Overview Table

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Table 67 ■ Abnormal findings in the renal pelvis, ureter, and bladder ro

3 Renal pelvis and ureter Bladder

Wall changes Intraluminal findings

Pyelectasis (p. 380) Diverticula, pseudo- Ureterocele (p. 386)

diverticula (p. 384)

Urinary stone colic (p. 380) Bladder wall thickening Sediment, pus, clotted blood

Obstructive pyelocalyceal Bladder carcinoma (p. 384) Stones (p. 387) ectasia, urinary tract obstruction (p. 382)

Polypoid bladder tumors Foreign bodies (p. 387) (p. 384)

n Pyelectasis (Fig. 560): ampullary renal pelvis associated with increased urinary excretion

• Triangular or cone-shaped hypoechoic mass in the renal sinus echo

• Absence of calyceal ectasia

• No ureteral dilatation

• CDS: absence of vascularity n Note: It is important to exclude an obstruction.

Fig. 560 Pyelectasis (P), CDS. a A large renal vein can be excluded from the differential diagnosis. K = right kidney. b Obstructive pyelocalyceal ectasia with acute urinary stone colic: anechoic separation of the central echo complex with mild dilatation of the ureteropelvic junction n Urinary stone colic (Figs. 561-563; see also Fig. 86, p. 65):

• Clinical features: acute, intense waves of abdominal pain caused by a kidney stone or, rarely, by blood clots. Perirenal fluid extravasation leads to urinoma 380 formation.

Urinary Stone EchoUrinary Stone Echo

Fig. 561a, b Renal colic due to a ureteropelvic junction stone. a Hydronephrotic kidney (K) with a dilated, fluid-filled renal pelvis and extravasated fluid (urinoma, FL). b Ureteropelvic junction stone (arrow, U) and dilated renal pelvis (P). Oblique upper abdominal longitudinal scan over the course of the right ureter

Central Caliceal Dilatation

Fig. 562a-c a High transverse scan of the right kidney (K). Posterior to the artery is the ectatic renal pelvis (P) with no dilatation of the proximal ureter. VC = inferior vena cava. b, c Dilated pyelocaliceal system in a patient with flank pain. Suspicion of biliary colic. b Dilated calix (CA) communicating with the dilated and obstructed renal pelvis (PY). c A proximal ureteral stone causing obstructive caliceal ectasia. Scan shows tow anechoic masses in the central echo complex. The upper mass represents an ectatic caliceal neck. The enlargement of a caliceal neck to more than 5 mm (here 11 mm) indicates obstruction. The lower mass is the dilated renal pelvis

Mode Acoustic

Fig. 563a, b Urinary stone colic with a detectable stone (arrow) in the prevesical ureter (U). a B-mode image: high-amplitude echo with a partial acoustic shadow. Oblique lower abdominal transverse scan. b CDS 4days later: nonoccluding stone in the ureteral orifice; urine jet (red); faint "twinkling artifact" in the acoustic shadow of the stone

Fig. 563a, b Urinary stone colic with a detectable stone (arrow) in the prevesical ureter (U). a B-mode image: high-amplitude echo with a partial acoustic shadow. Oblique lower abdominal transverse scan. b CDS 4days later: nonoccluding stone in the ureteral orifice; urine jet (red); faint "twinkling artifact" in the acoustic shadow of the stone

• Sonographic criteria: Ureteral obstruction can be detected sonographically at the classic sites of predilection. The level and nature of the obstruction can be accurately determined in over 80% of cases. If the neck of the calix is enlarged more than 0.4 cm and the pelvis and ureter to more than 0.5 cm, urinary stasis is present.

n Obstructive pyelocalyceal ectasia: caused by UTO, Fig. 564). As the duration of the obstruction increases, the anechoic fluid exerts an increasing mass effect that leads to parenchymal thinning and obliteration of the central echo complex. This chronic process can be classified into several grades of severity (Figs. 565-568).

Echocomplex Mass Uterus

a Metastasizing tumors in the lesser pelvis (ovary, uterus; here: rectal carcinoma). b Bladder carcinoma (urothelial carcinoma, arrows), often located near the ureteral orifice. The differential diagnosis includes metastasis from prostatic carcinoma. U = ureter, IA = iliac artery, B = bladder

- Pyelocalyceal ectasia due to anechoic compartmentalization of the renal sinus echo complex

- Possible anechoic dilatation of the ureteropelvic junction and ureter

- Preservation of a prominent sinus echo 382 - Normal thickness of the renal parenchyma

Fig. 565 Mild urinary stasis: anechoic splaying of the central echo band with preservation of the sinus echo and normal thickness (1.3-2 cm) renal parenchyma (K). P = renal pelvis, U = ureter

Calyceal Ectasia

Moderate urinary stasis (grade II, Fig. 566):

- Marked calyceal dilatation to 5-10 mm, pyelectasis

- Ureteral dilatation, incipient ureteral tortuosity

- Renal parenchyma is normal or slightly thinned

- Diminished renal sinus echo

Fig. 566 Moderate urinary stasis: marked anechoic pyelocalyceal ectasia (C) with a diminished sinus echo and incipient thinning of the renal parenchyma. K = kidney

Calyceal Ectasia

- Massive calyceal dilatation, marked anechoic dilatation of the renal pelvis

- Marked ureteral dilatation and tortuosity

- Obliterated renal sinus echo

- Thinning of the renal parenchyma

Fig. 567 Severe urinary stasis: pronounced anechoic pyelocalyceal ectasia (C, P) with an obliterated sinus echo, parenchymal thinning, and ureteral dilatation (U). K = kidney

- Anechoic cystic mass in the central echo complex caused by severe pyelocalyceal dilatation

- Complete loss of the renal sinus echo

- Complete or almost complete loss of the renal parenchyma

Hydronephrotic SacCentral Calyceal Dilation

Fig. 568 Hydronephrotic sac. The calyces (C) and renal pelvis (P) have coalesced to form an anechoic hydro-nephrotic sac with loss of the renal parenchyma

n Bladder diverticula or pseudodiverticula (Fig. 569): high incidence of diverticular carcinoma

• True diverticula: anechoic, usually solitary outpouching of the bladder wall (prolapses between muscle bundles at a site of congenital weakness)

• Pseudodiverticula: multiple protrusions due to thickening of the bladder wall (usually a result of obstructive or neurogenic bladder dysfunction)

Hyperplasia Walls Thick
aly): no wall thickening. b Pseudodiverticulum (arrows): significant wall thickening. The patient presented clinically with benign prostatic hyperplasia. IC = indwelling catheter

n Bladder wall thickening (Fig. 570a): mural hypertrophy, trabeculated bladder

• Wall thickening > 8 mm in the full bladder

• Usually results from an infravesical outflow obstruction n Plaque-like bladder carcinoma (Fig. 570b; see also Fig. 564b, p. 382):

• Relatively broad area of wall thickening

• CDS: spot-like tumor vessels n Polypoid bladder tumors (Fig. 571 ): polypoid or polypous tumors, "bladder papillomas," mostly noninvasive carcinomas, staged according to the criteria in Fig. 572

• Circumscribed wall thickening with intraluminal protrusion

• Tumor surface is usually lobulated (and occasionally echogenic)

• Nonhomogeneous internal echo pattern

• CDS: spot-like tumor vessels

Bladder Diverticula Cytoscopy
Fig. 570a, b Thickening of the bladder wall. a The bladder wall is thickened to 15.8 mm (cursors) as a result of prostatic enlargement (P). b Wall thickening due to a plaque-like bladder tumor (T; histology; papillary urothelial carcinoma, probably a diverticular tumor). D = diverticula
Histology Papillary Tumor Bladder

Fig. 571a-d Polypoid bladder tumors. a Benign "bladder papilloma" (cursors). b Lobulated hypoechoic mass (arrow) on the bladder floor (cystoscopy: papillary tumor; histology: urothelial carcinoma). c Echogenic tumor with an echogenic halo and no evidence of wall infiltration (histology: urothelial carcinoma). d Intravesical tumor with irregular margins (papillary urothelial carcinoma). The high surface echogenicity results from a "blooming" effect

Fig. 571a-d Polypoid bladder tumors. a Benign "bladder papilloma" (cursors). b Lobulated hypoechoic mass (arrow) on the bladder floor (cystoscopy: papillary tumor; histology: urothelial carcinoma). c Echogenic tumor with an echogenic halo and no evidence of wall infiltration (histology: urothelial carcinoma). d Intravesical tumor with irregular margins (papillary urothelial carcinoma). The high surface echogenicity results from a "blooming" effect

Urothelial involvement L. propria Muscle Adventitia

Tis

Ta

T1

T2

T3a

T3b

T4

Invasion of extra-vesical organs

Prostate, uterus, vagina, pelvis wall, abdominal wall

New TNM

0

I

II

III

IV

stage

(2002)

Fig. 572 Staging of bladder carcinoma. Tis = carcinoma in situ, Ta = noninvasive papillary carcinoma, T1 = tumor invades subepithelial connective tissue, T2 = tumor invades muscle, T3 = tumor invades perivesical tissue, T3a = microscopically, T3a = macroscopically (extravesical mass), T4 = tumor invades adjacent organs

n Ureterocele (Fig. 573):

• Echogenic band bulging into the bladder lumen (invaginated ureteral orifice)

• Ureteral obstruction

Bilateral Ureteric Obstruction

Fig. 573a-c Ureteroceles. a, b Bilateral ureteroceles (C, UC). The right uretero-cele contains a stone (S = acoustic shadow), and the left ureterocele is associated with ureteral obstruction (U). B = bladder. c Large ureterocele on the right side: echogenic oval membrane within the bladder lumen (image courtesy of Dr. K. Ringewald)

n Benign prostatic hyperplasia (BPH, Fig. 574):

• Spherical or nodular protuberance of the middle lobe of the prostate n Sediment, pus, blood clots (Fig. 575):

• Sediment: sharply marginated echogenic layer that moves with position changes

Benign Bladder Mass
Fig. 574a, b Benign prostatic hypertrophy (BPH; adenoma of the middle lobe). a Polypoid tumor mass (T) in the bladder (B). b Angled scan demonstrates BPH, excluding a primary bladder tumor. P = prostate
Figs And Bladder Health
Fig. 575a, b Bladder sediment and clotted blood. a Purulent sediment: echogenic layer with a horizontal free margin (arrows). b Large polypoid clot (arrows): moves and changes shape with position changes, shows transient swirling of clot particles. B = bladder

• Clots: round or shaggy areas of increased echogenicity; distinguishable from polypoid tumors by noting movement or swirling in response to position changes or irrigation (bladder tamponade by clotted blood, see Fig. 177, p. 134)

• Both: absence of internal vessels found on CDS n Stone (see Fig. 563, p. 382):

• High-amplitude echo

• Distal acoustic shadow

• Mobility n Foreign body (Fig. 576): e.g., ureteral stent, indwelling catheter

• Ureteral stent (drain): echogenic double band in contact with the ureter (Fig. 576a)

• Catheter balloon: typical round, echogenic balloon wall, fluid-filled lumen, echogenic center (tube, Fig. 576b), and double-walled tubing

Large Intravesical Prostate

Fig. 576a, b Foreign bodies in the bladder: ureteral stent and indwelling catheter. a Echogenic ureteral stent inserted for urothelial carcinoma of the ureter. b Indwelling catheter balloon (arrow): echogenic balloon wall surrounding a bright central echo from the catheter tip

Fig. 576a, b Foreign bodies in the bladder: ureteral stent and indwelling catheter. a Echogenic ureteral stent inserted for urothelial carcinoma of the ureter. b Indwelling catheter balloon (arrow): echogenic balloon wall surrounding a bright central echo from the catheter tip

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