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Kidneys
a. Retroperitoneal
b. 10 – 15 cm in length (xray); Left > Right
c. 3 and ½ lumbar vertebrae
d. Hilum at L1 vertebral level; Ant to Post: VAP
e. Functional unit : Nephron

 Relations
a. Posteriorly:
Diaphragm,
12th Rib, Pleura,
med – lat:
Psoas, QL, TA
b. Superiorly:
Adrenals
c. Anteriorly:
Right: Liver,
Duod 2nd, Asc
colon, SI.
Left: Stomach,
Pancreas,
Spleen, SF,
Jejunum

 Capsules
a. Fibrous capsule: surrounds kidney
b. Renal fascia of Gerota (ant) and Zuckerkandl (post): Fuse
Laterally as lateral Conal Fascia

 Developmental anomalies
1. Duplication of collecting system
– commonest (4%)
2. Persistant fetal lobulation
3. Accessory arteries

 Blood supply
Renal arteries from Aorta at L1/L2 level.
Right renal artery > Left; posterior to IVC
Left renal vein > Right; anterior to Aorta

Large left renal
pelvic calculus
with deviation of left
ureter

Ultrasound
 Kidney size smaller than on radiographs – 9-12 cm
 Visualization: Posterolateral, Lateral or Posterior approach

Junctional cortical/ parenchymal
defects: triangular echogenic areas
In upper pole. Represent normal
extensions of renal sinus due to
partial fusion of embryonic renunculi.
DD: Renal Scar, Angiomyolipoma

Hypertrophied
Column of Bertin:
Partial renal duplication
of septal cortex in mid
portion of kidney –
pseudomass
appearance
Associated with bifid
pelvis

Uncomplicated
renal cyst
• well-marginated
anechoic lesion
with thin walls
• a few thin septa
(5% of cysts)
• the back wall
should be visible
• posterior
acoustic
enhancement -
nonspecific
• a small amount
of intracystic
hemorrhage/deb
ris may be
present, and
may require
further
evaluation

Complicated renal cyst
• cystic lesions with
thickened or irregular
walls or septa are
suspicious for renal cell
carcinoma and warrant
further work up
• vascularity of the septa on
color or spectral Doppler
is suspicious for renal cell
carcinoma

Calculus in lower
pole
• echogenic foci
• acoustic
shadowing
• twinkle artefact on
colour Doppler
• colour comet-tail
artefact

Chronic kidney disease
Grade 1 Grade 2
Grade 3

Pyelonephritis
 particulate matter/debris in the collecting system
 reduced areas of cortical vascularity by using power Doppler
 gas bubbles (emphysematous pyelonephritis)
 abnormal echogenicity of the renal parenchyma 1
 focal/segmental hypoechoic regions (in oedema) or hyperechoic
regions (in haemorrhage)
 mass-like change

CT KUB
 Slices T12 to L3
 Renal substance: homogenous in unenhanced CT [HU - 30-50]
 After IV contrast:
a. Arterial corticomedullary: after 25 – 70 sec
b. Venous Nephrographic: 80 – 180 sec (contrast homogenous)
c. Excretory phase: after 180 sec (contrast in collecting system)
Arteries in first 25 secs; Veins after 60 secs

 Findings
 identification of calcified renal tract calculi size and position
 stone composition assessment with dual energy CT
 assessment of the sequelae of calculi
 obstruction
 infection
 assessment of other causes of flank pain if negative for
calculus disease
 presence of further calculi at risk of obstructing

Staghorn calculus
with enlarged left
kidney

Pyelonephritis with subcapsular collection

Ureters
 25 – 30 cm long; diameter of 3mm
 Narrower at following sites:
• Junction of pelvis and ureter
• Pelvic brim
• Intravesical ureter

 Relations:
 Abdominal ureter
 Following the course of the ureter from
superior to inferior:
 posteriorly: psoas muscle; genitofemoral
nerve; common iliac vessels; tips of L2-L5
transverse processes
 anteriorly
 Right
ureter: descending duodenum, gonadal
vessels; right colic vessels; ileocolic
vessels
 left ureter: gonadal artery; left colic
artery; loops of jejunum; sigmoid
mesentery and colon
 medially
 right ureter: IVC
 left ureter: abdominal aorta, inferior
mesenteric vein

 Pelvic ureter
• posteriorly: sacroiliac
joint, internal iliac artery
• inferiorly
• male: seminal vesicle
• female: lateral fornix of
the vagina
• anteriorly
• male: ductus deferens
• female: uterine artery (in
the broad ligament)
• medially
• female: cervix

 Development
a. Blind diverticulum from the
metanephric duct
 Developmental anomalies
a. Duplication: commonest
significant congenital
anomaly of urinary tract.
Commoner in females.
b. Weigert-Meyer law: during
complete duplication, ureter
serving the upper renal
moiety drains fewer calyces
and is inserted lower into the
bladder than that draining the
lower moiety – maybe as low
as the bladder neck
Upper moiety – obstruction
Lower moiety – reflux

 IVU:
oProne views aid filling
oDistension of proximal part by compression band across
abdomen
oOblique views for UV junction
 Ultrasound:
oProx and distal visible when well distended.
 CT:
oReplaced IVU as IOC for ureteric calculi

Bladder
 pyramidal muscular organ when empty
 It has a triangular shaped base posteriorly
 The ureters enter the posterolateral angles and the urethra
leaves inferiorly at the narrow neck , which is surrounded by
the (involuntary) internal urethral sphincter
 Extraperitoneal – only superiorly covered
 The ability of the full bladder to elevate and displace bowel
loops is taken advantage of in pelvic ultrasound, where the
full bladder provides an acoustic window

median ligament is
the fibrous remnant
of the urachus
medial ligaments are
the fibrous remnants of
the umbilical arteries

 Relations:
 male
a. anteriorly: pubic symphysis
b. posteriorly: rectovesical pouch and rectum
c. inferiorly: prostate, obturator internus muscle, levator ani
muscle
d. superiorly: peritoneum
e. laterally: ischioanal fossa
 female
a. anteriorly: pubic symphysis
b. posteriorly: vesicouterine pouch, uterus, cervix, vagina
c. inferiorly: pelvic fascia, perineal membrane
d. superiorly: uterus, peritoneum
e. laterally: ischioanal fossa

 Bladder is relatively fixed inferiorly via
a. condensations of pelvic fascia, which attach it to the back
of the pubis, the lateral walls of the pelvis and the rectum
b. continuity with the prostate in male - strong puboprostatic
ligaments
Bladder rupture - # pelvis
- Blunt injury abd

 Development:
 Trigone from mesoderm
 Ventral bladder wall endodermal from urogenital sinus
Double bladder

Hyperdense lesion in right lateral wall

Right VUJ calculus Normal bladder - < 10HU

Intraperitoneal
bladder rupture with
extravasation of
contrast

Prostate
 shaped like an upside-down truncated cone and surrounds
the base of the bladder and the proximal (prostatic) urethra,
extending inferiorly to the urogenital diaphragm and external
sphincter.
 weighs between 20-40 grams with an average size of 3 x 4 x
2 cm
 70% glandular tissue and 30% fibromuscular or stromal
tissue
 seminal vesicles are superior and posterior to the prostate
gland. Its ejaculatory ducts pierce the posterior surface of the
prostate below the bladder

3 zones:
- Peripheral (70%)
- Central (25%)
- Transition (5%)

Prostatic calcification in Prostate cancers with bony mets

 Transabdominal Ultrasound can assess the volume of the
prostate but is not reliable to diagnose carcinoma
 fill their bladder with at least 60ml of fluid
 probe is angled approximately 30 degrees caudal using the
bladder as a window

BPH
 increase in volume of the
prostate with a calculated
volume exceeding 30 mL
(width x height x length x
0.52)
 central gland is enlarged,
and is hypoechoic or of
mixed echogenicity
 calcification may be seen
both within the enlarged
gland as well as in the
pseudocapsule
(representing
compressed peripheral
zone)
 PVR

BPH
CT KUB
 central zone
appears
hyperdense
between 40-60
HU
 peripheral zone
appears
hypodense
between 10-25
HU
 useful staging
metastatic
spread

Prostate CA
In advanced disease, CT scan is the test of choice to detect enlarged pelvic
and retroperitoneal lymph nodes, hydronephrosis and osteoblastic
metastases

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