(2) urology & vascular

X-RAYSX-RAYS

By

Prof Dr IBRAHIM DAWOUD

Prof of Surgery

Mansoura University

How to read

Urology UTP (Urinary Tract Plain). IVU (Intravenous Urography). MRU. Urethrography. Ascending Cystography. CT scan. US. Fistula: Fistulography.

Plain X-ray abdomen ( Rt hypochondrium). The patient is more or less well prepared. It revealed * A radio-opaque shadow in the Rt hypochondrium. Diagnosis

Radio-opaque Shadow in the Rt hypochondrium for DD most probably

RT Renal Stone

How to read

DD of radio-opaque shadow {1} Gall stone -----shape of the stone

------ in lat view in front of the spine

{2} Renal stone -- ---- Cholecystography or IVU

{3} Calcified LN

{4} Fecolith or FB in the small intestine

{5} Phlebolith

{6} Atherosclerotic renal artery

{7} Hydatid cyst in the liver

{8} Calcified TB kidney or suprarenal gland

{9} Calcified costal cartilage

{10} Fracture transverse process of lumbar vertebra

Questions

How to readHow to read

Plain X-ray abdomen ( Lt hypochondrium). The patient is more or less well prepared. It revealed

* A radio-opaque shadow in the Lt hypochondrium.

Diagnosis

Radio-opaque Shadow

in the Lt hypochondrium for DD

most probably

LT Renal Stone


Plain X-ray abdomen. The patient is more or less well prepared. It revealed

* Multiple radio-opaque shadows in the pelvis.

In the course of both pelvic ureters

Diagnosis

Radio-opaque Shadows

in the course of both pelvic ureters

most probably

Ureteric stones


Plain X-ray abdomen ( Lt hypochondrium). The patient is more or less well prepared. It revealed

* A radio-opaque shadow in the Lt hypochondrium.

Giving a stag-horn appearance

Diagnosis

Radio-opaque Shadow


most probably

LT Renal Pelvis

Stag-horn Stone

Questions Questions

Pathology Clinical Picture Investigations Treatment

Stones of the Urinary System Stones of the Urinary System


IVU The pelvis of the ureter is triangular.

The calyces are directed laterally.

The hilum is directed medially.

The pelvis meets the calyces at the lower calyx.

Each calyx has a waist.

The blind end of the calyx is cupped.

Diagnosis most probably

Normal IVU


IVU The Lt kidney and ureter have normal appearance.

The RT kidney.

- The pelvis shows mild dilatation.

- The calyces revealed signs of hydronephrosis

(flattening- loss of waist- clubbing- ballooning).

- No definite site of distal obstruction appeared in the film.


Right Hydronephrotic Kidney

How to readHow to read IVU The Lt kidney and ureter have normal appearance.

The right kidney.

- The pelvis shows severe dilatation.

- The calyces revealed signs of hydronephrosis

(flattening- loss of waist- clubbing- ballooning).

- The upper 1/3 of the ureter revealed dilatation

with stricture at the junction bet upper and middle 1/3.

- The UB is normal


Right Hydronephrotic Kidney

with Hydroureter


IVU Both kidneys.

- The Rt pelvis shows mild dilatation and the Lt is severe.

- The calyces revealed signs of hydronephrosis (ballooning).

Rt ureter: - revealed stricture at the lower 1/3.

Lt ureter:- revealed double strictures

(at the pelvi-ureteric junction and at the lower 1/3 with Hydroureter).

UB: Normal


Bilateral Hydronephrotic Kidney

With stricture ureters


IVU The Rt kidney and ureter have normal appearance.

The left side.

- No visualization of dye.

- A radio-opaque shadow is seen in the course

of the Lt lumbar ureter.

Diagnosis

Non visualized Lt Kidney

most probably due to obstruction by a stone

in the Lt lumbar ureter

How to readHow to read IVU The Rt kidney and ureter show signs of hydronephrosis

and hydroureter, with stricture at the pelvic ureter.

The left side.


- A radio-opaque shadow is seen in the course of the Lt pelvic ureter.

Diagnosis

Rt Hydronephrosis and hydroureter

With stricture pelvic ureter


most probably due to obstruction by a stone

in the Lt pelvic ureter

How to readHow to readIVU The Lt kidney and ureter show signs of

hydronephrosis and hydroureter, with stricture at the pelvic ureter.

The right side.

- normal secretion.

The UB:

- normal.

Diagnosis

Lt Hydronephrosis and hydroureter

With stricture pelvic ureter

Normal Rt kidney



The right side.


- Multiple radio-opaque shadows are seen in the course

of the right pelvis and ureter .

Diagnosis

Non visualized Rt Kidney

most probably due to obstruction by stones

in the Rt ureter


IVU The Rt kidney shows double pelvis.

The Rt kidney and ureter show signs of hydronephrosis and hydroureter, with stricture at the middle 1/3 ureter.

The left side.


UB: normal

Diagnosis

Rt Hydronephrosis and hydroureter

Double pelvis with stricture middle 1/3 ureter




The right side.

- Normal secretory function.

- Double pelvis and 2 ureters united at the lower end of the upper 1/3.

Diagnosis

Normal Lt Kidney

Bifid Rt ureter


IVU in an infant The Rt kidney and ureter have normal appearance.

The Left side.

- Mild hydonephrosis.

- The left kidney is descended downward and rotated outward.

Dropped Lilly sign

The UB

- Free .


Neuroblastoma

Wilms tumor, Kidney

Wilms tumor

•The photograph shows the cut surface of a kidney with Wilms tumor.

•The tumor has massively replaced much of the kidney. Only a small remnant of grosslyrecognizable kidney is seen

(arrow). •On cut section, the tumor is light tan, fleshy and shows

irregular areas of hemorrhage.


IVU The 2 kidneys lie at a lower level and closer to the middle

line.

The lower poles are nearer to each others than the upper.

Their pelves lie anteriorly.

Some calyces are directed medially and others laterally.

The ureters converge slightly over the isthmus and then diverge gradually in a characteristic

Flower vase

The U B - Free .


Horse-shoe kidney


IVU The Rt kidney lie at a lower level.

The Rt pelvis lies anteriorly.

The calyces are directed medially.

A fistulus track connecting the lower calyx to outside

The left kidney non visualized

The UB -- normal


Horse-shoe kidney with Rt urinary fistula

Non visualized lt kidney (nephrectomy)


IVU The pelvicalyceal system show elongation,

attenuation and wide separation

Smooth Spider leg appearance The U B Free


Polycystic kidney


MRU The pelvicalyceal system show elongation,

attenuation and wide separation

Smooth Spider leg appearance

Multiple cysts ocuppying the whole kidney

and not communicating with each other.

The U B Free


Polycystic kidney


IVU The 2 kidneys and ureters show mild hydroureter and

hydronephrosis

The lower end of the left ureter is shifted laterally

The UB

A large irregular filling defect occupying

the left side of the UB with moth-eaten appearance


Cancer UB

ADENOCARCINOMA

TCC


Cystogram The UB

A large irregular filling defect occupying

the right side of the UB with moth-eaten appearance


Cancer UB


Cancer Bladder


Cystogram The UB

A diverticulum is senn outpouching between

the junction of the UB and Rt ureter


UB diverticulum

or Uretrocele


Urethrogram The male urethra

A stricture is seen between the prostatic urethra and membranous part


Urethral stricture


Plain X-ray abdomen . The patient is more or less well prepared. A catheter is introduced in the Rt ureter. It revealed

* A large radio-opaque shadow

in the Lt hypochondrium.

Diagnosis

Radio-opaque Shadow


most probably

LT Renal Stone


Right Renal Cell Carcinoma


Left Renal Cell Carcinoma

Renal cell adenocarcinoma, Kidney

Renal Cell Adenocarcinoma

•The kidney has been bivalved to show the cut surface of a large spherical tumor involving the upperpole (arrowheads).

•The tumor has sharply defined borders and show a variegated cut surface. Areas of grossly viable

tumor (v) are seen with areas of necrosis (n) and hemorrhage (h).


Ascending Cystography Fracture pelvis

Intact UB

Types of Rupture Bladder

(1) Intraperitoneal rupture bladder

(2) Extraperitoneal rupture bladder

Cystogram of Extraperitoneal bladder rupture.

Note the fractured pelvis and contrast extravasation into the space of Retzius

Cystogram of Intraperitoneal bladder rupture.

The contrast enters the intraperitoneal cavity

and outlines loops of bowel(Fluffy Cotton Appearance)

Adult polycystic kidney disease, Kidney

Adult Polycystic Kidney Disease

•This is the external surface of one kidney. •Both the right and left kidneys of this patient had the same

appearance. •Note the numerous intact, unruptured cysts on the surface.

Adult polycystic kidney disease, Kidney

Adult Polycystic Kidney Disease

•This is a cut section of an adult polycystic kidney •Cysts of varying sizes are present throughout the renal parenchyma.

Neuroblastoma, Kidney

Neuroblastoma encasing kidney

• The tissue mass is an adrenal neuroblastoma. The tumor has completely encased the kidney (K(.

• The tumor has entered and expanded the renal sinus (arrowhead(.

Adenocarcinoma, Prostate

Prostate Adenocarcinoma

• The blue arrows point to the margins of two nodules of tan adenocarcinoma. The other lobe shows hyperplasia.

• The red arrow points to the urethra. • The black staining at the periphery is ink applied to the

specimen to identify the margins of resection.

Cavernas T.B. KIDNEY

X-RAYSX-RAYS

By

Prof Dr IBRAHIM DAWOUD

Prof of Surgery

Mansoura University

How to read

X-RAY with dye

Vascular Plain X-Ray. Venography (Phlebography) Arteriography. DVI ( Digital Venous Image). DSA ( Digital Subtraction Angiography). CT scan. Duplex US. MRA.


Normal lower limb Phlebography

Revealed Visualization of the Deep System (4-6 veins)

(Vena Comitants of the 3 arteries of the leg). Presence of valves along the whole length of the veins.

With No obstruction. No attenuation of the dye No filling defect. No varicosity of the Deep System No Visualization of the Superficial System


lower limb Phlebography

Revealed Visualization of the Deep System (4-6 veins)

With No obstruction. No attenuation of the dye No filling defect. No varicosity of the Deep System Visualization of the Superficial System, with varicosity

and Incompetent SF Valve

Primary Varicose Vein LSS of the LL

With Incompetent SFV



Revealed Visualization of some the Deep System (2 veins)

With Attenuation of the dye Varicosity of the Deep System Visualization of the Superficial System, with varicosity

and Incompetent SF Valve And With Incompetent Perforators

Secondary Varicose Veins

With Incompetent Leg Perforators



Revealed Visualization of some the Deep System (2 veins)

With Attenuation of the dye Varicosity of the Deep System Visualization of the Superficial System, with varicosity


AND With Incompetent Perforators


With Incompetent Leg Perforators



Revealed Failure of Visualization of some the Deep System apart

from the upper part of Femoral Vein.

With Attenuation of the dye Varicosity of the Femoral vein with no valves. Visualization of the Superficial System, with varicosity



With Deep Venous Obstruction

QUESTIONSQUESTIONS

Anatomy of the Venous System of the lower limb. Etiology of Varicose Veins. Pathology of V.V. D.D. between Varicose ulcer and Postphlebitic ulcer. Clinical picture. Other investigations. Treatment.

1ry VV 2ry VV

Varicose ulcer Postphlebitic ulcer

History of V.V. with no DVT History of DVT

Painless Painful

Related to a feeding V.V. Related to ankle perforator

Small Large

Oval or rounded Irregular

Superficial Deep

Rapid healing power Resistant to healing

----------------------Perforators

Treatment

1ry V.V.1- Conservative 4- Triple ligation

2- Injection sclerotherapy 5- Trendlenberg op

3- Localized stripping 6- Trendlenberg & Stripping

2ry V.V.

1- 2ry to DVT A- Actual DVT treatment of DVT

B- Postphlebitic leg

D.V. Insufficiency D.V. Obstruction

C- Perforators without ulcer

D- Perforators with ulcer

2- 2ry to other causes


Femoral Angiography

Revealed Total occlusion of the Superficial Femoral Artery just

at its origin. Hypertrophied Deep Femoral Artery. Distal refilling of the middle third of the Deep Femoral

artery through collaterals. Total occlusion of the supragenicular portion of the

Popliteal artery with no distal run off. No distal run off or opacification of the leg arteries. Fracture of the lower end femur with nail fixation.

Acute Ischemia ( post traumatic)

Etiology of Acute ischemia.

1- Arterial injury 2- Arterial embolism 3- Acute thrombus Clinical picture.

1- PP 2- Pain 3- Pallor 4- Prog ↓ of temp 5- paralysis Investigations. Treatment.

Arterial Injury Arterial Embolism Acute Thrombus

A r t e r I a l I n j u r y

------------Lt Common Iliac

----------Lt External Iliac

-----Lt Common Femoral

A

------------ LT Common Iliac

--------- LT External Iliac

-- LT Common Femoral

A

LT Common Iliac--------------------

LT External Iliac-----------------------

LT Common Femoral-----------------

A

A

B

----------------Rt Superficial Femoral-----------------

B


B

B


B


B

-------------Obstructed Rt SFR -----------------

C

-------------Obstructed Rt SFR -----------------

C

C

-----------------Obstructed Rt SFR --------------------

C

C

C

Obstructed Rt SFR-------

---------SFA

D

---------SFA

SFA

D

D

SFASFA

D

E

Refilling -

Refilling

E

Refilling

E

RefillingE

RefillingE


Bilateral lower limb Angiography

Right L.L

Total occlusion of the Rt Common iliac artery, External Iliac artery, and Common Femoral Artery.

The Rt Superficial Femoral Artery is seen refilled through collaterals.

With obstruction of its lower part at the Adductor canal.

Distal refilling of the Rt Popliteal artery through collaterals


Left L.L

Normal Left Common Iliac, Left External Iliac, and Left Common Femoral Arteries.

Total Occlusion of the Left SFA, at its origin from the Lt CFA.

Refilling of the SFA at the mid thigh from collaterals.

Opacified left Popliteal artery.

A

A

A

A

B

B

C

C

C

D

D

D

D

E

E

F

F

G

G



Right L.L Normal opacified Rt Common iliac artery, External

Iliac artery, and Common Femoral Artery. Total Occlusion of the Left SFA, at its origin from

the Lt CFA. The Rt Superficial Femoral Artery is seen refilled

through collaterals. Total occlusion of the Rt Popliteal artery. Distal refilling of the inferogenicular portion of Rt

Popliteal artery through collaterals. Opacified Rt Anterior and posterior tibial arteries

down to the Rt ankle joint.


Left L.L

Normal opacified Left Common Iliac artery, Left External Iliac, and Left Common Femoral Arteries, Left SFA, left Popliteal artery, and left leg arteries down to the left ankle joint

A

A

B

B


Digital Subtraction Imaging Angiography

Left L.L

Marked irregularity of the wall of the Left Common Iliac, Superficial Femoral, and Popliteal arteries.

With multiple short stenotic areas. Suggestive of marked atherosclerotic changes



Atherosclerotic changes of the Left Common Femoral artery with multiple small marginal defects.

Total occlusion of the Rt Common Femoral Artery with multiple collaterals.

Distal refilling of the Rt superficial femoral and Rt Deep Femoral arteries.



Normal course and caliber of the opacified Iliac Arteries.

Normal course of both Common Femoral arteries

and left SFA. Total occlusion of the Rt SFA, high up at its origin

With short markedly stenotic segment above the obstruction.

Etiology of Chronic ischemia. Clinical picture. 1- Pain 2- Color changes

3- Paraesthesia 4- Trophic changes

Investigations. Treatment. 1- Conservative treatment

2- Arterial reconstruction

A- Thromb-end arterectomy

B- Bypass Grafting

3- Balloon Angioplasty.

4- Catheter fibrinolysis

5- Sympathectomy

6- Amputation and rehabilitation


Flush Aortogram

Fusiform Aneurysm of the lower Abdominal Aorta and the Iliac Arteries.

Atherosclerotic changes of the Left Common Iliac Artery with multiple marginal defects ( Atheromas).

Short stenotic segment at the junction of Rt Common and External Iliac arteries

Non opacified Internal Iliac Arteries on both sides

Aortic aneurysm

Aortic aneurysm


Popliteal and leg Angiography

A small pseudoaneurysm is seen related to the upper part of the left anterior tibial artery.

Likely post-traumatic

Etiology Congenial Traumatic Pathological

Pathology Types ( Fusiform - Saccular - Dissecting)

Sequelae ( Cure - Rupture - Suppuration)

Clinical picture Treatment 1- Endo-aneurysmorrhaphy

2- Arterial reconstruction

3- Excision and ligation

4- Simple ligation

5- Introduction of foreign material

Superior Vena Cava Obstruction

Education

(2) urology & vascular