Pathology & Imaging

• Pathology & Imaging of the Urinary System

  RA504 & RA702
• Learning Outcomes


  • Understand variations to normal urinary anatomy
  • Understand common pathologies of the urinary system and discuss their impact in the wider context of medical imaging
  • Understand the different imaging procedures for the urinary systems and identify important structures
• Normal Anatomy of Urinary System

  • Two kidneys
  • Two Ureters
  • Bladder
  • Urethra
• Abdomen X-ray - includes

  • Diaphragms to symphysis pubis
  • Lateral borders of abdominal flank
• KUB - includes


  • From superior to the kidneys to the symphysis pubis
  • Lateral to the lateral borders of kidney
• Pathology


  • Ureteral Cancer - Rare
  • Renal Cancer
  • Bladder Cancer
  • Polycystic Kidney Disease
  • Calculi
  • Vesicoureteral reflux
  • Hydronephrosis
• Ureteral Cancer


  Usually transitional cell carcinoma. Same cell types as bladder therefore patients with bladder Ca may be diagnosed with both (and vice versa). Increased risk with age.
• Ureteral Cancer Symptoms


  • Haematuria
  • Urination problems – nocturia, increased frequency etc
  • Pain during urination or sex
  • Weight loss and fatigue
• Ureteral Cancer Actions


  Thickening of ureteral wall leading to stricture and blockage
• Ureteral Cancer Tests


  • Urinalysis and urine cytology
  • CT
  • MRI
  • Ureteroscopy – direct visualisation
  • Biopsy (usually during ureteroscopy)
• Ureteral Cancer Treatment


  • Electrosurgery/laser – may destroy cells in less advanced disease
  • Surgical removal of part of ureter (less advanced cases) and kidney +/- bladder (advanced disease)
  • Chemotherapy
  • Radiotherapy
  • Nephrostomy, stents – relieve pressure on kidney from obstruction, improving function
• Renal Cancer


  Ninth most common cancer, 1.5x more common in men. Adenocarcinoma of the renal cortex, most often appearing in the upper pole of the kidney. Renal cell carcinoma (RCC) or clear cell renal cell carcinoma (ccRCC).
• Renal Cancer Symptoms


  • Haematuria
  • Lower back pain
  • Lump in the lower back or side of the waist
  • Unexplained weight loss, night sweats, fever, fatigue
• Renal Cancer Actions


  Arises from the epithelial cells of the nephron
• Renal Cancer Tests


  • Blood tests
  • Urinalysis and urine cytology
  • CT
  • MRI
  • US
  • Renal arteriography and venography
  • Biopsy
• Renal Cancer Treatment


  • Surgery (partial or radical nephrectomy)
  • Cryotherapy (small, early-stage tumours)
  • Microwave and radiofrequency ablation (small, early-stage tumours)
  • Active surveillance (if tumour is less than 4cm)
• Bladder Cancer


  Transitional cell carcinoma (most common), squamous cell carcinoma (SCC), adenocarcinoma (rare) and sarcoma (rare).
• Bladder Cancer Symptoms


  • Haematuria
  • Frequent urination
  • Painful urination
  • Back pain
  • Recurrent UTIs
• Bladder Cancer Actions


  Develops from the lining of the bladder and grows through the deeper layers of the bladder wall.
• Bladder Cancer Tests


  • Blood tests
  • Urinalysis and urine cytology
  • Cystoscopy
  • CT
  • MRI
  • US
  • PET
• Bladder Cancer Treatment


  • Transurethral resection of bladder tumour (TURBT)
  • Chemotherapy
  • Cystectomy
  • Radiothrapy
• Polycystic Kidney Disease


  Congenital condition causing multiple cysts within the kidney
• Polycystic Kidney Disease Symptoms

  • Lower back pain
  • Headaches
  • Haematuria
  • High blood pressure
  • Kidney Failure
  • UTIs
• Polycystic Kidney Disease Actions

  Clusters of cysts develop primarily within the kidneys, causing them to enlarge and lose function over time
• Polycystic Kidney Disease Tests

  • Urinalysis
  • US
  • CT
  • MRI
  • Genetic testing
• Polycystic Kidney Disease Treatment

  • Medication (Tolvaptan to slow progression of cyst development and protect kidneys' function)
  • Healthy lifestyle
  • Painkillers
  • Antibiotics (to treat UTIs)
  • Dialysis and/or kidney transplant (for more severe cases)
• Calculi


  Stones formed within the urinary system.
• Calculi Symptoms


  • Intermittent suprapubic or lower back pain
  • Nausea/Vomiting
  • Haematuria
  • UTIs symptoms (fever, cloudy urine)
• Calculi Actions


  May remain within the renal parenchyma or renal collecting system or be passed into the ureter and bladder. During passage, they may irritate the ureter and may become lodged, obstructing urine flow.
• Calculi Tests


  • Urinalysis
  • CT
  • US
• Calculi Treatment


  • Conservative
  • Analgesic
  • Calculus removal (shock wave lithotripsy, retrograde ureteroscopy with laser lithotripsy, retrograde ureteroscopy guided direct removal)
  • Calculus dissolution (by prolonged alkalinization of the urine with potassium citrate) - rare
• Vesicoureteral reflux


  Retrograde urine flow, often genetic. Affects infants and children.
• Vesicoureteral reflux Symptoms


  • Strong, persistent urge to urinate
  • Burning sensation when urinating
  • Need to pass small amount of urine frequently
  • Cloudy urine
  • Side or abdomen pain
• Vesicoureteral reflux Actions


  It increases the risk of UTIs which can then lead to kidney damage
• Vesicoureteral reflux Tests


  • Urinalysis
  • US
  • Fluoroscopy – MCUG and FUDS
• Vesicoureteral reflux Treatment


  • Conservative – encouraging the child to drink plenty of fluids and use the restroom regularly, low doses of antibiotics
  • Surgery – to repair the defect in the valve between the bladder and each affected ureter
• Hydronephrosis


  Obstructed kidney, dilated collecting system
• Hydronephrosis Symptoms


  • Incomplete voiding
  • Pain when urinating
  • Nausea, vomiting
  • Cloudy urine
  • Side or abdomen pain
• Hydronephrosis Tests


  • Urinalysis
  • US
  • Fluoroscopy
• Hydronephrosis Treatment


  • Likely to resolve if cause is treated – ie blockage removed, antibiotics effective
  • Surgery – nephrostomy and/or stent to allow relive pressure on kidney
  • Monitor kidney function – failure = dialysis/transplant