Genitourinary tract

Placenta previa

If the placental edge is >2 cm away from internal os, it is considered normal. Only two terminologies prefereed.

Two vessel cordOne umbilical artery and one umbilical veinIn isolation, no adverse clinical outcomeWhen accompanied by other anomalies, 50% chance for trisomy 13 and 18IUGR in 15% cases Imaging Free loop of cord with 2 vessels70% absent left umbilical arterySingle umbilical artery is larger in size than 3 vessel umbilical artery, the single umbilical artery…

Post transplant renal artery stenosis

Ovarian hyperstimulation syndrome

7th edition AJCC TNM staging of adrenocortical carcinoma

TXPrimary tumor cannot be assessedT0No evidence of primary tumor T1Tumor 5 cm or less in greatest dimension, no extra-adrenal invasionT2Tumor greater than 5 cm, no extra-adrenal invasionT3Tumor of any size with local invasion, but not invading adjacent organsT4Tumor of any size with invasion of adjacent organsNXRegional lymph nodes cannot be assessedN0No regional lymph node metastasis N1Metastasis in…

Goldman and Sandler classification of urethral injuries

Grade IPosterior urethra stretched but intactGrade IIPartial or complete posterior urethral tear above intact urogenital diaphragmGrade IIIPartial or complete tear of combined anterior and posterior urethra with torn urogenital diaphragmGrade IVBladder neck injury with extension to the urethraGrade IVaInjury to bladder base with extravasation simulating type IV Grade VIsolated anterior urethral injury

Colapinto and McCallum classification of urethral injuries

Grade IPosterior urethra stretched but intactGrade II Posterior urethral tear above intact urogenital diaphragmGrade IIIPosterior urethral tear with extravasation through torn urogenital diaphragm

AAST renal injury scale

GradeParenchymaCollecting systemVascularGrade I Sub capsular hematoma and/or contusionNo injuryNo injuryGrade II Laceration < 1 cm in depth and into cortex, small perirenal hematoma contained within Gerota fasciaNo injuryNo injuryGrade IIILaceration > 1 cm in depth and into medulla, hematoma contained within Gerota fasciaNo injuryNo injuryGrade IVLaceration through the parenchyma into the urinary collecting systemLaceration, one or more…

FIGO staging of ovarian carcinoma

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Risk stratification in prostate cancer by European Association of Urology

Low riskPSA < 10 ng/ml Gleason score < 7 Clinical stage T1 – T2aIntermediate riskPSA 10-20 ng/ml Gleason score 7 Clinical stage T2bHigh riskPSA > 20 ng/ml Gleason score > 7 Clinical stage > T2c or N+

Risk stratification in prostate cancer by American Urological Association

Very low riskPSA < 10 ng/ml Grade group I Clinical stage T1 – T2a < 34% biopsy cores positive No core >50% involved PSA density < 0.15 ng/ml/ccLow riskPSA < 10 ng/ml Grade group I Clinical stage T1 – T2aIntermediate riskPSA 10-20 ng/ml Grade group 2 or 3 Clinical stage T2b-c Favorable: grade group 1…

Bladder cancer staging

Tx Primary tumor cannot be assessedT0No evidence of residual tumorTaSuperficial non invasive papillary carcinomaTisSuperficial flat tumor (carcinoma in situ)T1Invasion of subepithelial connective tissue (lamina propria)T2aSuperficial invasion of muscularis mucosa (into inner half)T2bDeep invasion of muscularis mucosa (into outer half)T3aMicroscopic perivesical spreadT3bMacroscopic perivesical spread T4aInvasion of adjacent organs (prostate, seminal vesicles, uterus or vagina)T4bInvasion of pelvic side wall…

Upper tract urothelial carcinoma staging

T0No evidence of primary tumorTaNon-invasive papillary carcinomaTisCarcinoma in situT1Tumor invades sub epitheliumT2Tumor invades muscularis T3Tumor invades beyond muscularis into perirenal or periureteric fat or into renal parenchymaT4Tumor invades adjacent organs or through the kidney into perinephric fatN0No regional lymph nodesN1Spread to single lymph node < 2 cmN2Spread to single lymph node > 2 cm or multiple…

2017 modification TNM renal cell carcinoma staging

T1aTumor confined to kidney, small, < 4 cmT1bTumor confined to kidney > 4 cm, < 7 cmT2aTumor confined to kidney > 7 cm, < 10 cmT2bTumor confined to kidney > 10 cmT3aTumor spread to perinephric fat, renal vein or pelvicalyceal systemT3bTumor spread to cava below diaphragmT3cTumor spread to cava above diaphragm or invades the wall…

Differentials for right iliac fossa pain

AppendicitisEctopic pregnancyOvarian cyst with or without torsionSalpingitisEndometriosisDiverticulitisInfectious ileocecitisCrohn’s diseaseMalignancyIntussusceptionMeckel’s diverticulumCholecystitisUrolithiasisMesenteric adenitis

O-RADS MRI risk stratification and management system

O-RADS MRI scoreRisk categoryPositive predictive value for malignancyRemarks0Incomplete evaluation–1Normal ovaries-No ovarian lesionSimple cyst < or equal to 3 cm in premenopausal womenHemorrhagic cyst < or equal to 3 cm in premenopausal womenCorpus luteum with or without hemorrhage < or equal to 3 cm in premenopausal women2Almost certainly benign< 0.5%Cyst: unilocular, any type of fluid content.…

Emphysematous disease of the urinary tract

Emphysematous pyelonephritis gas in renal parenchymafocal or diffusemay involve collecting system and perinephric spacehigh mortalitymay require nephrectomy Emphysematous pyelitis gas in pelvicalyceal system and ureter alonelow mortalitypercutaneous drainage and antibiotics helps Emphysematous cystitis gas in urinary bladder and bladder walltypically in diabetics

Testicular torsion

Peripubertal boys, and in infancyNormally tunica vaginalis converges posterior to fix testis to scrotal wall This convergence is deficient or patulous leading to ‘bell clapper’ deformity and torsionAfebrile boy with acute scrotal pain and vomitingAcute torsion – 24 hrs to 10 daysTesticular salvage rates: 80% first 6 hours, 20% if beyond 24 hrs Imaging US: enlarged…

Testicular atrophy

Previous epididymo-orchitis, testicular torsion, cryptorchidism, varicocele, mumps, estrogen therapyPart 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 tubulesAssociated with cryptorchidism, infertility, Klinefelter syndrome, testicular infarction, testicular dysgenesis, infertility, testicular torsion and atrophyAssociation with malignancy is controversial and not establishedIn 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, European Society of Urogenital…

Benign prostatic hyperplasia

Arises in transition zoneHyperplasia 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 zoneDynamic contrast enhanced MRI shows rich vascular areas interspersed with variable vascular areas. Read more Kahn, T., et al. “Prostatic…

Post-transplant renal artery stenosis

Late complicationOccurs at anastomosis site – between donor and recipient arteryPresents 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 segmentFalse positive: kinking or tortuosity of vessels. If USG and clinical picture correlates,…

Nephrocalcinosis

Deposition of calcium in renal parenchymaDeposition of calcium phosphate and calcium oxalateDue to conditions that cause hypercalcemia, hyperphosphatemia and increased excretion of calcium, phosphate or oxalateCan be medullary or cortical Medullary nephrocalcinosis Due to metabolic dysfunctionMore common formHyperparathyroidismSarcoidosisMedullary sponge kidney diseaseRenal tubular acidosisLoop diuretics Beta thalassemia Inherited tubulopathiesOxalosis Vitamin-D therapy Cortical nephrocalcinosis Renal cortical nephrocalcinosisGlomerulonephritisRenal allograft rejectionAlport syndromeOxalosis…

Ureteropelvic junction obstruction

Congenital seen in 1 in 500 live birthsIntrinsic narrowing of proximal ureter as it joins pelvisCongenital disruption of muscle developmentIn 10% cases, aberrant or accessory renal artery crosses and obstructs proximal ureterAntenatal hydronephrosis detectionAbdominal massIntermittent flank pain Imaging Voiding cystourethrogram is used to rule out reflux diseaseDiuretic renography – DTPA or MAG3. Shows delayed radio…

Ovarian hyperstimulation syndrome

Potential life-threatening complicationOccurs during luteal phase or early pregnancy following IVF ovarian stimulationCaused by vasoactive substances that increase vascular permeability, ascitic fluid shift into abdomenAbdominal distension, nausea, vomiting, weight gainPleural effusion, intravascular fluid depletion, hemoconcentration, thromboses, renal failure, shock Imaging USG – technique of choiceBilateral symmetrical enlarged ovaries (≥6 cm)Multiple peripheral-placed thin walled cysts/folliclesEnlarged ovaries…

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 criteriaOligo and or anovulationHyperandrogenism (clinical and/or biochemical)Polycystic ovaries6-15% women have polycystic ovaries. 80% have infertility, menstrual irregularity or hirsuitism Imaging Transvaginal ultrasoundSensitive methodBetter spatial resolutionAvoided…

Angiomyolipoma

BenignComposed of variable amounts of fat, smooth muscle and abnormal blood vesselOccur spontaneouslyWomen in 50sYounger age, multiple in patients with tuberous sclerosisRare in neurofibromatosis and in adult polycystic kidney diseaseConsists of thick-walled inelastic blood vesselsRisk of hemorrhage higher in lesions larger than 4 cm in diameter Imaging USGDepends on proportions of fat, muscle and vascular…

Parapelvic and peripelvic cysts

Occur in renal sinusCauses sinus distortion but no obstructionPeripelvic: lymphatic originParapelvic: serous cysts arising from renal parenchyma present in the sinusImportant 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.” American Journal of Roentgenology 138.4 (1982):…

Radiographic grading of Vesicoureteric Reflux

GradeFindingIureter and upper collecting system without dilatationIImild dilatation of ureter and renal pelvis with minimal blunting of fornicesIIImoderate dilatation of ureter and renal pelvis with minimal blunting of fornicesIVmoderate dilatation and tortuosity of ureter with moderate dilatation of renal pelvis and calyces, obliteration of sharp angle of fornices, but maintenance of papillary impression in majority…

Ultrasound classification of pelvicalyceal dilatation

TypeFinding0collecting system hardly visible, normalIjust renal pelvis visible, calyces not seen. pelvic diameter <7 mm, considered normalIIaxial renal pelvis diameter <10 mm, some calyces visible but with normal forniceal and papillar shape / configurationIIImarked dilatation of calyces and pelvis, pelvic axial width >10 mm with flattened papilla and rounded fornices, but without parenchymal narrowingIVgross dilatation…

Adrenal dysfunction

Diagnosed clinically and biochemicallyImaging to identify causal lesion, unilateral or bilateral, plan surgical or medical management Types Cortical hyperfunctionCushing’s syndromeConn’s syndromeAdrenogenital syndromeMedullary hyperfunctionAdrenal medullary hyperplasiaPheochromocytomaCortical hypofunctionAddison’s diseaseSecondary cortical insufficiency (due to decreased ACTH)

Adrenal myelolipoma

RareBenign, non-functioningAdrenocortical dysfunction in 10%<5 cm, solitaryHematopoietic precursor cells and mature adipose tissue May have fibromyxoid degeneration, hemorrhage, necrosis, calcificationAsymptomatic Large lesions sometimes cause abdominal pain or retroperitoneal bleeding Imaging Recognizable capsuleMay have calcificationVarying amounts of fatMyeloid soft tissue component enhances with contrastFat attenuation < -30 HU is typical. Adenomas HU mostly never falls below -20

Adrenal cysts

Endothelial cyst Vascular cystEndothelial lining45% of adrenal cysts2/3 in females8% bilateralMay have residual adrenocortical tissue in wall Hemorrhagic cyst Pseudocyst39% of adrenal cystsMiddle-aged women Seen in Beckwith-Wiedemann syndromeOriginally would have been an endothelial cyst, that underwent hemorrhage, and secondary fibrosis or hemosiderin deposition Parasitic cyst EchinococcalAsymptomaticImaging types:Simple cysts with no internal architectureWater lily sign with separation…

Imaging an adrenal mass

Incidental masses in 5% of abdominal scans6% of people >60 years carry an adrenal adenoma. 70-80% of these are non-functioningPrevalence of 9-13% in patients with an extra-adrenal malignancyIn a patient with known carcinoma, only 26 – 36% are metastatic European Society of Endocrinology Clinical Practice Guidelines for adrenal masses Unenhanced CT should be performed to…

The normal adrenal gland

Adenomyosis

endometrial tissue in myometriumsecondary smooth muscle hypertrophy and hyperplasiadiffuse or focal clinical presentation dysmenorrheadysfunctional uterine bleeding ultrasound enlarged, globular uterusmyometrial heterogeneityechogenic myometrial nodulessubendometrial echogenic linear striations2-6 mm subendometrial cystsendometrial pseudowidening: poor definition of endomyometrial junctionrain shower appearance: multiple fine areas of attenuation throughout the lesiondoppler: speckled pattern of increased vascularity within heterogeneous area MRI areas…

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 Acute epididymorchitis -…

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 o…

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 uncomplicated…

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 https://www.youtube.com/watch?v=1fk5P72mIGk https://www.youtube.com/watch?v=5Iv5htVCOaw https://www.youtube.com/watch?v=-Q_9k_su8_A Findings Indirect left inguinal hernia with an afferent and efferent loop of distal descending colon / proximal sigmoid colon as content with associated…

Bicornuate unicollis uterus

Clinical presentation 40 year old lady presented for evaluation of abdominal pain. MRI https://www.youtube.com/watch?v=QMpeC_XJ-y4 https://www.youtube.com/watch?v=xPUfkxLzsOE https://www.youtube.com/watch?v=ceSaXJCX-s4 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…

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. https://www.youtube.com/watch?v=P47AWVzpS0M https://www.youtube.com/watch?v=Q8nDrKNMjuA https://www.youtube.com/watch?v=_bwoQsPKXFI Annotated…