Holdorf Outline Urinary Tract Part I of II Normal anatomy Anatomical Terminology Renal Congenital abnormalities Ectopic Kidney Horseshoe Kidney Cross fused Renalo Ectopia Fused pelvic kidney ID: 908355
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Slide1
Lecture 9 The Kidney and Urinary Tract Part 1
Holdorf
Slide2Outline
Urinary Tract
Part I of II
Normal anatomy
Anatomical Terminology
Renal Congenital abnormalities
Ectopic Kidney
Horseshoe Kidney
Cross fused Renalo Ectopia
Fused pelvic kidney
Dromedary Hump
Junctional Parenchymal defect
Duplex Kidney
Column of Bertin
Renal Agenesis
Extrarenal Pelvis
Posterior Urethral Valves
Renal cysts
Atypical renal cysts
Autosomal Dominant Polycystic kidney disease
Autosmal recessive polycystic kidney disease
Multicystic Dysplastic kidney
Slide3Normal Anatomy
The paired kidneys and ureters are retroperitoneal, lying against the deep muscles of the back. The right is slightly inferior in location as compared to the left, mostly due to the liver’s location on the right.
In relation to the right kidney, the:
Adrenal gland is superomedial
Liver is superolateral
Right colic flexure is inferior
2
nd
portion of the duodenum is medial
Slide4The right kidney
Slide5Gerota’s Fascia
Slide6Slide7The large intestine
Slide8In relation to the left kidney, the:Adrenal gland and spleen are superior
Pancreatic tail is anterior to the upper pole
Left colic flexure is inferior
The diaphragm, psoas muscle, and quadratus lumborum muscle are on the posterior aspect of the kidneys
Slide9Diaphragm, psoas muscle
Slide10Psoas
Slide11At the hilum of the kidney, the:Vein exits anteriorlyArtery enters between vein and ureter
Ureter exits posteriorly
Slide12The renal hilum (transverse)
Slide13Transverse kidney w/vein
Slide14EchogenicityRenal cortex is isoechoic or hypoechoicMedullary pyramids are anechoic
Reanl sinus is hyperechoic
Slide15Echogenicity of the kidney
Slide16Anatomical TerminologyRenal cortex
-outer reanl parenchyma from renal sinus to renal capsule (normal= > 1 cm
Renal medulla
- inner portion of kidney from base of pyramids to center of kidney.
Renal sinus
-inner hyperechoic portion of kidney which contains fat, calyces, renal pelvis, connective tissue, renal vessels, and lymphatics
Slide17Renal cortex, medulla
Slide18Medullary pyramids- anechoic, equally spaced triangles of collecting tubules between cortex and renal sinus. Commonly seen in neonatal and pediatric kidneys.
Renal pelvis
- funnel shaped transition from the major calyces to the ureter.
Renal hilum
– medial opening from entry / exit of artery, vein, and ureter.
Major calyces
- 3 extensions for the renal pelvis
Minor calyces
- extensions of the major calyces that collects urine from the medullary pyramids.
Slide19Medullary pyramids, Renal pelvis, renal hilum, major and minor calyces.
Slide20Renal papilla – apex of medullary pyramids.
Gerota’s fascia
– fibrous sheath enclosing kidney and adrenal glands. This is also referred to as the perirenal space.
Nephron
- functional unit of kidney consisting of the renal corpuscle, proximal convoluted tubule, descending and ascending limbs of Henle’s loop, distal convoluted tubule, and collecting tubules.
Renal corpuscle
(Malpighian body) – consist of glomerulus and glomerular capsule (Bowman’s capsule).
Slide21Renal Papilla, Gerota’s fascia, Nephron, Renal Corpuscle.
Slide22RENAL VASCULATUREThe kidneys are supplied with arterial blood via the
main renal artery
which branches off the aorta.
At the hilum, the main renal artery divides into 5
segmental arteries
.
At the level of the medullary pyramids, the segmental arteries divide into the
interlobar
arteries
which travel perpendicular to the renal capsule.
Slide23At the base of the medullary pyramids, the arcuate arteries branch from the interlobar arteries in the manner that is parallel to the renal capsule. Typically the arcuate arteries are difficult to obtain an ideal spectral waveform as they typically travel perpendicular to the Doppler sound beam.
The
interlobular arteries
are the smallest renal arteries that branch off the arcuate arteries running perpendicular to the renal capsule.
Slide24Main renalSegmental
Interlobar
Arcuate
Interlobular
Slide25Renal blood flow
Slide26Renal congenital abnormalities
Embryologically, the kidneys originate in the pelvis and ascend into the upper abdomen so that the upper pole of each kidney is more medial than the lower pole (an inverted “V”).
Congenial anomalies of he genitourinary tract are more common than any other organ system.
Complications (Obstruction, stasis) associated with congenital abnormalities include:
Impaired renal function
Infection
Calculus formation
Slide27Ectopic Kidney
The word ectopic means displaced or n a location away from the normal position.
An ectopic kidney results from failure of the kidneys to ASCEND into the abdomen.
Often, an ectopic kidney is also referred to as a pelvic kidney.
With ectopic kidneys, there is an increased incidence of UPJ (Ureter-Pelvic Junction) obstruction, ureteral reflux, and multicystic renal dysplasia.
Slide28Ectopic kidney
Slide29Slide30Horseshoe kidney
Most common fusion anomaly in which the lower poles typically connect across the midline anterior to the aorta.
The larger U-shaped kidney lies lower in the abdomen because ascent is prevented by the inferior mesenteric artery.
Sonographically, the isthmus or connection anterior to the aorta is frequently mistaken for lymphadenopathy. The ureter is typically located anterior to the isthmus.
Slide31Horseshoe kidney
Slide32Slide33Crossed fused renal ectopiaThe developing kidneys fuse in the pelvis and one kidney ascends to its normal position, carrying the other one with it across the midline.
Two kidneys are visualized on one side of the abdomen with absence of a contralateral kidney.
Ureters connect on both sides of the bladder thus one ureter crosses the midline.
Slide34Cross fused renal ectopia
Slide35Examples of Cross-Renal ectopia (only D is fused)A. Bilaterally crossedB. S-Shaped
C. L-Shaped
D. Disc kidney
Slide36Fused pelvic kidneyKidneys may fuse to form a round mass in the pelvis know as a discord or pancake kidney.
Slide37Fused pelvic kidney/Pancake kidney
Slide38Dromedary HumpA common variant of cortical thickening on the lateral aspect of the left kidney.
Make certain the “hump” has the same echogenicity as the rest of the renal cortex.
Slide39Dromedary Hump
Slide40Junctional parenchymal defectAKA Fetal lobulation
Sonographically seen as a triangular hyperechoic area on the anterior aspect of the upper pole of he right kidney.
This defect is also known as fetal lobulation, which is partial fusion of the embryonic kidney.
Slide41Junctional Parenchymal Defect
Slide42Duplex Kidney
This is a duplication of the collecting system which occurs in approximately 15% of the population. The duplication may be:
Complete – two ureters
Incomplete – one ureter
Sonographically, a duplex kidney is typically longer than normal and has a complete central cortical break within the hyperechoic sinus.
With complete double ureters, the ureter draining the upper pole typically inserts in an ectopic location on the bladder. A frequent complication of ectopic ureter is a ureterocele; a prolapse of the distal ureter into the bladder. This will result in hydroureter and hydronephrosis of the upper collecting system of the kidney.
Slide43Duplex kidney
Slide44Duplex kidney
Slide45Column of BertinHypertrophy of the renal cortical parenchyma located between two medullary pyramids. This may give the appearance of a mass effect although the echogenicity is equal to the peripheral cortical tissue.
Slide46Slide47Column of Bertin
Slide48Renal Agenesis
Bilateral renal agenesis is associated with oligohydramnios and pulmonary hypoplasia. It is incompatible with life.
Unilateral renal agenesis is frequently associated with:
Bicornuate uterus in females
Seminal vesicle agenesis in males.
Compensatory hypertrophy of the solitary kidney maintains normal renal function.
Slide49Extrarenal pelvisThe renal pelvis normally is located within the renal sinus.
An extrarenal pelvis lies outside the renal sinus sonographically appearing as a cystic collection medial to the renal hilum.
Slide50Extrarenal pelvis
Slide51Posterior Uretheral Valve
Posterior urethral valve is a common cause of urinary obstruction in the male neonatal patient.
This obstruction is due to a flap of mucosa that has a slit-like opening in the area of the prostatic urethra.
Sonographic findings include:
Large bladder
Hydroureter
Hydronephrosis
Urinoma (an encapsulated collection of extravasated urine- typically found in the area adjacent to the kidneys)
Keyhole sign (in the pelvis)
Slide52Slide53PUVs
Slide54Renal cysts
Simple renal cysts occur in 50% of people over the age of 50.
Sonographic criteria include:
Acoustic enhancement
Absence of internal echoes
Sharply defined thin wall
Round or oval shape
Most renal cysts are simple cortical cysts that originate from obstructed uriniferous tubules.
Slide55Types of renal cysts include:Pylogenic cysts- calyceal diverticula that sonographically appear as a simple cyst.
Parapelvic cysts- cortical cysts that bulge into the central sinus of the kidney.
Paripelvic cysts- lymphatic cysts in the central sinus.
Sonographically, the different types of renal cysts can not be distinguished. Ultrasound determines the location of the cyst.
Cortical or parenchymal cysts – renal cysts located in the periphery of the kidney.
Peripelvic cysts- renal cysts located in the center (RENAL SINUS) of the kidney.
A renal psuedoaneurysm may mimic a simple cyst and is typically associated with a history of renal biopsy or trauma.
Slide56Simple renal cyst
Slide57Parapelvic cyst Parapelvic cysts that could be mistaken for a dilatated pelvicalyceal system
Slide58Hemorrhagic renal cyst
Slide59Atypical renal cysts
Cysts with a single thin septation, minimal wall calcification, internal echoes caused by artifact or lobulated shapes may all be associated with simple benign cysts.
Characteristics that are atypical and may suggest a malignant cystic lesion include:
Multiple thick septation
Irregular walls
Solid component
These cysts should require histological confirmation (FNA) for definitive diagnosis.
Slide60Atypical renal cyst/complex renal cyst
Slide61Autosomal dominant:One of several ways that a trait or disorder can be passed down through families. A pattern of inheritance in which an affected individual has one copy of a mutant gene and one normal gene on a pair of Autosomal chromosomes.
Autosomal recessive:
A genetic condition that appears only in individuals who have received two copies of an Autosomal gene, one copy from each parent.
Slide62Autosomal Dominant (adult) polycystic kidney disease: APKD
Bilateral renal enlargement due to the development of numerous cysts of varying sizes.
Associated with cysts in the liver, pancreas, and spleen.
Multiple renal cysts may be identified as early as 20-30 years of age.
Destruction of the residual renal tissue in advanced stages leads to renal failure and hypertension.
Associated with arterial aneurysms especially cerebral arterial (Berry) aneurysms of the circle of Willis.
Slide63Adult polycystic kidney disease
Slide64Autosomal recessive (infantile) Polycystic kidney disease AKA IPCKD
Sonographic findings include:
Enlarged kidneys bilaterally
Hyperechoic parenchyma
Loss of cortical medullary distinction
Sonographic appearance is due to multiple small cysts throughout the kidney. These cysts result from cystic dilation of the collecting tubules secondary to hyperplasia of eth interstitial portions of the ducts.
Slide65Associated with Renal dysfunctionPulmonary hypoplasia
Periportal fibrosis
Portal hypertension
Autosomal recessive polycystic kidney disease may be detected in utero with oligohydramnios.
Slide66IPCKD
Slide67Multicystic Dysplastic Kidney
Most common cause of abdominal mass in NEWBORNS.
It is typically unilateral, although may be bilateral.
This non-functioning kidney consists of non-communicating cysts with the absence of renal parenchyma.
Usually the result of atresia of the uretro-pelvic junction during fetal development.
Associated renal anomalies include:
Contralateral UPJ obstruction.
Contralateral renal agenesis or hypoplasia
Horseshoe kidney
Slide68Multicystic Dysplastic Kidney
Slide69Neonate
Slide70Diagnostic Medical Sonography Program
Abdominal Sonography I
Urinary Tract Part I of II
Homework
Define a hypertrophied Column of Bertin and show an image of it.
What is a duplex collecting system and how an image of it.
What is multicystic dysplastic kidney and show several images of it.
Explain the scanning technique for imaging the kidneys with ultrasound. Include in your answer imaging the renal arteries.
Explain the anomalies related to the ascent of the kidney.
Provide an image of a horseshoe kidney.
Slide71Name three notable structures posterior to the kidneys.
What is the orientation of structures that enter and exit the renal hilum?
Trace the branches or the renal artery.
Name the fascia which encloses the kidneys, adrenal glands, and perinephric fat.
What renal structure is a concentrated area of collecting tubules which is sonographically seen in newborns and infants as hypoechoic equally space triangles.
Bilateral renal agenesis associated with Oligohydramnios and pulmonary hypoplasia is incompatible with life. What is associated with UNILATERAL renal agenesis?
Describe the development and sonographic appearance of crossed renal ectopia and crossed fused renal ectopia.
Describe the development and sonographic appearance of a horseshoe kidney.
A duplex kidney is discovered with dilation of the upper pole collecting system. In this situation, is there partial or complete ureter duplication?
What is the most common cause of urinary obstruction in male neonates?
What are the sonographic findings of urinary obstruction in male neonates?
Describe the appearance of a dromedary hump.
Describe the appearance of a junctional parenchymal defect.
Describe the appearance of eh column of Bertin.
Describe the appearance of an extra renal pelvis.