IMAGING OF THE WEEK

PROF.Dr.RAMASAMY’s UNIT

Dr.K.SENTHAMIZHSELVAN

32 year old female , presented with vague lower abdominal pain for

the past three months,

her BP was normal

p/a-no mass palpable

ULTRASOUND AND X RAY KUB REVEALED NOTHING CONCLUSIVE

HENCE CT SCAN WAS TAKEN

UPPER URINARY TRACT ANOMALIES

• ANOMALIES OF NUMBER

• ANOMALIES OF ASCENT

• ANOMALIES OF FORM AND FUSION• ANOMALIES OF ROTATION • ANOMALIES OF RENAL VASCULATURE • ANOMALIES OF COLLECTING SYSTEM

ANOMALIES OF NO.

AGENESIS

UNILATERAL

BILATERAL

SUPER NUMARY

ANOMALIES OF ASCENT

SIMPLE RENAL ECTOPIA

CEPHALAD RENAL ECTOPIA

THORACIC KIDNEY

ANOMALIES OF RENAL VASCULATURE

MULTIPLE/ACCESSORY

VESSELS

RENAL ARTERY ANEURYSM

RENAL AV FISTULA

ANOMALIES OF FORM AND FUSION

HORSE SHOE KIDNEY

CROSSED RENAL ECTOPIA

ANOMALIES OF ROTATION

VENTRAL DORSAL

VENTROMEDIAL LATERAL

Anomalies of collecting systemCALYX & INFUNDIBULUM; 1.CALYCEAL DIVERTICULUM 2.HYDROCALYX 3.MEGACALYX 4.UNIPAPILLARY KIDNEY 5.EXTRARENAL CALYX 6.PSEUDO TUMOR KIDNEY 7.INFUNDIBULOPELVIC DYSGENESISPELVIS 1.EXTRA RENAL PELVIS 2.BIFID PELVIS

CROSSED RENAL ECTOPIA• KIDNEY IS PRESENT ON OPPOSITE SIDE OF MIDLINE FROM ITS URETER• SLIGHT MALE PREPONDERANCE 3:2• INCIDENCE 1:1000• LEFT RENAL ECTOPIA IS COMMON EMBRYOLOGY:-URETERAL BUD ENTERS METANEPHRIC

BLASTEMA(LS SPINE);OVER THE NEXT 4 WKS.KIDNEY LIES AT L1,L3

THEORIES:-PATH OF LEAST RESISTANCE, URETERAL PHENOMENON, CLOACA&WOLFFIAN DUCT, TERATOGENICITY , GENETIC

• FUSION OCCURS AT TRUE PELVIS BEFORE ASCENT LATE STAGES OF ASCENT• ADVANCEMENT IS IMPEDED BY INFERIOR MESENTERIC A. AORTIC BIFURCATION BASE OF SMALL BOWEL MESENTERY• FINAL SHAPE OF FUSED KIDNEY DEPENDS ON TIME OF

FUSION ,EXTENT OF FUSION AND DEGREE OF ROTATION• POSITION OF RENAL PELVIS PROVIDES A CLUE TO THE

CHRONOLOGY OF DEFECT • ANTERIOR PELVIS-EARLY FUSION;;MEDIAL PELVIS-LATE

FUSION;;NO CHANGE AFTER FUSION

TYPES OF CROSSED ECTOPIA

Proximal kidney normal;distal kidney from opposite side crosses &fuses;both pelvis anterior ,ureters cross

Crossed kidney is inferior ;fusion occurs late;pelvis in opposite direction ;

Extensive union ;Ureters don’t cross

Tandem kidney;crossed kidney assumes transverse position;Both pelvis anterior ;

Doughnut kidney or pancake kidney;Pelvis anterior ;ureters uncrossed ;

Rarest ;both pelvis anterior

BLOOD SUPPLY NORMAL KIDNEY-BRANCHES OF MULTIPLE RENAL ARTERIES FROM AORTA

ECTOPIC KIDNEY –BRANCHES FROM COMMON ILIAC ARTERY,RARELY FROM AORTA

SOLITARY CROSSED KIDNEY-BRANCHES FROM AORTA or COMMON ILIAC ARTERY OF THE CORRESPONDING SIDE

ASSOCIATED ANOMALIES

CROSSED SOLITARY -HEMITRIGONE ECTOPIA POORLY DEVELOPED TRIGONE

CROSSED KIDNEY-ECTOPIC URETERAL ORIFICE,CYSTIC DYSPLASIA,PUJ.OBSTRUCTION,CARCINOMA

UNCROSSED KIDNEY-ECTOPIC URETEROCELE

VURIMPERFORATE ANUSVERTEBRAL ANOMALIES

CLINICAL FEATURES ASYMPTOMATICVAGUE LOWER ABD.PAINHAEMATURIA ,PYURIA ,UTIABDOMINAL MASSHYDRONEPHROSISRENAL CALICULI HYPERTENSION(DUE TO VASCULAR LESION IN

ANOMALOUS VESSELS)INCREASED RISK OF TRAUMA

INVESTIGATIONS&TREATMENT BASELINE INVESTIGATIONS TREATMENTIVU - SYMPTOMATIC ;

MCU - NEPHRECTOMY

USG ABDOMENCT ABDOMENRADIONUCLIDE STUDIESCYSTOSCOPYRENAL ANGIOMRI

HORSE SHOE KIDNEYTWO DISTINCT RENAL MASS,VERTICALLY ORIENTED,

ON EITHER SIDE OF MIDLINE, CONNECTED AT THEIR POLES

MOST COMMON RENAL FUSION ANOMALYINCIDENCE 1 :400MALE PREPONDERANCE 2:1EMBRYOLOGY---AT 4 WEEKS, SLIGHT ALTERATION OF

VASCULAR MORPHOLOGY LEADS TO FUSION ---POST.NEPHROGENIC CELLS MIGRATE

ABNORMALLY ,TO FORM AN ISTHMUS BETWEEN THE KIDNEYS

BOTH THE PELVIS ARE ANTERIOR INDICATING MALROTATION

INFERIOR MESENTERIC ARTERY PREVENTS ASCENT 95%-INFERIOR POLE FUSION 5%-SUPERIOR POLE FUSION ISTHMUS –PARENCHYMA _ FIBROUSBLOOD SUPPLY –BIL.MULTIPLE RENAL ARTERIES ISTHMUS-BR.OF RENAL A. /ABD.A/IMA/ILIAC A.

CLINICAL FEATURES 50% ASYMPTOMATIC LIFELONG 50% PRESENT AT LATER AGE VAGUE ABDOMINAL PAIN UTI,RENAL CALCULUS PUJ OBSTRUCTION HYDRONEPHROSISROVSING ‘S SIGNCARCINOMA-50%RCC,REST WILM’S ,RENAL PELVIC

TUMORS

ASSOCIATED ANOMALIES VSD ,NEURAL TUBE DEFECTSANO RECTAL MALFORMATIONGENITO URINARY ANOMALIES –HYPOSPADIAS, UNDESCENDED TESTIS,BICORNUATE UTERUS SEPTATE VAGINA,URETERAL DUPLICATION MULTICYSTIC DYSPLASIA,HIGH INSERTION OF URETERMETABOLIC –HYPERCALCIURIA ,HYPEROXALURIA, HYPOCITRATURIA SYNDROMES –TURNER, EDWARD &TOWNE BROCK

THANK YOU