Genitourinary tract

Hydrops fetalis

Single umbilical artery

Two vessel cord One umbilical artery and one umbilical vein In isolation, no adverse clinical outcome When accompanied by other anomalies, 50% chance for trisomy 13 and 18 IUGR in 15% cases Imaging Free loop of cord with 2 vessels 70% absent left umbilical artery Single umbilical artery is larger in size than 3 vesselContinue reading “Single umbilical artery”

Post transplant renal artery stenosis

Ovarian hyperstimulation syndrome

7th edition AJCC TNM staging of adrenocortical carcinoma

TX Primary tumor cannot be assessed T0 No evidence of primary tumor  T1 Tumor 5 cm or less in greatest dimension, no extra-adrenal invasion T2 Tumor greater than 5 cm, no extra-adrenal invasion T3 Tumor of any size with local invasion, but not invading adjacent organs T4 Tumor of any size with invasion of adjacentContinue reading “7th edition AJCC TNM staging of adrenocortical carcinoma”

Goldman and Sandler classification of urethral injuries

Grade I Posterior urethra stretched but intact Grade II Partial or complete posterior urethral tear above intact urogenital diaphragm Grade III Partial or complete tear of combined anterior and posterior urethra with torn urogenital diaphragm Grade IV Bladder neck injury with extension to the urethra Grade IVa Injury to bladder base with extravasation simulating typeContinue reading “Goldman and Sandler classification of urethral injuries”

Colapinto and McCallum classification of urethral injuries

Grade I Posterior urethra stretched but intact Grade II  Posterior urethral tear above intact urogenital diaphragm Grade III Posterior urethral tear with extravasation through torn urogenital diaphragm

AAST renal injury scale

Grade Parenchyma Collecting system Vascular Grade I  Sub capsular hematoma and/or contusion No injury No injury Grade II  Laceration < 1 cm in depth and into cortex, small perirenal hematoma contained within Gerota fascia No injury No injury Grade III Laceration > 1 cm in depth and into medulla, hematoma contained within Gerota fascia NoContinue reading “AAST renal injury scale”

FIGO staging of ovarian carcinoma

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Risk stratification in prostate cancer by European Association of Urology

Low risk PSA < 10 ng/ml Gleason score < 7 Clinical stage T1 – T2a Intermediate risk PSA 10-20 ng/ml Gleason score 7 Clinical stage T2b High risk PSA > 20 ng/ml Gleason score > 7 Clinical stage > T2c or N+

Risk stratification in prostate cancer by American Urological Association

Very low risk PSA < 10 ng/ml Grade group I Clinical stage T1 – T2a  < 34% biopsy cores positive No core >50% involved PSA density < 0.15 ng/ml/cc Low risk PSA < 10 ng/ml Grade group I Clinical stage T1 –  T2a Intermediate risk PSA 10-20 ng/ml Grade group 2 or 3 Clinical stage Continue reading “Risk stratification in prostate cancer by American Urological Association”

Bladder cancer staging

Tx  Primary tumor cannot be assessed T0 No evidence of residual tumor Ta Superficial non invasive papillary carcinoma Tis Superficial flat tumor (carcinoma in situ) T1 Invasion of subepithelial connective tissue (lamina propria) T2a Superficial invasion of muscularis mucosa (into inner half) T2b Deep invasion of muscularis mucosa (into outer half) T3a Microscopic perivesical spreadContinue reading “Bladder cancer staging”

Upper tract urothelial carcinoma staging

T0 No evidence of primary tumor Ta Non-invasive papillary carcinoma Tis Carcinoma in situ T1 Tumor invades sub epithelium T2 Tumor invades muscularis  T3 Tumor invades beyond muscularis into perirenal or periureteric fat or into renal parenchyma T4 Tumor invades adjacent organs or through the kidney into perinephric fat N0 No regional lymph nodes N1Continue reading “Upper tract urothelial carcinoma staging”

2017 modification TNM renal cell carcinoma staging

T1a Tumor confined to kidney, small, < 4 cm T1b Tumor confined to kidney > 4 cm, < 7 cm T2a Tumor confined to kidney > 7 cm, < 10 cm T2b Tumor confined to kidney > 10 cm T3a Tumor spread to perinephric fat, renal vein or pelvicalyceal system T3b Tumor spread to cavaContinue reading “2017 modification TNM renal cell carcinoma staging”

Differentials for right iliac fossa pain

Appendicitis Ectopic pregnancy Ovarian cyst with or without torsion Salpingitis Endometriosis Diverticulitis Infectious ileocecitis Crohn’s disease Malignancy Intussusception Meckel’s diverticulum Cholecystitis Urolithiasis Mesenteric adenitis

O-RADS MRI risk stratification and management system

O-RADS MRI score Risk category Positive predictive value for malignancy Remarks 0 Incomplete evaluation – – 1 Normal ovaries – No ovarian lesion Simple cyst < or equal to 3 cm in premenopausal women Hemorrhagic cyst < or equal to 3 cm in premenopausal women Corpus luteum with or without hemorrhage < or equal toContinue reading “O-RADS MRI risk stratification and management system”

Emphysematous disease of the urinary tract

Emphysematous pyelonephritis gas in renal parenchyma focal or diffuse may involve collecting system and perinephric space high mortality may require nephrectomy Emphysematous pyelitis gas in pelvicalyceal system and ureter alone low mortality percutaneous drainage and antibiotics helps Emphysematous cystitis gas in urinary bladder and bladder wall typically in diabetics

Testicular torsion

Peripubertal boys, and in infancy Normally tunica vaginalis converges posterior to fix testis to scrotal wall  This convergence is deficient or patulous leading to ‘bell clapper’ deformity and torsion Afebrile boy with acute scrotal pain and vomiting Acute torsion – 24 hrs to 10 days Testicular salvage rates: 80% first 6 hours, 20% if beyondContinue reading “Testicular torsion”

Testicular atrophy

Previous epididymo-orchitis, testicular torsion, cryptorchidism, varicocele, mumps, estrogen therapy Part of normal aging Imaging  US: iso- or hyporeflective compared with normal side. Homogeneous or mixed parenchymal reflectivity Read more Lipshultz, Larry I., and Joseph N. Corriere Jr. “Progressive testicular atrophy in the varicocele patient.” The Journal of urology 117.2 (1977): 175-176.

Testicular microlithiasis

Calcium deposits in lumina of seminiferous tubules Associated with cryptorchidism, infertility, Klinefelter syndrome, testicular infarction, testicular dysgenesis, infertility, testicular torsion and atrophy Association with malignancy is controversial and not established In isolation, microlithiasis needs no follow up  When associated with previous malignancy, maldescent, atrophy (<12 ml), orchidopexy or history of testicular malignancy in first-degree relative,Continue reading “Testicular microlithiasis”

Benign prostatic hyperplasia

Arises in transition zone Hyperplasia of prostatic tissue  Variable degrees of glandular, muscular and fibrous components Imaging  Heterogeneity of hypertrophy seen as varying signals in T2 and variable diffusivity  Nodules may grow exophytically to protrude into peripheral zone Dynamic contrast enhanced MRI shows rich vascular areas interspersed with variable vascular areas.   Read more Kahn,Continue reading “Benign prostatic hyperplasia”

Post-transplant renal artery stenosis

Late complication Occurs at anastomosis site – between donor and recipient artery Presents with severe hypertension or renal dysfunction Imaging  US: renal artery velocity >200 cm/s, gradient of 2:1 between stenotic and pre-stenotic segment and spectral broadening. Downstream turbulence, tardus parvus waveform distal to stenotic segment False positive: kinking or tortuosity of vessels.  If USGContinue reading “Post-transplant renal artery stenosis”

Nephrocalcinosis

Deposition of calcium in renal parenchyma Deposition of calcium phosphate and calcium oxalate Due to conditions that cause hypercalcemia, hyperphosphatemia and increased excretion of calcium, phosphate or oxalate Can be medullary or cortical Medullary nephrocalcinosis Due to metabolic dysfunction More common form Hyperparathyroidism Sarcoidosis Medullary sponge kidney disease Renal tubular acidosis Loop diuretics  Beta thalassemia Continue reading “Nephrocalcinosis”

Ureteropelvic junction obstruction

Congenital seen in 1 in 500 live births Intrinsic narrowing of proximal ureter as it joins pelvis Congenital disruption of muscle development In 10% cases, aberrant or accessory renal artery crosses and obstructs proximal ureter Antenatal hydronephrosis detection Abdominal mass Intermittent flank pain Imaging Voiding cystourethrogram is used to rule out reflux disease Diuretic renographyContinue reading “Ureteropelvic junction obstruction”

Ovarian hyperstimulation syndrome

Potential life-threatening complication Occurs during luteal phase or early pregnancy following IVF ovarian stimulation Caused by vasoactive substances that increase vascular permeability, ascitic fluid shift into abdomen Abdominal distension, nausea, vomiting, weight gain Pleural effusion, intravascular fluid depletion, hemoconcentration, thromboses, renal failure, shock Imaging USG – technique of choice Bilateral symmetrical enlarged ovaries (≥6 cm)Continue reading “Ovarian hyperstimulation syndrome”

Polycystic ovaries

Polycystic ovarian syndrome (2003 definition based on joint meeting of American society of reproductive medicine and European society for human reproduction and embryology) requires 2 out of the 3 following criteria Oligo and or anovulation Hyperandrogenism (clinical and/or biochemical) Polycystic ovaries 6-15% women have polycystic ovaries. 80% have infertility, menstrual irregularity or hirsuitism Imaging TransvaginalContinue reading “Polycystic ovaries”

Angiomyolipoma

Benign Composed of variable amounts of fat, smooth muscle and abnormal blood vessel Occur spontaneously Women in 50s Younger age, multiple in patients with tuberous sclerosis Rare in neurofibromatosis and in adult polycystic kidney disease Consists of thick-walled inelastic blood vessels Risk of hemorrhage higher in lesions larger than 4 cm in diameter Imaging USGContinue reading “Angiomyolipoma”

Parapelvic and peripelvic cysts

Occur in renal sinus Causes sinus distortion but no obstruction Peripelvic: lymphatic origin Parapelvic: serous cysts arising from renal parenchyma present in the sinus Important to distinguish from hydronephrosis – dilated infundibula are not seen to connect to a dilated renal pelvis Read more Hidalgo, H., et al. “Parapelvic cysts: appearance on CT and sonography.” AmericanContinue reading “Parapelvic and peripelvic cysts”

Radiographic grading of Vesicoureteric Reflux

Grade Finding I ureter and upper collecting system without dilatation II mild dilatation of ureter and renal pelvis with minimal blunting of fornices III moderate dilatation of ureter and renal pelvis with minimal blunting of fornices IV moderate dilatation and tortuosity of ureter with moderate dilatation of renal pelvis and calyces, obliteration of sharp angleContinue reading “Radiographic grading of Vesicoureteric Reflux”

Ultrasound classification of pelvicalyceal dilatation

Type Finding 0 collecting system hardly visible, normal I just renal pelvis visible, calyces not seen. pelvic diameter <7 mm, considered normal II axial renal pelvis diameter <10 mm, some calyces visible but with normal forniceal and papillar shape / configuration III marked dilatation of calyces and pelvis, pelvic axial width >10 mm with flattenedContinue reading “Ultrasound classification of pelvicalyceal dilatation”

Adrenal dysfunction

Diagnosed clinically and biochemically Imaging to identify causal lesion, unilateral or bilateral, plan surgical or medical management Types  Cortical hyperfunction Cushing’s syndrome Conn’s syndrome Adrenogenital syndrome Medullary hyperfunction Adrenal medullary hyperplasia Pheochromocytoma Cortical hypofunction Addison’s disease Secondary cortical insufficiency (due to decreased ACTH)

Adrenal myelolipoma

Rare Benign, non-functioning Adrenocortical dysfunction in 10% <5 cm, solitary Hematopoietic precursor cells and mature adipose tissue  May have fibromyxoid degeneration, hemorrhage, necrosis, calcification Asymptomatic  Large lesions sometimes cause abdominal pain or retroperitoneal bleeding Imaging  Recognizable capsule May have calcification Varying amounts of fat Myeloid soft tissue component enhances with contrast Fat attenuation < -30Continue reading “Adrenal myelolipoma”

Adrenal cysts

Endothelial cyst Vascular cyst Endothelial lining 45% of adrenal cysts 2/3 in females 8% bilateral May have residual adrenocortical tissue in wall  Hemorrhagic cyst Pseudocyst 39% of adrenal cysts Middle-aged women  Seen in Beckwith-Wiedemann syndrome Originally would have been an endothelial cyst, that underwent hemorrhage, and secondary fibrosis or hemosiderin deposition Parasitic cyst Echinococcal AsymptomaticContinue reading “Adrenal cysts”

Imaging an adrenal mass

Incidental masses in 5% of abdominal scans 6% of people >60 years carry an adrenal adenoma. 70-80% of these are non-functioning Prevalence of 9-13% in patients with an extra-adrenal malignancy In a patient with known carcinoma, only 26 – 36% are metastatic  European Society of Endocrinology Clinical Practice Guidelines for adrenal masses Unenhanced CT shouldContinue reading “Imaging an adrenal mass”

The normal adrenal gland

Adenomyosis

endometrial tissue in myometrium secondary smooth muscle hypertrophy and hyperplasia diffuse or focal clinical presentation dysmenorrhea dysfunctional uterine bleeding ultrasound enlarged, globular uterus myometrial heterogeneity echogenic myometrial nodules subendometrial echogenic linear striations 2-6 mm subendometrial cysts endometrial pseudowidening: poor definition of endomyometrial junction rain shower appearance: multiple fine areas of attenuation throughout the lesion doppler:Continue reading “Adenomyosis”

Simple renal cyst

Prostate and adjacent structures

Acute epididymo orchitis

Clinical presentation 40 year old gentleman with fever, hemiscrotal heaviness and pain. Ultrasound Findings Hypoechoic enlarged right testis and epididymis with diffusely increased vascularity demonstrated in power doppler setting. Learning points Most common differential for acute onset scrotal pain. It is often accompanied by febrile illness. The worrisome differential is testicular torsion. Read more AcuteContinue reading “Acute epididymo orchitis”

Transitional cell carcinoma – urinary bladder

Clinical presentation Hematuria in an otherwise healthy fit young 25 year old gentleman. MRI Findings and Discussion Focal exophytic growth with signal intensity similar to urinary bladder wall is seen arising from right posterolateral wall approximately 2cm cranial to right vesicoureteric junction. It shows diffusion restriction and enhances in post gadolinium administration. Cystoscopic biopsy was doneContinue reading “Transitional cell carcinoma – urinary bladder”

Duplex renal collecting system

Clinical presentation Health check up incidental pick up in a 35 year old lady. USG Findings and Discussion Duplex collecting system is a common developmental variant seen most often in children, but incidentally in adults. They need to be documented due to their association with vesicuoureteric reflux or ureteroceles. The easiest clue is the disruption oContinue reading “Duplex renal collecting system”

Hydrocele

Clinical presentation Long standing scrotal swelling for assessment. USG Findings Approximately 75ml of fluid with fine internal echoes is seen in right tunica vaginalis. No fluid fluid levels. Both testes and epididymis are normal. No varicocele. A 10mm simple cyst is seen in the body of left epididymis. Discussion This is an example of uncomplicatedContinue reading “Hydrocele”

Indirect inguinal hernia

Clinical presentation 50 year old gentleman with a 2 year history of inguinoscrotal swelling presented with acute severe pain at the site of swelling since one day. USG CT Findings Indirect left inguinal hernia with an afferent and efferent loop of distal descending colon / proximal sigmoid colon as content with associated sigmoid mesentery. mildContinue reading “Indirect inguinal hernia”

Bicornuate unicollis uterus

Clinical presentation 40 year old lady presented for evaluation of abdominal pain. MRI Findings Two separate horns of uterus with independent endometrial canals fusing to a common cervical canal. Small submucosal fibroid in fundal left horn. Discussion Documenting variants of uterine anatomy is imperative especially in cases of repeated abortions and infertility workup. Read moreContinue reading “Bicornuate unicollis uterus”

Hydrocele of canal of Nuck

Clinical presentation 35 year old multiparous lady presented with a relatively painless right inguinolabial swelling. Ultrasound identified a fluid filled inguinal lesion raising suscpicion of indirect inguinal vs femoral hernia. A contrast enhanced CT study was done. CT Oral postivie contrast followed by i.v. iodinated contrast administration and portovenous phase acquisition. Annotated curved planar reconstructionContinue reading “Hydrocele of canal of Nuck”