura, the 12th rib and musculuss of the posterior abdominal wall.

Relationss of the left kidney

Front tooth: left suprarenal secretory organ, lien, tummy, pancreas, the left colic flection, and cringles of jejunum.

Ureters

Anatomy

It is a fibro muscular tubing, lined with transitional mucous membrane, which is formed as the funnel of the nephritic pelvic girdle narrows, at the pelviureteric junction ( PUJ ) .

It is 25 centimeter long and at the pelvic lip, it runs anterior to the bifurcation of the common iliac vass, in forepart of the sacro-iliac articulation and so down the postero-lateral wall of the pelvic girdle in close relation to the internal iliac vass.

At the degree of the ischial spinal columns, it turns anteromedially to fall in the trigone of the vesica at the vesico-ureteric junction ( VUJ ) , which lies at the posterolateral angle of the vesica.

There are three normal narrowings of the ureters ( where stones most commonly impact ) :

At the pelvi-ureteric junction

At the ureter crosses the pelvic lip

At the vesico-ureteric junction.

Blood supply and lymphatic drainage

Upper – ureteric subdivision of the nephritic arteria.

Mid – Branchs of the gonadal arteria

Lower -Branches of the internal iliac arteria

There is attach toing venous drainage.

Lymphatic drainage is into the sidelong para-aortic nodes and the internal iliac nodes in the pelvic girdle.

Nerve supply

Sympathetic nervousnesss to the ureter arise from the nephritic and gonadal retes ( T12-L2 ) and, in the pelvic girdle, from the hypogastric rete. Afferent fibres return along the sympathetic tracts to come in the spinal canal at the L1 and L2 intervertebral hiatus.

Relationss of the ureters

Anterior ( right ) : duodenum ( 2nd portion ) , right gonadal, right gripes and ileocolic vass and the root of the little intestine mesentery, the terminal ileum and appendix.

Anterior ( left ) : left gonadal and left colic vass, cringles of little and big intestine and the sigmoid mesocolon.

Posterior ( right and left ) : psoas musculuss, and in the pelvic girdle, the bifurcation of the left common iliac vass.

Male pelvis- ureter base on ballss over the seminal cysts and so hooks under the vessel deferens before come ining the vesica.

Female pelvis- ureter runs inferior to the uterine arteria in the wide ligament of the womb, and lies next to the sidelong fornix of the vagina prior to come ining the vesica.

URINARY BLADDER

Anatomy

Pyramidal in form, lies wholly within the pelvic girdle.

Apex lies behind the upper boundary line of the symphysis.

The inferior angle or cervix gives rise to the urethra, surrounded by the nonvoluntary internal urethral sphincter.

The superior surface of the vesica is wholly covered by peritoneum.

In the male, the cervix of the vesica rests on the prostate secretory organ, whereas in the female it rests straight on the pelvic facia above the urogenital stop.

When the vesica fills, it becomes egg-shaped and the superior surface rises extraperitoneally into the venters.

Blood supply

Superior and inferior vesical arterias.

The venas of the vesical rete drain to the internal iliac venas.

Lymph drainage is to the internal iliac, thence to the paraaortic lymph nodes.

Categorization OF URINARY TRACT PATHOLOGY

** KIDNEY**

[ I ] CONGENITAL

( A ) Anomalies of figure or development:

-agenesis

-hypo generation

( B ) Anomalies of rotary motion / Malrotaion:

-non-rotation or uncomplete rotary motion

( C ) Anomalies of place:

-ectopic kidney

-crossed fused ectopia

( D ) Anomalies of merger:

-horse-shoe kidney

-duplex kidney

( Tocopherol ) Potter ‘s diseases:

– I Autosomal recessionary polycystic kidney disease

-II Multicystic dysplastic kidney

– Three Autosomal dominant polycystic kidney disease

[ II ] INFECTIVE/INFLAMMATORY

-Acute and chronic pyelonephritis

-Emphysematous pyelonephritis

-Xanthogranulomatous pyelonephritis

-Acute focal bacterial Bright’s disease

-Renal abscess

-Papillary mortification

-Parasitic infection

-Tuberculosis

[ III ] OBSTRUCTIVE

-Hydronephrosis i.e. mild, moderate, terrible

-Pyonephrosis

[ IV ] NEOPLASTIC

Benign:

Oncocytoma

Angiomyolipoma

Lipoma

Renal cell adenoma

Malignant:

Renal cell carcinoma ( Adenocarcinoma ) – clear cell, papillose, chromophobe and multicentric

Urothelial carcinoma-transitional cell carcinoma, squamous cell carcinoma

Lymphoma

Wilms tumour

Metastatic tumours

[ V ] VASCULAR

-Accessory nephritic arterias

-Hypoplastic nephritic arteria

-Renal arteria stricture ( coronary artery disease, fibromuscular dysplasia, takayasu arteritis etc )

-Renal vena thrombosis

-Renal infarct

[ VI ] MISCELLANEOUS:

Reflux kidney disease

**URETER**

[ I ] CONGENITAL

-Pelvi-ureteric junction obstructor

-Duplex ureter

-Ureterocoele

-Primary mega ureter

[ II ] ACQUIRED ( largely taking to obstructor )

( A ) Intraluminal causes:

-Calculi

-Blood coagulums

-Sloughed papilla

-Fungal ball

( B ) Intramural causes ( bulk lead to formation of stenosis ) :

{ I } Inflammatory – TB, bilharzia, radiation ureteritis

{ two } Neoplastic – malignant transitional cell carcinoma, benign villoma and extension from carcinoma of vesica, neck, prostate

( C ) Extraluminal causes

-Retroperitoneal fibrosis

– Retroperitoneal lymphadenopathy

-Large pelvic tumours

**URINARY BLADDER**

[ I ] CONGENITAL

-Exstrophy

-Urachal anomalousnesss i.e. patent urachus, urachal cyst, urachal fistula, urachal diverticulae

[ II ] INFECTIVE

-Tuberculous cystitis

-Acute and chronic cystitis

-Emphysematous cystitis

[ III ] NEOPLASTIC

Benign: Urothelial villoma

Malignant: transitional cell carcinoma, Squamous cell carcinoma and glandular cancer

[ IV ] MISCELLANEOUS

-Diverticulae

-Cystocoele

-Fistulae i.e. vesico-vaginal, vesico-enteric

MDCT APPEARANCE OF URINARY TRACT PATHOLOGY ( COMMON PATHOLOGIES )

Kidney

[ I ] CONGENITAL:

Agenesis:

Incidence – 1:1000 population.

Complete absence of nephritic tissue ensuing from failure of the ureteric bud to reach the nephrogenic blastema.

Ipsilateral ureter and nephritic arteria absent.

Bilateral agenesia – incompatible with life.

Association with VACTERL, Fanconi syndrome, Kallman syndrome.

CT scan- non visual image of one kidney in nephritic pit or any ectopic site and compensatory hypertrophy of contra sidelong kidney.

Hypoplasia

Besides known as midget kidney and is somewhat smaller in size than normal.

NECT – little sized kidney, CECT – shows uniformly hypoplastic nephritic arteria with compensatory hypertrophy of contralateral kidney.

D/D – chronic pyelonephritis ( shows cortical scarring ) .

ANOMALIES OF ROTATION / MALROTATION: -NON-ROTATION OR INCOMPLETE ROTATION

Normally during acclivity from pelvic girdle to its concluding place during foetal life the kidney rotates by 90* so that the hilus faces medially and somewhat frontward.

Any anomalousness in this procedure consequences in malrotation.

On CECT – malrotated kidney with abnormally directed hilus which normally faces anteriorly.

Excretory stage – outlines the axis of Personal computer system and the ureter.

ECTOPIC KIDNEY

Abnormally positioned kidney on same side as the vesical gap which may be cranial or caudal to the normal site.

Ectopic sites – iliac pit, pelvic girdle intrathoracic ( rare ) .

NECT scan- localisation of ectopic kidney ; Arterial stage – aid in function of nephritic vasculature which may hold an deviant beginning.

In instance of intrathoracic kidney, CECT shows the diaphragmatic defect through which the kidney base on ballss and besides its vascular supply from chief or accessary nephritic arterias.

CROSSED FUSED ECTOPIA

Incidence – 1:1,000 births, M & gt ; F.

Refers to an anomalousness where the kidneys are fused and located on the same side of the midplane.

NECT – delineates the location and boundaries of the amalgamate kidneys, arterial stage – aid in showing the vascular supply and the excretory stage – reveals working.

HORSE SHOE KIDNEY

Incidence: 1:400

Characterized by the merger of the lower poles across the midplane ensuing in an isthmus of tissue ( parenchymal or hempen ) between the two which is located anterior to the aorta.

NECT – localisation of kidneys and sensing of concretion. CECT – demonstrates whether the isthmus is composed of working nephritic parenchyma or the hempen tissue on the footing of enhancement features and elimination of contrast.

Renal parenchymal alterations ( marking, cystic disease ) and roll uping system abnormalcies ( duplex system, hydronephrosis ) can besides be diagnosed.

DUPLEX KIDNEY

Shows two separate pelvicalyceal systems. The two run outing ureters may fall in before emptying into the vesica ( partial duplicate / bifid ureters ) or infix individually into the vesica ( complete duplicate ) .

CT Urography – semidetached house kidney is good seen with dual ureters which may be partial or complete.

POTTER ‘S Disease:

{ I } AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY DISEASE

Most common heritable disease manifesting in babyhood and childhood.

Kidney and liver normally involved.

CECT scan kidneys are enlarged with a smooth lineation and low fading with focal point of nephritic calcifications. Focal liver cysts and findings of portal high blood pressure may be seen.

{ II } MULTICYSTIC DYSPLASTIC KIDNEY

Developmental, not familial anomalousness with multiple, smooth nonfunctioning, non-communicating cysts.

Typically one-sided, bilateral signifier normally associated with inborn GI and cardiac abnormalcies.

On CT scans in type IIA kidney is enlarged due to polymorphous and multilocular cysts while in type IIB kidney is smaller.

{ III } AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Familial upset characterized by cysts in kidney, liver, pancreas, and ovary and associated with intracranial aneurisms.

85 % instances – unnatural cistron on short arm of chromosome 16 ; 5-10 % unnatural cistron on long arm of chromosome 4.

CECT scan – grounds of multiple cysts of changing sizes with hypertrophied kidneys ; excretory stage – Normal operation.

[ II ] INFECTIVE/INFLAMMATORY

ACUTE PYELONEPHRITIS

Inflammatory procedure impacting the collection system and the nephritic interstitium ; the underlying etiology can be bacterial, fungous or seldom viral.

NECT – nephritic puffiness and parenchymal denseness may be reduced, or increased if there is bleeding.

On CECT- sweetening typically patchy, with set and cuneate countries of reduced sweetening widening from the papillae to the nephritic border seen best in nephrogram stage.

EMPHYSEMATOUS PYELONEPHRITIS

Severe nephritic infection with gas organizing beings characterized by presence of gas in the nephritic parenchyma or roll uping system. Normally seen in diabetics.

Type I – less common, parenchymal devastation and gas within with no grounds of any unstable aggregation.

Type II -more common, shows intrarenal gas, nephritic and perirenal aggregations and gas within the pelvicalyceal system.

NECT and CECT scans ideal to observe presence of air, its site within kidney every bit good as perirenal and pararenal extensions.

XANTHOGRANULOMATOUS PYELONEPHRITIS

Rare chronic granulomatous redness in patients with rocks and obstructor.

Characterized by devastation and replacing of nephritic parenchyma with lipid laden macrophages which are PAS positive.

Phases are: I- merely kidney involved, II- extension in Gerota ‘s facia, III- perinephric extension.

CT scan – concretion, calcifications and non heightening cystic xanthoma aggregations with nephritic vena thrombosis ( less common ) .

ACUTE FOCAL BACTERIAL NEPHRITIS

CECT scan – focal countries of low denseness with patchy sweetening and deficiency of good defined wall.

D/D: nephritic abscess ( heightening good defined wall ) .

RENAL ABSCESS

CECT scan – aggressively marginated country of low fading due to necrosis surrounded by a peripheral enhancing rim bespeaking a mature abscess.

Detects alterations in nephritic contour, parenchymal denseness, enhancement form, inspissating of Gerota ‘s facia, psoas musculus engagement.

PAPILLARY NECROSIS

Etiology – diabetes, analgetic maltreatment, reaping hook cell disease, desiccation, haemophilia.

CT scan – acute signifier consisting of hypertrophied kidneys with terrible papillose shedding ; chronic signifier which shows patchy or spread engagement but IVP is more specific ( egg in cup mark, lobster claw mark and signet pealing mark ) .

PARASITIC INFECTION

Most common – hydatid cyst formation.

CECT scan – focal cystic multitudes, normally thick walled and irregular and may demo calcification of crushed eggshell form.

Tuberculosis

Feature of station primary TB with reactivation at the cortico medullary junction followed by local infiltration into the parenchyma with papillose mortification.

Bacilli enter the collection system ensuing in multifocal stricturing and formation of caseous Pus and calcification.

CECT – hydro calyces and/or a hydronephrosis, with dust, countries of calcification and parenchymal loss.

CHRONIC PYELONEPHRITIS

Chronic redness characterized by cortical marking overlying the involved calyx taking to little contracted kidney.

D/D: CT scan shows cortical scarring and helps to distinguish it from foetal lobulation ( cicatrix in between calyces ) and inborn hypoplasia ( less than five calyces with smooth uniformly hypoplastic nephritic arteria. )

[ III ] OBSTRUCTIVE

HYDRONEPHROSIS I.E. MILD, MODERATE, SEVERE

It refers to distensionA and dilation of the nephritic pelvic girdle and calyces caused byA obstructor of the free flow of piss from the kidney. Untreated, it leads to progressive wasting of the kidney.

CT scanning should be performed if the echography consequences are unequal or inconclusive.

PYONEPHROSIS

Refers to infection in an obstructed collection system ( due to calculi, stenosis or tumour ) with suppurative devastation of nephritic parenchyma

CT scan shows grounds of hydronephrosis which is hyperdense as compared to fluid ( urine ) denseness or heterogenous. CECT shows irregular, thickened and heterogeneously heightening Urothelial liner.

[ IV ] NEOPLASTIC

ONCOCYTOMA

Benign nephritic tumour ; symptomless or abdominal ball.

CT scan – big good demarcated tumours with perinephric fat-stranding may be present A due to edema

CECT – variable sweetening with cardinal radial non-enhancing cicatrix ( in 1/3rd instances ) .

ANGIOMYOLIPOMA

Most normally in Adults ( F & gt ; M ) .

Benign mesenchymal tumor ; composed of variable proportions of blood vass, smooth musculus, and adipose tissue.

Sporadic or seen in association withA phakomatoses, tuberous induration, VHL or NF1.A

CECT scan – demonstrate fat denseness and an heightening solid constituent within the lesion.

RENAL CELL ADENOMA

Found in patients with acquired nephritic cystic disease and those undergoing long term haemodialysis.

Identical from nephritic cell carcinoma on imaging features.

RENAL CELL CARCINOMA ( ADENOCARCINOMA ) – Clear CELL, PAPILLARY, CHROMOPHOBE AND MULTICYSTIC

Most common primary nephritic malignant tumor in grownups.

M & gt ; F

Ailments: macroscopic haematuria, wing hurting, tangible mass.

NECT scans – iso- , hypo- or hyper attenuating ; Calcifications normally formless.

CECT scan – solid and heterogeneously heightening. Sometimes RCC is a preponderantly cystic mass, with thick septa and wall nodularity.

Accurate designation of engagement of the nephritic vena and inferior vein cava is really of import for right patient direction. The reported truth utilizing CT is about 96 % .

Thrombus is seen as a filling defect within the vena.It is possible to distinguish tumour thrombus from bland thrombus by the sweetening seen in the later.

CT is a sensitive method for the sensing of lung metastases.

TRANSITIONAL CELL CARCINOMA, SQUAMOUS CELL CARCINOMA

Rare in the kidneys, located more centrally and towards the hilus.

CT scans – irregular filling defects of the pelvicaliceal system and ureters, which tend to be associated with obstructor and distension of the ureter and pelvic girdle proximal to the lesion with associated wall thickener.

Lymphoma

Part of multi-systemic lymphoma, seldom as a primary disease.

Flank hurting, weight loss, and haematurias, mass or acute nephritic failure.

Typical forms – single/multiple multitudes or diffuses nephritic infiltration which is about ever bilateral disease with nephritic expansion.

Atypical form – self-generated bleeding, mortification, cystic alterations and calcification.

WILMS TUMOR

Most common primary malignant nephritic tumour of childhood.

CECT – big, at least partly intrarenal mass that normally has a cardinal denseness and presence of pneumonic metastases at the clip of diagnosing.

Associations: WAGR, Denys-Drash or Beckwith-Weidmann syndrome

METASTATIC TUMORS

Common primary sites are breast, bronchus, GI piece of land, melanoma and lymphoma.

Can besides be due to direct extension of tumour from pancreas, adrenal.

CECT – single/multiple heterogeneously heightening diffuse lesions easy to name in scene of a known primary.

[ V ] VASCULAR

ACCESSORY RENAL ARTERIES

Common developmental discrepancy seen in up to 25 % of unrecorded births.

Failure of involution of one or more of the arterias acquired during acclivity of kidney.

Significance – If certain surgical processs are being considered ( partial nephrectomy, nephritic organ transplant ) designation really of import to forestall complications.

On CT scan in arterial stage, their beginning and class is good delineated.

HYPOPLASTIC RENAL ARTERY

D/D: contracted pyelonephritic kidney.

Kidney is smaller with smooth contour, in contrast to the irregular contour of the little kidney in chronic pyelonephritis.

The arteria of the hypoplastic kidney is described to be uniformly narrow in its whole length, ( pyelonephritis – beginning of the arteria has as a regulation normal breadth, although the remainder of the arteria may be narrow ) .

Nephritic ARTERY STENOSIS ( ATHEROSCLEROSIS, FIBROMUSCULAR DYSPLASIA, TAKAYASU ARTERITIS )

Potentially reversible cause of high blood pressure.

Less than 5 % of grownup patients with high blood pressure.

MDCT – dependable, noninvasive showing scrutiny for the sensing of RAS with about 100 % specificity in the diagnosing of terrible ( & gt ; 50 % ) stricture of the nephritic arteria.

Depicts secondary marks of RAS – poststenotic distension and nephritic wasting and reduced cortical sweetening.

Atherosclerotic disease – most common cause ( old age ; M & gt ; F ) . Plaque and calcification are located at the proximal nephritic arteria near the opening.

Fibro muscular dysplasia affects immature or middle-aged adult females and lesions are seen in mid or distal chief nephritic arteria.

It is classified as -intimal, median and adventitial fibroplasias.

Medial fibroplasia – most common type ; multiple ridges, which appear as jumping countries of narrowing and distension on CT scan i.e. “ twine of beads ” .

RENAL VEIN THROMBOSIS

Causes in children- desiccation and sepsis, in grownups -glomerulonephritis, collagen vascular disease, diabetes, Trauma, tumours.

In the ague province -hypo rarefying make fulling defect within an hypertrophied nephritic vena and thrombus can widen into IVC and turn toward the right side of the bosom.

The presence of nonuniform sweetening in the thrombus is declarative of tumour engagement.

In chronic province – thrombus may contract and extended collateral vass may develop.

Expansion of the ipsilateral kidney, hydrops in the nephritic fistula and perinephric infinite, and the harsh striations of a lessened nephrogram may be present in instance of nephritic vena thrombosis.

RENAL INFARCT

CECT scan demoing low-attenuation, frequently cuneate non heightening peripheral multitudes.

[ VI ] MISCELLANEOUS:

REFLUX NEPHROPATHY

Nephritic cortical marking develops in association with dilated calyces due to severe VUR and UTI.

Different classs of VUR are:

I-Reflux into the ureter entirely

II-Reflux into the ureter and pelvic girdle

III-Reflux into ureter and pelvic girdle with mild distension

IV-Reflux into ureter and pelvic girdle with moderate distension and saving of the papillae

V-Reflux into ureter and pelvic girdle with gross hydronephrosis and annihilation of the papillae

Though the diagnosing of VUR is made on MCU, CT scan can uncover cortical scarring, calyectasis, hydronephrosis and hydroureter.

Ureter

[ I ] CONGENITAL

PELVI-URETERIC JUNCTION OBSTRUCTION

Present at any age. M=F.

Hydronephrosis with a narrowed PUJ, which fails to loosen up and convey the peristaltic moving ridge to the ureter.

Possible causes: intrauterine ischaemic abuse, extra collagen within the wall of the PUJ, presence of deviant blood vass.

MDCT – anatomy of PUJ obstructor, uncovering an intrinsic or high-insertion PUJ, traversing vass and their relationship to PUJ which can steer to the most effectual intervention mode.

DUPLEX URETER

Common, being found in 10 % of the population and are characterized by two ureters and nephritic pelvic girdle.

Incomplete duplicate ( the ureters blending at some point in their class and holding a common distal ureter and opening ) – in few instances it may be associated with yo-yo reflux.

Complete duplicate ( both ureters holding separate distal openings ) – The lower nephritic mediety drains via the ureter with the orthotropic interpolation but is frequently associated with VUR.

The ureter run outing the upper mediety is inserted ectopically and its expiration is ever distal to the lower mediety interpolation.

The upper mediety ureter has a strong association with Ureterocoele formation.

CECT scan shows an hypertrophied kidney with two Personal computer systems and ureters in unsophisticated instances and hydronephrosis, operation of the medieties, Ureterocoele in the remainder.

URETEROCOELE

Cystic distension of the distal intravesical section of the ureter with bulge into the vesica lms

On CECT scan, unit of ammunition or egg-shaped denseness of opacified piss ( in the dilated distal section of the ureter ) separated from opacified piss in the vesica by a thin ( 2- to 3-mm ) aura stand foring the wall of the prolapsed ureter and the vesica mucous membrane ( cobra caput mark ) .

PRIMARY MEGA URETER

Due to congenitally unnatural muscular structure of the distal ureter, taking to focal failure of vermiculation. The ureter above the unnatural section becomes dilated.

Bilateral in 25 % with a male preponderance.

Increased hazard of infection and concretion.

[ II ] ACQUIRED ( largely taking to obstructor )

( A ) INTRA-LUMINAL Cause:

Calculi, Blood coagulums, Sloughed papilla, fungous ball- lead to changing grades of obstructor and proximal distension of ureter and Personal computer system.

On NECT scan concretions by and large appear as hyperdense whereas the remainder can demo variable densenesss.

Excretory stage aid to separate between partial and complete obstructor.

( B ) INTRAMURAL CAUSES ( MAJORITY LEAD TO FORMATION OF STRICTURE ) :

TUBERCULOUS URETERITIS

CECT ureteric distension, calcification and calyceal abnormalcies. Ureteric alterations are those of hydrops and thickener, come oning to multifocal ureteric stenosiss.

Schistosomiasis

Normally affects the vesica, but reflux can take to ureteric engagement and the development of ureteritis germinating into a stenosis.

MALIGNANT TRANSITIONAL CELL CARCINOMA

On CECT it can show as:

an intraluminal filling defect with environing ureteric distension ;

adjacency of the lesion with the ureteric wall ;

a dotted visual aspect caused by contrast stuff come ining the interstices of the tumour ;

Changing grades of proximal obstructor.

Extension FROM CARCINOMA OF BLADDER, CERVIX, PROSTATE

Most common malignant etiology.

Carcinoma of the ovary, neck, uterus, colon, vesica and prostate may occupy the ureters by direct extension or by spread to periureteric lymph nodes.

CECT – grounds of ureteric obstructor with the designation of chief pathology.

( C ) EXTRA LUMINAL CAUSES

RETROPERITONEAL FIBROSIS ( PERIAORTITIS )

Ureters displaced medially and narrowed at the L4-5 degree.

The grade of calycine distension may be mild despite the presence of obstructor.

NECT and CECT – a plaque-like mass environing the aorta or iliac arterias. The mass tends non to displace the aorta anteriorly. There may be loss of the fat plane between the mass and the psoas musculus.

URINARY BLADDER

[ I ] CONGENITAL

EXSTROPHY

M & gt ; F, association with epispadias.

Rare, vesica is unfastened anteriorly which varies in badness from a little gap in the anterior abdominal wall to finish absence of the anterior vesica wall.

There is normally separation of the symphysis pubic bone and there may be associated spinal and anorectal anomalousnesss but with normal upper urinary piece of lands.

[ II ] INFECTIVE

ACUTE CYSTITIS

MDCT non necessary for diagnosing ; ultrasound and laboratory probes suffice.

However, for perennial cystitis or in the presence of antibiotic opposition, the full urinary piece of land should undergo imaging to look for any implicit in abnormalcy.

CECT and full vesica images – thickened, irregular, trabeculated vesica wall with marks of underlying etiology if any.

TUBERCULOUS CYSTITIS

Characterized by gradual addition in the thickness of the vesica wall and increasing decline of the volume.

VUJ openings are affected by progressive fibrosis, with subsequent hydronephrosis and hydroureter.

NECT – patchy vesica calcification. CECT – little capacity vesica with thickened wall. CT SINOGRAM – Fistulous withers or fistula piece of land visualised ( rare ) .

CHRONIC CYSTITIS

It may be characterized by gross wall thickener, decrease in vesica capacity and the development of VUR and/or ureteric distension.

Rarely does it take to the development of squamous metaplasia, which may be associated with white spots ( leucoplakia ) .

Full vesica images – little contracted vesica with diffusely thickened irregular wall.

EMPHYSEMATOUS CYSTITIS

Rare, associated with diabetes mellitus and is normally due to E. coli.

NECT- Mural and luminal gas easy identified ( by Hounsfield units ) .

The gas may go up into the ureters and pelvicalyceal systems.

Schistosomiasis

Normally caused by Schistosoma haematobium.

NECT – characteristic calcification of the vesica wall noted.

CECT – Single or multiple distinct filling defects ( may bring forth a honeycomb visual aspect ) .

[ III ] NEOPLASTIC

BENIGN i.e. PAPILLOMA

Benign, frond like tumour that normally arises on the trigone ; considered as a low-grade malignance.

CECT and full vesica stages – Solitary or multiple polypoid defects with smooth or irregular borders, no grounds of vesica wall invasion.

MALIGNANT i.e. TRANSITIONAL CELL CARCINOMA

Age: & gt ; 50 old ages M & gt ; F ; ailments of haematuria, frequence, and dysuria.

NECT – hypodense polypoidal sessile or pedunculated mass lesion with occasional calcification.

CECT- variable heterogenous sweetening enlarged pelvic lymph nodes, liver, lung or skeletal metastases if any.

Full vesica – polypoid defects that arise from the vesica wall and are fixed in place.

[ IV ] MISCELLANEOUS

DIVERTICULAE

Focal herniations of the urothelium and submucosa through weak sites in the vesica wall.

Etiology – due to chronic lift of the intravesical force per unit area associated with vesica outflow obstructor or neurogenic vesica, particularly in old age.

In the early phases, sacculations and trabeculations are identified. As they enlarge above two centimetres they become defined as diverticulum.

CECT with full vesica images – smooth inner wall of the diverticulum, frequently associated with a trabeculated vesica.

Prone to calculi, infection and on occasion malignance.

CYSTOCOELE

Abnormal vesica descent associated with venereal organ prolapsus.

Stress incontinency, vesica escape or distal ureteric obstructor.

Full vesica images – Descent of any portion of the vesica that reaches the inferior pubic rami or below indicates a cystocele.

ENTEROVESICAL FISTULA

Etiology – diverticulitis, tumor, and inflammatory intestine disease, radiation therapy, pelvic surgery.

M & gt ; F, but adult females are at significantly increased hazard after hysterectomy.

CECT – should be performed prior to instrumentality of the vesica. It may or may non show the fistulous piece of land but other implicative findings are good depicted like intravesical air, focal vesica wall thickener, and excess luminal multitudes.

VESICOVAGINAL FISTULAE

Etiology – complication of childbearing, hysterectomy.

Showing ailment – changeless watery escape per the vagina.

Delayed CECT shows elimination of endovenous contrast stuff into the vagina was observed in 60 % of instances, strongly proposing the diagnosing.

Air or fluid in the vagina may besides be present.

OBSERVATION AND ANALYSIS

NUMBER OF PATIENTS IN EACH AGE GROUP

Age

Frequency

Percentage

& gt ; 10 – 20

5

10.0 %

& gt ; 20 – 30

5

10.0 %

& gt ; 30 – 40

5

10.0 %

& gt ; 40 – 50

8

16.0 %

& gt ; 50 – 60

12

24.0 %

& gt ; 60 – 70

13

26.0 %

& gt ; 70 – 80

2

4.0 %

Entire

50

100.0 %

Urinary piece of land pathologies are normally seen in age groups between 50 to 70 old ages ( about 50 % patients )

SEX DISTRIBUTION OF THE PATIENT POPULATION

Sexual activity

Frequency

F

24

Meter

26

Entire

50

PIE CHART DEMONSTRATING THE SAME

No sex preference for urinary piece of land pathologies in general was observed in the present survey with about equal figure of males and females.

( C ) NUMBER OF PATIENTS WITH SPECIFIC COMPLAINS

COMPLAINS

NO. OF PATIENTS ( OUT OF 50 )

Pain

21

Fever

16

Hematuria

10

Burning Micturition

13

PALPABLE MASS

10

Majority of patients have ailment of hurting ( 42 % ) .

( D ) SEX DISTRIBUTION OF THE BASIC UNDERLYING PATHOLOGIES

sex

BENIGN NEOPLASM

CONGENITAL

CONGENITAL & A ; OBSTRUCTIVE

INFECTIVE

INFECTIVE & A ; OBSTRUCTIVE

MALIGNANT NEOPLASM

MALIGNANT NEOPLASM & A ; VASCULAR

MISCELLANEOUS

OBSTRUCTIVE

OBSTRUCTIVE AND MISCELLANEOUS

VASCULAR

Sum

F

3

5

1

7

0

4

0

1

0

1

2

24

Meter

1

4

0

8

1

8

1

0

1

0

2

26

No sex preference was noted in morbific pathologies.

More figure of females had benign pathologies as compared to males.

However in instance of malignances, the Numberss of males were about dual the figure of females.

( Tocopherol ) FINDINGS ON URINE EXAMINATION

Microscopy

NO.OF PATIENTS ( OUT OF 50 )

PUS CELLS

13

Red blood cell

8

EPITHELIAL CELLS

6

The most frequent determination in urine scrutiny is presence of Pus cells.

( F ) SENSITIVITY AND SPECIFICITY OF MDCT IN DIAGNOSING MALIGNANT LESIONS OF URINARY TRACT

Trial

MALIGNANT

NON MALIGNANT

Positive

12 ( true positive )

1 ( false positive )

Negative

1 ( false negative )

36 ( true negative )

SENSITIVITY = ( 12 x 100 ) / ( 12 + 1 )

= 92.3 %

SPECIFICITY = ( 36 X 100 ) / ( 36 + 1 )

= 97.2 %

Discussion

It was observed that though in a few instances, ultrasound was to take to the concluding diagnosing in patient, MDCT with different protocols decidedly provided valuable extra information to steer to the uroradiodiagnosis.

In the present survey:

The maximal Numberss of patients were of the age 50-70 old ages with about equal figure of males and females.

The most common presenting ailment was abdominal hurting followed by febrility.

Lesions to which assorted basic pathologies were assigned in this survey harmonizing to their MDCT visual aspects include:

Benign NEOPLASM: adipose tumor, Angiomyolipoma

MALIGNANT NEOPLASM: malignances of kidney, ureter or vesica ( most normally TCC ) and nephritic metastases

CONGENITAL: PCKD, Equus caballus shoe kidney, malrotation, ectopic kidney, nephritic agenesia, duplex Personal computer sytem, PUJ obstructor

VASCULAR: nephritic arteria stricture, hypoplastic nephritic arteria, nephritic vena thrombosis

OBSTRUCTIVE: HDN, pyonephrosis, urinoma ( gen. post-obstructive )

INFECTIVE: ague pyelonephritis, emphysematous pyelonephritis, chronic pyelonephritis, cystitis, morbific aggregations

MISCELLANEOUS: vesicovaginal fistulous withers

No sex preference was noted in morbific pathologies.

More figure of females had benign pathologies as compared to males.

However in instance of malignances, the figure of males were about dual the figure of females.

In all instances of malignant tumor, MDCT provided critical information sing the extent, vascularity ( in signifier of sweetening ) , abutments and infiltration of the pathology and hence aids in theatrical production.

The portal venous and venous stages were helpful in naming upper urinary piece of land tumours whereas delayed and full vesica stages provided of import extra information in ureteric and vesica malignances.

In the present survey, the sensitiveness and specificity of MDCT for diagnosing of malignant pathologies ( primary and metastatic ) were 92.3 % and 97.2 % severally.

This is in harmony with the survey performed by Max Kupershmidt, A Myles Margolis, A Hyun-Jung Jang etal in the Mount Sinai Hospital and Women ‘s College Hospital, Toronto, Canada found that the sensing rate of the proximal two upper urinary piece of land sections was significantly higher than that for the distal sections ( pA & lt ; 0.001 ) and sensitiveness, specificity, and negative prognostic value of portal venous stage MDCT were 95 % , 97 % , and 100 % , severally.

It confirms the presence of fat in the lesion on the footing of denseness in hounsefield units and hence aids in the diagnosing of lesions like adipose tumor and Angiomyolipoma.

In the present survey, most instances with vascular pathologies were under diagnosed or missed on ultrasound due to difficulty in visual image of vass because of intestine gas.

In “ vascular ” lesions i.e. nephritic arteria stricture, nephritic vena thrombosis, accessary nephritic arterias etc. , the MIP images outline the vass in full extent and assisting word picture of the lesion and appraisal of badness. Hence we found that MDCT is a good noninvasive imagination technique for the rating of nephritic vass.

This observation is supported by the survey “ Arteriographic correlativity in 30 patients with nephritic vascular disease diagnosed with multislice CT “ done by AU Echevarria JJ, Miguelez JL, Lopez-Romero et Al which proved that it had a sensitiveness of 96.5 % , specificity 78.5 % when compred with DSA.

In instance of “ inborn ” pathologies, the most common was polycystic kidney disease ( 3 out of 9 ) followed by malrotation of full kidney or one of its pole and nephritic agenesia. Most patients with inborn pathoogies were symptomless and therefore detected by the way on ultrasound or MDCT.

The survey “ Congenital nephritic anomalousnesss detected in maturity ” in the Biomedical Imaging and Intervention Journal, Thailand compared abdominal radiogram, IVP, RP, US and CT and concluded that CT was the best imagination mode to measure anatomy, map and complications of patients with nephritic anomalousnesss. However the most often encountered pathology in this survey was Equus caballus shoe kidney but in present survey is polycystic kidney disease.

In this survey two instances of URINOMA were diagnosed in which ultrasound could merely show grounds of aggregation. However, MDCT in delayed stages showed extravasation of contrast within the aggregation and hence we clinched the diagnosing.

A assortment of lesions can show as multiple hypoechoic countries in kidneys on ultrasound. However, MDCT AIDSs in naming nephritic abscesses on the footing of peripheral sweetening with or without cardinal necrotic countries.

MDCT plays polar function in distinction of a hypoplastic kidney from one affected with chronic pyelonephritis.

As in this survey the patients with lone urinary piece of land concretions were excluded from the survey, we observed that in patients with non calculus causes of obstructor, the existent etiology ( extraluminal, intramural, intraluminal ) was good delineated.

Decision

Therefore through this survey we conclude that:

MDCT has an of import function in uroradiodiagnosis for sensing of urinary piece of land pathologies, to determine assorted radiological characteristics and categorise lesions in congenital, morbific, vascular or neoplastic status and evaluate extent of disease procedure.

In a broad assortment of pathologies, MDCT provides critical extra information that helps to clinch the concluding diagnosing.

It is non affected by factors like fleshiness or inordinate intestine gas which are a hinderance for sonographic diagnosing.

One of the major drawbacks is the radiation exposure, and therefore we need to weigh it against the advantages offered by the mode and purely employ protocols tailored to the patients complains and the suspected pathology.

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