泌尿系統(tǒng)影像學檢查

1、泌尿系統(tǒng)影像學檢查浙江大學醫(yī)學院附屬第一醫(yī)院放射科第一學時：提綱 泌尿系影像的檢查方法及比較、正常影像表現(xiàn) 疾病的影像基本征象 常見病變的影像診斷腎臟：發(fā)育變異與異常；感染性病變；腫瘤性病變；外傷性病變 膀胱：腫瘤性病變腎上腺：腫瘤性病變前列腺病變腎上腺病變影像觀察與分析 實質(zhì)部分：雙腎實質(zhì)、輸尿管壁、膀胱壁 數(shù)目、位置、形態(tài)、大小、密度改變及強化特點等 空腔部分：腎盞、腎盂、輸尿管腔及膀胱腔 位置、形態(tài)、擴張與狹窄、充盈缺損等周圍結(jié)構(gòu)有無異常一、檢查技術(shù)超聲 Ultraso un d-a natomy普通X線檢查尿路平片 KUB-Plain film of abdomen-Cheap and

2、 easy to obtain 尿路造影 Intravenous urography and pyelography (IVU and IVP) -an atomy & fun cti onCT Computed tomography-anatomy & function動脈造影 ArteriographyMRI Magnetic resonance imaging (MRI)-anatomy & function放射性核素檢查 Radionuclide examination-function PET/CT-Fluorodeoxyglucose positron em

3、ission tomography (FDG-PET)/CT-anatomy+function, under investigation放射診斷學檢查方法X線檢查：腹部平片、排泄性尿路造影、逆行尿路造影、腹主動脈造影CT檢查：平掃及動態(tài)增強掃描、CTU、CTAMRI檢查：平掃及動態(tài)增強掃描、MRU、MRADSA 動態(tài)增強掃描包括腎皮質(zhì)強化期、腎髓質(zhì)強化期、腎盂期各檢查方法優(yōu)缺點對比檢查方法X線檢查尿路平片尿路造影排泄性尿路造影(IVP) 逆行性尿路造影 血管造影KUB排泄性尿路造影 Intravenous Urographyand pyelography (IVP) 檢查前準備：碘過敏試驗禁食

4、禁水清潔腸道造影劑泛影葡胺(Urografin)碘 必樂( Iopamidol)磺普羅胺(lopromide排泄性尿路造影( IVP)常規(guī)法 2040ml 造影劑靜注后，攝 5'、 10'、 15'雙側(cè)腎區(qū)片，去 除腹部壓迫攝 30'全尿路片。大劑量法100ml造影劑+等量5%葡萄糖5-10分鐘靜脈內(nèi)滴完；攝5'、 10'、 15'、 30'片IVP examination逆行性尿路造影技術(shù)Retrograde urography 膀胱鏡下把導管插入輸尿管 每側(cè)注入造影劑5 - 10ml后攝片適用于靜脈尿路造影顯影不佳者DSA血管

5、造影腹主動脈造影：導管送至T12及L1水平快速注射造影劑后采集造影圖 像選擇性腎動脈造影：導管送到腎動脈內(nèi)快速注射造影后采集造影圖像Computed Tomography, CT 快速連續(xù)無間隔的容積掃描 高質(zhì)量、實時的多平面重組圖像 高質(zhì)量的三維重建圖像和血管造影圖像,可在某些部位獲得仿真內(nèi)窺 鏡圖像，高檔螺旋CT機具有CT透視功能，可準確指導介入手術(shù)。Computed Tomography, CT 根據(jù)組織形態(tài)、定位與密度的差異（所括增強掃描）判斷正常與異常。 病變診斷與鑒別診斷 增強掃描CT after injection of contrast mediumCorticomedulla

6、ry phase （皮髓質(zhì)期）CT scan with 35-40s delay timeArtery and cortex enhancedNephrographic phase （實質(zhì)期）CT scan with 90s delay timeRenal parenchyma homogeneously enhancedCT urography & angiographyCTU and/or CTA 指征 Indications for CTU & CTAInvestigation of renal calculi （腎結(jié)石）Investigation of haematur

7、ia （血尿）Characterization of a renal mass （腎腫塊）Staging and follow-up of renal carcinoma （腎癌）To delineate renal vascular anatomy（eg. suspected renal arterystenosis or prior to live related kidney donation）（腎動脈狹窄 &移植供體評估）To diagnose or exclude trauma （外傷）How to do CTU?Non-contrast CT KUB: Thin secti

8、ons and reformattedTo identify any calculi of KUB and potential lesions of abdomen CTU is obtained 10 min after injection of contrast mediumUrographic phase （尿路造影期）10-15 min delayDense contrast in pelvicaliceal system （集合系統(tǒng)） , ureter （ 尿管） ,and bladder （膀胱）Reformats neededMRIValues similar to CT ,mo

9、re helpful in rare casesAdvantageNo radiation ,multiple planes,multiple parameter imaging Sensitive to hydronephrosisT1WI and T2WINearly no or low allergic complication due to constrast DisadvantageInsensitive to calcification and thus stones-Con trast enhan ceme nt n eeded and phases similar to CT

10、and more variable-Sen sitive to moti on第二學時二、泌尿系病變的影像基本征象Kidney 位置變化，輪廓：壓跡或膨隆 局部壓跡 -persistent fetal lobulations or scars 局部膨隆 -mass or cyst ,variant-splenic hump 大小和 實 質(zhì)厚度 ：Renal length about 10 to 16 cm and parenchymal width 2 to 2.5cm腎盞 Calices:Evenly distributed and reasonably symmetrical. 杯口狀凹陷

11、 Cupped in normal shape 棒狀擴張 Clubbedwhen dilated due to destruction of the papilla（ uncommon） and obstruction （often） 壓跡 Compressed and pushed by mass不規(guī)貝y形破壞Irregular after invasion by tumor 腎盂和輸尿管 Renal pelvis and uretersPart of the length seen in IVUDilatation due to obstruction or congenital vari

12、antFilling defect: tumor, calculi ,clot et. 腎蒂：由前向后排列腎靜脈、腎動脈、腎盂 ?膀胱 Bladder ：Smooth影像觀察與分析 實質(zhì)部分：雙腎實質(zhì)、輸尿管壁、膀胱壁 數(shù)目、位置、形態(tài)、大小、密度改變及強化特點等 空腔部分：腎盞、腎盂、輸尿管腔及膀胱腔 位置、形態(tài)、擴張與狹窄、充盈缺損等 周圍結(jié)構(gòu)有無異?；静∽?位置、輪廓及數(shù)目異常 腫塊 密度異常 管腔異常 血管異常 周圍結(jié)構(gòu)異常三、疾病診斷Urinary Tract Disorders 先天性發(fā)育異常 Congenital abnormalities 尿路梗阻性病變 Obstructiv

13、e lesions 腫塊 Masses: cysts and tumors 感染性病變 Infections 血管性病變 Vascular lesions 外傷性病變 Traumatic lesionsCongenital abnormalitiesUrinary Tract重復畸形 Bifid collecting systemUreters or/and pelvis are bifidUreters may join at any levels and open jointly or separately into bladder輸尿管囊腫 Ureterocele-Dilated low

14、er ureter prolapse into bladder.Congenital pelviureteric junction obstructionKidneyEctopic kidney 異位腎Ascent of kidney halts during fetal development Kidneys in lower position with rotation Or/and on the same side and fused Horseshoe kidney 馬蹄腎Due to failure of separation during development Commonly

15、fused in the lower poles多囊性腎病多囊腎Autosomal dominant polycystic kidney disease Usually presents at age of 35 to 55 y Multiple cysts on US, CT,and MRI Liver and pancreas may involved SI and density of cysts similar to water No enhancement第三學時Urinary Tract Disorders 先天性發(fā)育異常 Congenital abnormalities 尿路梗阻

16、性病變 Obstructive lesions 腫塊 Masses: cysts and tumors 感染性病變 Infections 血管性病變 Vascular lesions 外傷性病變 Traumatic lesions Obstructive lesions Imaging modalitiesX-ray exam in ati on -irst choiceIVU needed-primary imaging modalityPlain CT and CTU may alternative to IVUCauses:Within the lumenIn the wall,Out

17、of the wall,Congenital尿路結(jié)石 Urinary calculi-Mostly uni formly calcified (may lam in ated in bladder) andidentified on plain X-ray examinations (about 95%)-CT superior to X-ray and IVU especially in low calcified calculi-Shape: round ,oval, Staghorn calculi-Calculi and dilatation of ureter and pelvcal

18、iceal system尿路結(jié)石 腎結(jié)石 位于腎盂、腎盞內(nèi)圓形、卵圓形、桑椹狀、珊瑚狀高密度影。 造影片上與腎盂、腎盞內(nèi)造影劑重疊。腎盂腎盞可擴張積水。 CT平片時結(jié)石顯示高密度影。尿路結(jié)石 輸尿管結(jié)石棗核狀、米粒狀。 停留于生理狹窄處，長軸與輸尿管平行 造影片上示結(jié)石上方輸尿管或腎盂、腎盞擴張。CT平掃時結(jié)石呈高密度影。尿路造影膀胱結(jié)石圓 形或卵圓形，分層或 同心圓狀。結(jié)石可 隨體位 改變位置CT平掃顯示膀胱內(nèi)致密影MRI檢查，結(jié)石在T1WI及T2WI上均呈低信號。 尿道結(jié)石多發(fā)生在后尿道平片呈高密度影Necrotic papillary -sloughed papillaBlood clo

19、tTransitional cell carcinomaInfective strictures-usually TB and schitosomiasisCongenital intrinsic pelviureteric junction(PUJ) obstruction-different from baggy pelvis (an insignificant abnormality)Extrinsic causes of obstructionTumorsCarcinoma of cervix ,ovary, rectosigmoid colonMetastasislymphomaRe

20、troperitoneal tumors 腹膜后腫瘤 Retroperitoneal fibrosis Idiopathic 特發(fā)性 Usually obstructed at L4-5 level CT check-up recommended ,and MRRenal parenchymal masses 孤立性腫塊 Solitary mass 惡性 Malignant tumor成人透明細胞癌 Clear cell tumor in adult 兒童腎母細胞瘤 Wilm 's tumor in young children 轉(zhuǎn)移癌 Met良性 Benign- 血管平滑肌脂肪瘤 a

21、ngiomyolipoma, 腎腺瘤 adenoma Non-tumor-renal abscess, hydatid cyst 多發(fā)性腫塊 Multiple massesMultiple simple cysts, Polycystic disease, Malignant lymphoma, Met, Inflammatory massesRenal cell carcinomaOverviewUsually spherical and lobulatedSpace occupying and bulging ,invasion and Met CTHypo-or similar on u

22、nenhanced CT, 10% 不同形態(tài)鈣化Greatly enhanced though lower than normal kidneyApt to invade renal vein and IVC Lymph node MetMRHypo-on T1WI and hyper-SI on T2WIEnhancement pattern similar to CT IVUCompression and invasion of calyxKUB腎形增大，呈分葉慶或局部隆凸 10%有不同形態(tài)鈣化IVU腎形增大，局部隆凸 腎盂腎盞：受壓 狹窄 分離 破壞Simple renal cystCo

23、mmon in adult, sphericalCTand MRISI and density similar to waterNo enhancementAngiomyolipomaFat contained in the tumor on CT and MR May bleed多囊腎 腎血管平滑肌脂肪瘤 腎臟較為常見的良性腫瘤 常見于中年女性 由平滑肌、血管和脂肪組織構(gòu)成，比例差異較大 10%合并有結(jié)節(jié)性硬化。腎血管平滑肌脂肪瘤 KUB、IVU腎輪廓改變 腎盂、腎盞受壓 20%鈣化尿道上皮腫瘤 Urothelial tumorOverviewMost are transitional ce

24、ll tumorMay multicentric or Met, pelvicaliceal and/or ureter even bladder Haematuria is commonImagingFilling defect in the lumenLobulated or frondedWall thickening and MetUrinary tract obstruction Contrast enhanced DX: Calculi, blood clot, air腎盂癌 移行細胞癌（8090%）KUB:常無異常發(fā)現(xiàn)IVU :腎盂內(nèi)充盈缺損CT:腎竇區(qū)腫塊、增強、排泄期增強掃描

25、顯示腎盂內(nèi)充盈缺損。 MRI:腎竇內(nèi)腫塊、增強第四學時Urinary Tract Disorders 先天性發(fā)育異常 Congenital abnormalities 尿路梗阻性病變 Obstructive lesions 腫塊 Masses: cysts and tumors 感染性病變 Infections 血管性病變 Vascular lesions 外傷性病變 Traumatic lesions 外壓性改變 Extrinsic compressionInfection急性腎盂腎炎 Acute pyelonephritisOverviewUsually retrograde bacter

26、ia infectionMore common in womanAssociated underlying urinary tract disease-congenital, stones, etc.Selected patients require imagingImagingSwelling of kidney, edema of perirenal tissue,related abscess Renal and perinephric abscessesThick walls ,solid and cystic componentsEdema around the abscessPyo

27、nephrosis （膿腎）TuberculosisOverviewBlood-borne spread of Mycobacterium tuberculosisCortex and bilateral first infected, then urinary tract and bladder of one sideImagingCalcification common,AutonephrectomyIrregular calyx wall and adjacent cavityStrictures of pelvicaliceal system and dilatationBladder

28、 involved-small volume ,wall thickeningMultiple stictures in urethra尿路結(jié)核腎結(jié)核KUB平片早期可無異常發(fā)現(xiàn)云絮、環(huán)狀鈣化影CT:平掃腎實質(zhì)內(nèi)低密度灶。增強可見造影劑進入低密度灶內(nèi)。 嚴重者顯示腎盞腎盂擴張，大片高密度鈣化影。MRI:病灶T1WI為低信號，T2WI為高信號；MRU可顯示擴張的腎 盞、腎盂。Vascular lesionsRenal artery stenosisRenal hypertensionCausesCongenital fibromuscular stenosisAtherosclerotic ste

29、nosisArteritisUrinary Tract Disorders先天性發(fā)育異常 Congenital abnormalities尿路梗阻性病變 Obstructive lesions腫塊 Masses: cysts and tumors感染性病變 Infections血管性病變 Vascular lesions外傷性病變 Traumatic lesions外壓性改變 Extrinsic compressionRenal traumaOverviewOne of the most frequently susceptible organsClinical symptoms includ

30、e loin pain and haematuriaImaging valuesWhether perfusion of injured kidney is presentOpposite kidneyExtent of damageOther intra-abdominal organsImaging findingsContusion and laceration of kidney-Swelling of parenchyma and capsular haematomaLarge subcapsular and estracapsular blood collectionExtravasation of contrastRetroperitoneal hematomaRuptured or thrombosed renal artery leading to renal infarctionBladderBaldder tumorBladder diverticulaBladder caicificationNeurogenic bladderTrauma to bladder and urethra