Radiology

A. Intravenous pyelograms (IVP) of renal anomalies: kidney malrotation, bilateral pelvic kidneys, horseshoe kidney, and renal pelvis and ureter duplication (Figure 12-5)

B. CT scan, IVP, and arteriogram of renal cell carcinoma (Figure 12-6)

C. Radiographic views of normal kidney and different types of renal calculi (Figure 12-7)

Ivp Images Showing Renal Calculi

Figure 12-5. (A) IVP showing malrotation of the kidney. Note the abnormal appearance of the collecting system of the left kidney com- ^^^HB

pared with that of the right kidney. If the left kidney does not rotate 90° medially during fetal development, the minor calyces, major HiW W

calyces, and renal pelvis are oriented in the sagittal plane instead of the longitudinal plane. Note that the ureter also is displaced laterally. Note also that the left kidney is abnormally lower than the right kidney. The right kidney ascended and rotated normally, whereas the left kidney ascended and rotated abnormally. (B) IVP showing bilateral pelvic kidneys, resulting from the failure of both kidneys to ascend normally. Arrows indicate the collecting systems of both kidneys. The pelvis is the most common location of an ectopic kidney, a condition that usually occurs in boys, and usually on the left side. Approximately 50% of pelvic kidneys have some pathology, with poor function. (C) IVP showing a horseshoe kidney (arrows), which results from fusion of the inferior poles of both kidneys during fetal development. The left side of the horseshoe kidney shows delayed filling of the calyces (compared with the right side), probably because of an obstruction. (D) Duplication of the renal pelvis and the upper portion of the ureter of the right kidney. In this case, the two ureters on the right side fuse into a single ureter at vertebral level L4 (arrow). However, the two ureters may remain separate throughout their course and open separately as follows: the ureter from the lower pole of the kidney may open at the urinary bladder trigone, whereas the ureter from the upper pole of the kidney usually has an ectopic opening and is obstructed. In addition, this congenital anomaly often is associated with backflow of urine from the urinary bladder up the ureter (vesicoureteral reflux). This backflow most commonly occurs up the ureter to the lower pole of the kidney. (A-C reprinted and D adapted with permission from Eisenberg RL: Diagnostic Imaging in Surgery. New York, McGraw-Hill, 1987, pp 531—533.)

Gerota Fascia

Figure 12-6. (A) CT scan showing a large renal cell carcinoma (RCC) (M) of the left kidney within the perirenal fascia of Gerota (arrows). Stage I RCC is confined to the renal capsule. Stage II RCC extends into the perirenal space, but is confined within the perirenal fascia of Gerota. Stage III RCC extends into the perirenal space, with thrombosis to the renal vein, inferior vena cava (IVC), or lymph nodes. Stage IV RCC extends beyond the perirenal fascia of Gerota, resulting in distant metastasis. A = aorta. (B) IVP of RCC that has displaced the calyces upward (i.e., an RCC is never drained by a calyx). The following normal kidney bulges may be confused with RCC: a persistent fetal lobation pattern, a dromedary hump on the lateral border of the left kidney caused by the normal impression of the spleen, or a large renal column of Bertin. All normal kidney bulges are drained by a calyx. (C) Arteriogram of RCC. Note the haphazard vascular pattern within the RCC (M) compared with the normal pattern within the upper pole of the left kidney. An arteriogram also may be used to show the difference between an RCC, which shows a haphazard vascular pattern, and a large renal cyst, which is avascular. [A adapted with permission from McClennan BL, Lee JKT: Kidney. In Lee JKT, Sagel SS, Stanley RJ (eds): Computed Body Tomography. New York, Raven Press, 1983; Band C adapted with permission from Freedman M: Clinical Imaging: An Introduction to the Role of Imaging in Clinical Practice. New York, Churchill Livingstone, 1988, pp 452, 453.]

Normal Impressions Ivp

^ Figure 12-7. (A) I VP showing a normal kidney, with the normal collecting system of the kidney and the ureter. The ureters normally are constricted at three sites (X), and kidney stones most commonly cause obstruction at these sites. (B) Anteroposterior radiograph of renal calculi. A kidney stone (arrow) is located at the ureteropelvic junction (junction of the renal pelvis and ureter). (C) IVP of renal calculi. Unilateral hydronephrosis (dilation of the collecting system) caused by kidney stone obstruction at the ureteropelvic junction (arrow). In renal calculi, the classic IVP findings are: a very dense nephrogram in acute obstruction, a greatly delayed pyelogram, significantly delayed opacification of urine in an obstructed system, and atrophy of the kidney with narrowing of the kidney parenchyma in chronic obstruction. (D) IVP showing staghorn calculi. Kidney stones may conform to the shape of all or part of the collecting system. Kidney stones that fill at least two adjacent calyces are called staghorn calculi. These calculi usually are magnesium ammonium sulfate (struvite or triple phosphate) calculi caused by bacterial infection. (£) CT scan of renal calculi showing a kidney stone (arrow) within the calyces. All kidney stones appear dense on CT scans (in contrast to routine radiographs). (A adapted with permission from Pansky B: Review of Gross Anatomy, 6th ed. New York, McGraw-Hill, 1996, p 443; B and C adapted with permission from Eisenberg RL: Diagnostic Imaging in Surgery. New York, McGraw-Hill, 1987, p 542; D reprinted with permission from Freedman M: Clinical Imaging: An Introduction to the Role of Imaging in Clinical Practice. New York, Churchill Livingstone, 1988, p 435; E reprinted with permission from Parienty RA, Ducellier R, Pradel J-M et al: Diagnostic value of CT numbers in pelvo-calyceal filling defects. Radiology 145: 743—747, 1977.)

Suprarenal

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