a LANGE medical book Smith & Tanagho’s General Urology NINETEENTH EDITION Edited by Jack W McAninch, MD, FACS, FRCS(E)(Hon) Professor of Urology University of California School of Medicine Chief, Department of Urology San Francisco General Hospital San Francisco, California Tom F Lue, MD, FACS, ScD (Hon) Professor of Urology Department of Urology University of California School of Medicine San Francisco, California New York Chicago San Francisco Athens London Madrid Mexico City Milan New Delhi Singapore Sydney Toronto McAninch_FM_pi-xii.indd 11/02/20 11:21 AM Copyright © 2020 by McGraw-Hill Education All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-1-25-983434-9 MHID: 1-25-983434-4 The material in this eBook also appears in the print version of this 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damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise Contents Contributors vii Preface xi Anatomy of the Genitourinary Tract 10 Laparoscopic Surgery David B Bayne, MD, MPH; J Stuart Wolf, Jr., MD, FACS; Marshall L Stoller, MD; & Thomas Chi, MD Emil A Tanagho, MD; & Tom F Lue, MD, ScD (Hon), FACS 11 Robotic Surgery in Urology Emil A Tanagho, MD; Hiep T Nguyen, MD; & Michael DiSandro, MD 12 Urinary Obstruction & Stasis 31 13 Vesicoureteral Reflux 41 14 Bacterial Infections of the Genitourinary Tract 49 15 Specific Infections of the Genitourinary Tract 63 16 Sexually Transmitted Infections 243 Kristin Madden, PharmD; Amanda B Reed-Maldonado, MD, FACS; & John N Krieger, MD 107 Ryan Kohlbrenner, MD; & Roy L Gordon, MD Retrograde Instrumentation of the Urinary Tract 229 Emil A Tanagho, MD; & Christopher J Kane, MD, FACS Daniela Franz, MD; Scott Gerst, MD; & Hedvig Hricak, MD, PhD Vascular Interventional Radiology 201 Mary K Wang, MD; & Hillary L Copp, MD, MS Anobel Y Odisho, MD, MPH; Sima P Porten, MD, MPH; & Kirsten L Greene, MD, MS Radiology of the Urinary Tract 191 Thomas W Gaither, MD, MAS; & Hillary L Copp, MD, MS Maxwell V Meng, MD, MPH; & Emil A Tanagho, MD Urologic Laboratory Examination 177 Marshall L Stoller, MD; & Tom F Lue, MD, FACS, ScD (Hon) Benjamin N Breyer, MD, MAS, FACS Physical Examination of the Genitourinary Tract 167 Maxwell V Meng, MD, MPH Embryology of the Genitourinary System 17 Symptoms of Disorders of the Genitourinary Tract 149 17 Urinary Stone Disease 259 Marshall L Stoller, MD 117 18 Injuries to the Genitourinary Tract Marshall L Stoller, MD 291 Benjamin N Breyer, MD, MAS, FACS Percutaneous Endourology and Ureterorenoscopy 129 19 Urothelial Carcinoma: Cancers of the Bladder, Ureter, and Renal Pelvis David B Bayne, MD, MPH; Joachim W Thüroff, MD; Rolf Gillitzer, MD; & Thomas Chi, MD 309 Badrinath R Konety, MD, MBA; & Peter R Carroll, MD, MPH iii McAninch_FM_pi-xii.indd 11/02/20 11:21 AM iv Contents 20 Renal Parenchymal Neoplasms 329 Anobel Y Odisho, MD, MPH; & Kirsten L Greene, MD, MS 21 Cancer of the Prostate Gland 351 377 391 407 415 421 Tom F Lue, MD, FACS, ScD (Hon); & Emil A Tanagho, MD McAninch_FM_pi-xii.indd 37 Disorders of the Ureter and Ureteropelvic Junction 571 38 Disorders of the Bladder, Prostate, and Seminal Vesicles 585 Samuel L Washington III, MD; & Katsuto Shinohara, MD 453 39 Male Sexual Dysfunction 605 Amanda B Reed-Maldonado, MD, FACS; & Tom F Lue, MD 473 485 Anne M Suskind, MD, MS, FACS 30 Urinary Incontinence 563 Barry A Kogan, MD Anne M Suskind, MD, MS, FACS 29 Urodynamics 557 John M Barry, MD Karl-Erik Andersson, MD, PhD 28 Neurogenic Bladder 551 Brian K Lee, MD; & Flavio G Vincenti, MD 36 Renal Transplantation Yun Rose Li, MD, PhD; Alexander R Gottschalk, MD, PhD; & Mack Roach III, MD 27 Neurophysiology and Pharmacology of the Lower Urinary Tract 539 Brian K Lee, MD; & Flavio G Vincenti, MD 35 Chronic Kidney Disease and Renal Replacement Therapy Arpita Desai, MD; & Eric J Small, MD 26 Radiotherapy of Urologic Tumors 33 Diagnosis of Medical Renal Diseases 34 Acute Kidney Injury and Oliguria Vadim S Koshkin, MD; & Eric J Small, MD 25 Immunotherapy in Urologic Malignancies 521 Brian K Lee, MD; & Flavio G Vincenti, MD Maxwell V Meng, MD, MPH; Susan Barbour, RN, MS, WOCN; & Peter R Carroll, MD, MPH 24 Systemic Therapy of Urologic Tumors 32 Disorders of the Kidneys David B Bayne, MD, MPH; Jack W McAninch, MD, FACS, FRCS(E)(Hon); & Thomas Chi, MD Sima P Porten, MD, MPH; & Joseph C Presti, Jr., MD 23 Urinary Diversion and Bladder Substitutions 509 Michelle L McDonald, MD; & Christopher J Kane, MD, FACS Matthew R Cooperberg, MD, MPH; Samuel L Washington III, MD; & Peter R Carroll, MD, MPH 22 Genital Tumors 31 Disorders of the Adrenal Glands 499 40 Women’s Sexual Health 631 Alan W Shindel, MD, MAS; & Tami S Rowen, MD, MS 41 Disorders of the Penis and Male Urethra 645 Benjamin N Breyer, MD, MAS, FACS; & Jack W McAninch, MD, FACS, FRCS(E)(Hon) 11/02/20 11:21 AM Contents 42 Disorders of the Female Urethra 659 Donna Y Deng, MD, MS 43 Disorders of Sex Development 671 Laurence S Baskin, MD 44 Male Infertility 703 Thomas J Walsh, MD, MS; & James F Smith, MD, MS 45 The Aging Male James F Smith, MD, MS; Bogdana Schmidt, MD, MPH; & Thomas J Walsh, MD, MS McAninch_FM_pi-xii.indd 735 46 Genital Gender-Affirming Surgery: Patient Care, Decision Making, and Surgery Options v 747 Maurice M Garcia, MD, MAS 47 History and Physical Examination in Pediatric Urology 769 Michael DiSandro, MD 48 Introduction to Clinical Research Design 781 June M Chan, ScD; David Tat, DO; & Stacey Kenfield, ScD Index 793 11/02/20 11:21 AM This page intentionally left blank McAninch_FM_pi-xii.indd 11/02/20 11:21 AM Contributors Karl-Erik Andersson, MD, PhD June M Chan, ScD Institute for Regenerative Medicine Wake Forest University School of Medicine Winston Salem, North Carolina Program Director, Genitourinary Cancer Epidemiology and Population Sciences Department of Urology UCSF School of Medicine San Francisco, California Susan Barbour, RN, MS, WOCN Palliative Care Services UCSF School of Medicine San Francisco, California Thomas Chi, MD Associate Professor and Katzman Endowed Professor in Clinical Urology Department of Urology UCSF School of Medicine San Francisco, California John M Barry, MD Professor of Urology and Professor of Surgery Division of Abdominal Organ Transplantation Organ Health and Science University Portland, Oregon Matthew R Cooperberg, MD, MPH Associate Professor Department of Urology Helen Diller Family Comprehensive Cancer Center UCSF School of Medicine San Francisco, California Laurence S Baskin, MD Chief of Pediatric Urology University of California Children’s Medical Center UCSF School of Medicine San Francisco, California Attending Urologist Children’s Hospital Oakland Oakland, California Hillary L Copp, MD, MS Associate Professor of Urology and Pediatric Urology Fellowship Director Benioff Children’s Hospital UCSF School of Medicine San Francisco, California David B Bayne, MD, MPH Endourology Fellow Department of Urology UCSF School of Medicine San Francisco, California Donna Y Deng, MD, MS Associate Professor and Vice Chair Department of Urology UCSF School of Medicine San Francisco, California Neurourology Lead, Kaiser Permanente Northern California Medical Director, Kaiser NorCal Regional Spina Bifida Program Associate Fellowship Director, Female Pelvic Medicine Reconstructive Surgery, Kaiser East Bay/UCSF Oakland, California Peter R Carroll, MD, MPH Arpita Desai, MD Benjamin N Breyer, MD, MAS, FACS Clinical Instructor Department of Genitourinary Medical Oncology Helen Diller Family Comprehensive Cancer Center UCSF School of Medicine San Francisco, California Professor Ken and Donna Derr-Chevron Endowed Chair in Prostate Cancer Department of Urology UCSF School of Medicine San Francisco, California vii McAninch_FM_pi-xii.indd 11/02/20 11:21 AM viii Contributors Michael DiSandro, MD Kirsten L Greene, MD, MS Daniela Franz, MD Hedvig Hricak, MD, PhD Professor of Urology Department of Urology UCSF School of Medicine San Francisco, California Department of Diagnostic and Interventional Radiology Klinikum rechts der Isar Munich Technical University Munich, Germany Thomas W Gaither, MD, MAS Urology resident University of California Los Angeles, California Maurice M Garcia, MD, MAS Associate Professor of Urology and Anatomy (Adjunct) Departments of Urology and Anatomy UCSF Medical Center San Francisco, California Director, Cedars-Sinai Transgender Surgery and Health Program Division of Urology Cedars-Sinai Medical Center Los Angeles, California Scott Gerst, MD Associate Attending Physician Department of Radiology Memorial Hospital, Memorial Sloane-Kettering Cancer Center New York, New York Rolf Gillitzer, MD Clinical Director Department of Urology Johannes Gutenberg University Medical Center Mainz Mainz, Germany Roy L Gordon, MD Professor of Interventional Radiology Department of Radiology UCSF School of Medicine San Francisco, California Alexander R Gottschalk, MD, PhD Professor of Radiation Oncology Director of CyberKnife Departments of Radiation and Oncology UCSF School of Medicine San Francisco, California McAninch_FM_pi-xii.indd Professor and Chair Department of Urology University of Virginia Charlottesville, Virginia Chair Department of Radiology Memorial Sloan-Kettering Cancer Center Professor of Radiology Cornell University New York, New York Christopher J Kane, MD, FACS Dean of Clinical Affairs UC San Diego School of Medicine CEO, UC San Diego Health Physician Group La Jolla, California Stacey A Kenfield, ScD Associate Professor Department of Urology UCSF School of Medicine San Francisco, California Barry A Kogan, MD Professor, Surgery and Pediatrics Falk Chair in Urology Albany Medical College Albany, New York Ryan Kohlbrenner, MD Assistant Professor of Interventional Radiology Departments of Radiology and Biomedical Imaging UCSF School of Medicine San Francisco, California Badrinath R Konety, MD, MBA Associate Dean for Innovation Professor of Urology Director of the Institute for Prostate and Urologic Cancers University of Iowa Iowa City, Iowa Vadim S Koshkin, MD Assistant Clinical Professor Genitourinary Medical Oncologist Departments of Hematology and Oncology UCSF School of Medicine San Francisco, California 11/02/20 11:21 AM Contributors John N Krieger, MD Professor of Urology University of Washington School of Medicine Seattle, Washington Brian K Lee, MD Professor of Medicine The Connie Frank Kidney Transplant Center UCSF School of Medicine San Francisco, California Yun Rose Li, MD, PhD Anobel Y Odisho, MD, MPH Assistant Professor Department of Urologic Oncology UCSF School of Medicine San Francisco, California Sima P Porten, MD, MPH Assistant professor Department of Urology UCSF School of Medicine San Francisco, California Resident Physician Departments of Radiation and Oncology UCSF School of Medicine San Francisco, California Joseph C Presti, Jr., MD Tom F Lue, MD, FACS, ScD (Hon) Amanda B Reed-Maldonado, MD, FACS Professor of Urology Emil Tanagho Endowed Chair in Clinical Urology Department of Urology UCSF School of Medicine San Francisco, California Kristin Madden, PharmD Pharmacist Department of Veterans Affairs San Antonio, Texas Jack W McAninch, MD, FACS, FRCS(E)(Hon) Professor of Urology UCSF School of Medicine San Francisco, California Michelle L McDonald, MD Urologist San Diego, California Maxwell V Meng, MD, MPH Professor Department of Urology UCSF School of Medicine San Francisco, California Hiep T Nguyen, MD Associate Professor Surgery and Urology Harvard Medical School and Children’s Hospital Boston, Massachusetts McAninch_FM_pi-xii.indd ix Lead for Urologic Oncology Kaiser Permanente Northern California Oakland, California Chief, Male Reproductive Urology Department of Urology Tripler Army Medical Center Honolulu, Hawaii Mack Roach III, MD Professor of Radiation Oncology and Urology Department of Urology UCSF School of Medicine San Francisco Comprehensive Cancer Center San Francisco, California Tami S Rowen, MD, MS Assistant Professor Departments of Obstetrics, Gynecology, and Reproductive Sciences UCSF School of Medicine San Francisco, California Bogdana Schmidt, MD, MPH Urologic Oncology Fellow Stanford University Medical Center Stanford, California Alan W Shindel, MD, MAS Associate Professor Department of Urology University of California Davis, California 11/02/20 11:21 AM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 73 ▲▲Figure 6–11. Abnormal cystograms: retrograde cystograms or “cystograms” as part of excretory urogram studies Upper left: Neurogenic bladder This neurogenic bladder has a “Christmas-tree” shape, with gross trabeculation and many diverticula Residual myelographic contrast medium in spinal canal (straight arrow) Right vesicoureteral reflux (curved arrow) A 70-year-old man with urinary incontinence Upper right: Congenital “hourglass” bladder Transverse concentric muscular band (arrows) separates upper and lower bladder segments, both of which contracted and emptied simultaneously and completely with voiding A 66-year-old woman with urinary stress incontinence Middle left: Hodgkin’s disease of bladder Global thickening of the bladder wall (arrows), more apparent on the left A 54-year-old man with generalized Hodgkin’s disease Middle right: Papillary transitional cell bladder carcinoma Huge (12-cm) cauliflower-like bladder mass (arrows) filling almost the entire bladder “Cystogram” film of an excretory urogram in a 40-year-old man with recurrent bladder tumor Lower left: Voiding cystourethrogram shows right-sided vesicoureteric reflux with marked dilatation of the ureter and hydronephrosis Lower right: Voiding cystourethrogram shows bilateral vesicoureteral reflux (above and continued on next page) McAninch_CH06_p063-p106.indd 73 07/02/20 5:05 PM 74 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–11. (Continued) Aortograms at the level of the renal vessels are followed by selective catheterization of renal arteries CT and MR angiography involve peripheral injection of contrast media with breath hold rapid-sequence image acquisition through the targeted region of interest CT angiography offers higher spatial resolution than magnetic resonance angiography (MRA) but carries the risks of radiation exposure and iodinated contrast usage Indications for renal arteriography include suspected renal artery stenosis (renovascular hypertension), vascular malformations, tumor embolization to minimize surgical blood loss or treat bleeding tumors, and trauma Diagnostic renal angiography to demonstrate renal vascular anatomy is uncommon, as this information may be obtained noninvasively Complications from conventional catheter angiography include bleeding at the puncture site, contrast allergy or nephrotoxicity, and renal or distal emboli ▶▶Inferior Venacavography and Selective Venography (Figures 6–18 and 6–19) The common femoral veins, or less commonly the internal jugular veins, are catheterized for angiography of the inferior vena cava and the renal and adrenal veins Venography is rarely used today since the information can be obtained at cross-sectional imaging (CT or MRI) in almost all cases Adrenal and renal venography is performed occasionally for McAninch_CH06_p063-p106.indd 74 venous sampling to localize hormone secretion in patients with indeterminate noninvasive imaging studies ▶▶Miscellaneous Urologic Angiography Although angiography has little or no value in examination of the ureter, bladder, adrenals, and prostate, angiograms of these structures may be indicated in certain clinical situations, in which case the studies are usually tailored to the clinical problem In this era of multiple cross-sectional methods, these procedures are rarely used Although corpus cavernosograms are uncommon, they are filmed by direct injection of suitable contrast material into the corpora cavernosa of the penis They can be useful in examining for Peyronie’s disease or fibrosis, impotence, priapism, and traumatic penile lesions SONOGRAPHY (FIGURES 6–20 TO 6–26) ▶▶Basic Principles Sound is the mechanical propagation of pressure changes, or waves, through a deformable medium A wave frequency of cycle/s (cps) is called a hertz (Hz) Sound frequencies greater than 20 kHz are beyond the range of human hearing and are called ultrasound Medical sonography uses ultrasound to produce images The frequencies 07/02/20 5:05 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 75 ▲▲Figure 6–12. Abnormal prostate and posterior urethra: cystograms and urethrograms Upper left: Benign prostatic hyperplasia Gross enlargement of prostate gland producing marked elevation (arrows) of the bladder base The bladder shows small diverticula and slight trabeculation Excretory urogram (cystogram) in a 65-year-old man with history of obstructive voiding symptoms Upper right: Foreign body (eyeliner pencil cover) lodged in bladder and prostatic urethra, with urethrorectal fistula Radiopaque medium enters rectum and sigmoid colon (S) through fistula (arrow) from prostatic urethra Retrograde urethrogram in a 43-year-old man Lower left: Rhabdomyosarcoma of prostate Lobulated filling defects (large arrow) encroaching on widened prostatic urethra Voiding cystourethrogram in a 5-year-old boy with voiding difficulties Penile urethra (small arrow) Lower right: Posterior urethral valves Marked dilatation and elongation of prostatic urethra (P), with reflux into prostatic ducts (straight arrow) secondary to posterior urethral valves (curved arrow) with bilateral vesicoureteral reflux into dilated ureters (U) Voiding cystourethrogram in a 10-day-old boy McAninch_CH06_p063-p106.indd 75 07/02/20 5:05 PM 76 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–13. Abnormal anterior urethras: voiding cystourethrograms and retrograde urethrograms Upper left: Voiding cystourethrogram in a 78-year-old man with a history of urethral diverticulum of unknown etiology A 4-cm anterior urethral diverticulum (large arrow) and left vesicoureteral reflux (small arrow) Upper right: Urethral diverticulum in a woman Large irregular diverticulum (arrow) Voiding cystourethrogram in a 51-year-old woman with voiding difficulties and suspected urethral stricture Lower left: Ruptured urethra Extravasation of contrast medium around the membranous urethra (arrows) Retrograde urethrogram in a 16-year-old boy in whom blunt perineal trauma was followed by bloody urethral discharge and inability to void Lower right: Urethroscrotal fistula Extravasation (E) into extraurethral tissues from fistula in bulbous urethra (arrow) Retrograde urethrogram in a 26-year-old man after end-to-end urethroplasty for stricture McAninch_CH06_p063-p106.indd 76 07/02/20 5:05 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 77 ▲▲Figure 6–14. Abnormal anterior urethras: retrograde urethrograms Left: Urethral carcinoma Filling of irregular sinus tracts and channels in a large epidermoid carcinoma of the bulbocavernous urethra (straight arrow) There are multiple thin transverse strictures of the penile urethra (curved arrow) A 75-year-old man with obstructive voiding symptoms and 30-year history of urethral strictures requiring dilatations Right: Focal urethral stricture (arrow) Middle-aged man with obstructive voiding symptoms who denied previous urethritis commonly used in medical sonography range between 3.5 and 15 MHz Ultrasound waves for imaging are generated by transducers, devices that convert electrical energy to sound energy and vice versa These transducers act as both sonic transmitters and detectors Ultrasound images are reflection images formed when part of the sound that was emitted by the transducer bounces back from tissue interfaces to the transducer The sound reflected by stationary tissues forms anatomic grayscale images The sound reflected by moving structures has an altered frequency due to the Doppler effect By determining the Doppler shift, vascular flow direction and velocity can be encoded graphically (spectral Doppler) or by color (color Doppler) A more sensitive method of detecting flow, called power-mode Doppler, is available on modern equipment This technique displays the integrated power of the Doppler signal rather than the mean Doppler frequency shift Direction or velocity of flow is not displayed in power mode Newer intravascular microbubble contrast agents provide more exquisite imaging of vascularity, and their use will likely increase in coming years (Ascenti et al, 2007; Fan et al, 2008; Lu et al, 2015) Ultrasound images are rapidly updated on a video display, giving an integrated cross-sectional anatomic depiction of McAninch_CH06_p063-p106.indd 77 the site studied Individual frames may be frozen during an examination for motion-free analysis and recording, or cine images may be rapidly recorded as digital video ▶▶Clinical Applications Ultrasound is commonly used for the evaluation of the kidney, urinary bladder, prostate, testis, and penis Ultrasound is useful for assessing renal size and growth It is also helpful in triaging patients with renal failure For example, small echogenic kidneys suggest renal parenchymal (medical) disease, whereas a dilated pelvocaliceal system indicates an obstructive, and potentially reversible, cause of renal failure Renal ultrasound is useful in detection and characterization of renal masses Ultrasound provides an effective method of distinguishing benign cortical cysts from potentially malignant solid renal lesions Since the most common renal lesion is a simple cortical cyst, ultrasound is a costeffective method to confirm this diagnosis Ultrasound may also be used to follow up mildly complicated cysts detected on CT, such as hyperdense cysts or cysts with thin septations The differential diagnosis for echogenic renal masses includes renal stones, angiomyolipomas, renal cortical 07/02/20 5:05 PM 78 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–15. Congenital genitourinary anomalies: voiding cystograms and retrograde urethrograms Upper left: Utricle Midline outpouching (arrow) from verumontanum between orifices of ejaculatory ducts, representing Müllerian duct cyst Upper right: Gas cystogram combined with injection of utricle, oblique view (M = grossly dilated utricle [Müllerian duct cyst]; straight arrows = bladder distended with air; curved arrow = coincident partial filling of left seminal vesicle and vas deferens.) A 34-year-old man with urgency, frequency, and suspected retrograde ejaculation Lower left: Common urogenital sinus Vagina (V) and urethra (U) join (at arrow) into a common urogenital sinus (S) Voiding cystourethrogram in a 3-week-old girl pseudohermaphrodite with ambiguous genitalia and congenital adrenal hyperplasia Lower right: Male pseudohermaphrodite Bladder is distended with urine (black arrows) Retrograde urethrogram via hypospadiac meatus has fortuitously and selectively filled with contrast medium an extensive Müllerian duct remnant consisting of vagina (V), cervix and cervical canal (C), and retroverted uterus (U) Residual contrast medium in hypoplastic anterior urethra (white arrow) A 27-year-old man with small external genitalia, hypospadias, and perineal pain McAninch_CH06_p063-p106.indd 78 07/02/20 5:05 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 79 ▲▲Figure 6–16. Vasoseminal vesiculography (vasography) Left: Normal left vasoseminal vesiculogram (V = vas deferens; S = seminal vesicle; E = ejaculatory duct) A 40-year-old man with hypospermia Right: Seminal vesiculitis Bilateral vasogram Mass (M) produced by the swollen, nonfilling right seminal vesicle has displaced both ejaculatory ducts (E) toward the left and indented the medial aspect of the proximal left seminal vesicle and vas deferens (V) A 33-year-old man with painful ejaculations after repair of right varicocele neoplasms (including carcinoma), and, less commonly, abscesses and hematomas All echogenic renal masses should be correlated with clinical history and, if necessary, confirmed with another imaging modality or follow-up ultrasound Thin-section CT showing fat within the renal lesion characterizes it as a benign angiomyolipoma, and no further investigation is required Echogenic lesions smaller than cm are more difficult to characterize by CT owing to partial-volume averaging; in the correct clinical setting, follow-up ultrasound rather than repeat CT may be more useful Doppler sonography is useful for the evaluation of renal vessels, vascularity of renal masses, and complications following renal transplant It can detect renal vein thrombosis, renal artery stenosis, and ureteral obstruction prior to the development of hydronephrosis, arteriovenous fistulas, and pseudoaneurysms Perinephric hematoma following trauma as well as fluid collections following renal transplantation, extracorporeal shockwave lithotripsy, or acute obstructions are reliably detected by ultrasound Developments in other imaging modalities have decreased the use of ultrasound in several clinical scenarios Most patients with suspected renovascular hypertension are evaluated with CTA or MRA rather than Doppler McAninch_CH06_p063-p106.indd 79 ultrasonography Unenhanced helical low-dose CT is now the initial procedure of choice for the evaluation of the patient with acute flank pain and suspected urolithiasis Helical CT also has the potential for identifying other causes of flank pain such as appendicitis and diverticulitis For the evaluation of hematuria, recent studies indicate that CT (or CTU) is the preferred modality (Cowan, 2012) A balance between optimizing imaging quality and minimizing radiation exposure is advocated Applications of bladder sonography include assessment of bladder volume, wall thickness, and detection of bladder calculi and tumors The suprapubic transabdominal approach is most commonly used The transurethral approach during cystoscopy has been recommended for tumor detection and staging Ultrasound examination of the testis and scrotum is performed with a high-frequency transducer (10–15 MHz) for excellent spatial resolution The addition of color and spectral Doppler sonography provides simultaneous display of morphology and blood flow Sonography is highly accurate in differentiating intratesticular from extratesticular disease and in the detection of intratesticular pathology Ultrasound is commonly used to evaluate acute conditions of the scrotum It can distinguish between inflammatory processes, 07/02/20 5:06 PM 80 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–17. Angiography: aortorenal arteriography Upper left: Normal abdominal aortogram The aortic catheter is hidden by the opacified normal aorta Right (R) and left renal arteries and branches are well shown, as are the splenic (S) and hepatic (H) arteries arising from the celiac axis The superior mesenteric artery is superimposed over the aortic silhouette and is not visible here A 28-year-old healthy woman potential kidney donor Upper right: Bilateral renal artery stenoses Typical angiographic appearance and location of stenoses caused by atherosclerosis (small arrows) and fibromuscular dysplasia (large arrows) A 58-year-old woman with abdominal bruits and a 16-year history of hypertension Lower left: 3D coronal CT angiography image demonstrates an inferior accessory left renal artery (posterior view) Lower right: The left accessory renal artery origin (asterisk) is better demonstrated rotating the model in the axial plane A 65-year-old man undergoing preoperative evaluation for laparoscopic partial nephrectomy ▲▲Figure 6–18. Angiography: inferior venacavography Left: Double inferior vena cava (R, L) Persistent left supracardinal vein anomaly A 23-year-old man after orchiectomy for testicular teratocarcinoma Middle: Example of duplicated IVC on IV contrast-enhanced axial CT Normal IVC (arrow) and duplicated IVC (asterisk) Right: Example of duplicated IVC on IV contrast-enhanced axial T1-weighted fat-saturated MRI Normal IVC (arrow) and duplicated IVC (asterisk) McAninch_CH06_p063-p106.indd 80 07/02/20 5:06 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 81 ▲▲Figure 6–19. Angiography: renal venography Left: Normal left renal vein On the left side, the adrenal (A) and gonadal (G) veins enter the renal vein (arrow) (M = radiographic localization marker.) Young woman with proteinuria Right: Tumor thrombus Upper margin (straight arrows) of filling defect of the renal vein tumor thrombus (T) that extends into the vena cava (C) A 68-year-old man with gross hematuria from adenocarcinoma of the right kidney inguinal hernias, and acute testicular torsion (Hart et al, 2008; Sparano et al, 2008) Epididymitis not responding to antibiotics within weeks should be investigated further with scrotal ultrasonography ▶▶Advantages and Disadvantages The main advantages of ultrasound are ease of use, high patient tolerance, noninvasiveness, lack of ionizing radiation, low relative cost, and wide availability Disadvantages include a relatively low signal-to-noise level, tissue nonspecificity, limited field of view, and dependence on the operator’s skill and the patient’s habitus COMPUTED TOMOGRAPHY SCANNING (FIGURES 6–27 TO 6–33) ▶▶Basic Principles In CT scanning, a thin, collimated beam of x-rays is passed through the patient and captured by an array of solid-state or gas detectors The interconnected x-ray source and detector system are rapidly rotated in the gantry around the recumbent patient McAninch_CH06_p063-p106.indd 81 Computers integrate the collected x-ray transmission data to reconstruct a cross-sectional image (tomogram) Spiral (or helical) CT uses a slip-ring gantry that rotates continuously while the patient moves constantly through the collimated x-ray beam Spiral CT technology affords the ability to image during specific phases of contrast bolus enhancement, including the ability to perform CT angiography, and allows improved image reformations Multidetector, or multislice, helical CT scanners have an array of multiple rows of detectors in a helical scanner such that multiple scan images can be acquired per gantry rotation, and as a by-product thinner sections and higher resolution can be achieved Such systems are optimally paired with powerful computer workstations so that high-quality three-dimensional (3D) and multiplanar reformations can be quickly generated and analyzed ▶▶Clinical Applications Renal CT is most commonly used in the evaluation of acute flank pain, hematuria, and renal infection (search for abscesses) or trauma and in the characterization and staging of renal neoplasm CT evaluation of renal anatomy 07/02/20 5:06 PM 82 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–20. A 67-year-old man recently hospitalized for urosepsis Upper: Transverse color Doppler image of the right (R) and left (L) testicles reveals right-sided hyperemia with associated hypoechoic echotexture and surrounding hypoechoic mass Middle: Transverse grayscale right hemiscrotal image confirms hypoechoic right testicle (R) and extratesticular complex collection within the epididymal tail (C) Lower: Color Doppler confirms lack of flow within the complex collection Pathology confirmed chronic granulomatous orchitis, epididymitis, and periorchitis McAninch_CH06_p063-p106.indd 82 ▲▲Figure 6–21. Sonography of the kidney Upper: Normal kidney Renal cortex (C), normal renal sinus echoes (S) Middle: Moderate hydronephrosis and hydroureter; dilated renal pelvis (P) Dilated proximal ureter (proxure) Lower: Severe hydronephrosis of the transplanted kidney, compound sagittal scans, dilated clubbed calices (C), dilated renal pelvis (P) 07/02/20 5:06 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 83 ▲▲Figure 6–22. Renal calculus and the consequences of obstruction as detected by sonography Left: Transverse scan of the right kidney showing calicectasis (C) and renal calculus (arrow) Right: Acute obstruction of the right kidney (K) with spontaneous urine (U) extravasation into the perirenal space Renal calculus (arrow) ▲▲Figure 6–23. Sonography of renal neoplasms Upper left: Simple renal cyst (Cy) demonstrating sharp interfaces toward the renal parenchyma, no internal echoes, and increase through transmission Upper right: Complex renal cyst (arrow) with lobulated margins and thick wall Lower left: Solid tumor (T) in upper pole of left kidney with increased echogenicity relative to adjacent renal parenchyma Pathology was oncocytoma Lower right: Solid renal tumor (asterisk) in the right kidney (K) with separate hyperechoic interpolar partially exophytic mass The interpolar mass represented a known angiomyolipoma, while the upper pole mass represented renal cell carcinoma McAninch_CH06_p063-p106.indd 83 07/02/20 5:06 PM 84 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–24. Sonography with comparative study Film from IVP (left) and transabdominal ultrasound (right) of the urinary bladder in a patient with duplication of the left kidney, ectopic ureterocele, and a calculus (arrow) within it Urinary bladder (B) and pathology generally requires intravenous injection of iodinated contrast media; noncontrast scans are needed, however, when renal or perirenal calcification, hemorrhage, or urine extravasation is suspected, since scans obtained after the administration of contrast media may mask these abnormalities Also, pre- and postcontrast scans are required to determine whether a mass is solid or cystic Contrast medium is usually administered as a rapid intravenous bolus Using a bolus injection and multiphasic multidetector CT, renal arterial opacification is followed immediately by enhancement of the cortex A nephrogram phase with medullary enhancement is reached within 60 seconds Excretion of contrast material into the collecting structures can be expected within 2–3 minutes after initiation of contrast administration, depending on the renal excretory function Although CT can detect ureteral tumors, the current role of CT in evaluation of the ureters is predominantly for tumor staging and evaluation of the cause and level of obstruction Helical low-dose CT without oral McAninch_CH06_p063-p106.indd 84 or intravenous contrast is the preferred imaging modality for patients with renal colic or suspected urolithiasis (Figure 6–32) In evaluation of the urinary bladder, CT is used primarily in staging bladder tumors and diagnosing bladder rupture following trauma (Shin et al, 2007) and in the postoperative setting Performing CT after filling the bladder with dilute contrast medium (CT cystography) improves the sensitivity of this modality for detecting tumors and bladder rupture For prostate diseases, CT is used for detection of lymphadenopathy, for gross extraprostatic tumor extension, and to delineate prostatic abscesses CT is used for detection of the abdominal location of suspected undescended testes, for staging of testicular tumors, and in the search for nodal or distant metastasis The addition of delayed CT imaging 10–15 minutes after intravenous contrast-enhanced CT shows high sensitivity and specificity in characterizing adrenal lesions Benign adenomas, including lipid poor adenomas, show brisk contrast washout CTA or MRA are replacing 07/02/20 5:06 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 85 ▲▲Figure 6–25. The use of transrectal ultrasound in the evaluation of the prostatic urethra Upper left: Sonographic appearance of the prostatic urethra (U) following transurethral resection as seen on transrectal ultrasound in the sagittal plane of scanning Urinary bladder (B) The urethra (U) is dilated to the level of the verumontanum (arrow) Peripheral zone (P), rectum (R) Upper right: The prostatic urethra (U) is dilated to the level to the membranous urethra (arrow) Urinary bladder (B) The cursors are placed to measure the length of the prostatic urethra Lower images: Examples of testicular ultrasound Lower left: The right testis (T) is normal There is a hypoechoic lesion within the left testis (asterisk) At surgery, it was a seminoma Lower right: A large mixed solid and cystic intratesticular mass with foci of echogenic calcifications Benign epidermoid cyst This mass did not show the concentric lamellation sometimes associated with epidermoid cysts Ultrasound cannot always differentiate epidermoid cysts from malignant germ cell neoplasms conventional angiography for diagnostic examinations New, dual-energy CT using dual or alternating sources of scan energy offers added benefits for postcontrast evaluation and allows virtual noncontrast imaging Dual-energy CT will likely play an increasing role in evaluation for incidental renal (Brown et al, 2009; Graser et al, 2009) and adrenal (Mileto et al, 2015) masses, as well as in evaluation for urolithiasis, including stone composition determination McAninch_CH06_p063-p106.indd 85 (eg, for urate stones) (Eiber et al, 2012; Boll et al, 2009; Graser et al, 2008; Primak et al, 2007) ▶▶Advantages and Disadvantages The main advantages of CT include a wide field of view, the ability to detect subtle differences in the x-ray attenuation properties of various tissues, good spatial resolution, anatomical 07/02/20 5:06 PM 86 www.freebookslides.com SMITH & TANAGHO’S GENERAL UROLOGY ▲▲Figure 6–26. Grayscale and Doppler sonography: acute rejection in a renal transplant Upper left: Grayscale ultra- sound image of transplant kidney shows poor corticomedullary differentiation A small fluid collection is seen within the renal pelvis (arrow) Native external iliac vessels are shown as tubular hypoechoic structures (arrowheads) Upper right and lower left: Color Doppler images demonstrate flow within the native external iliac artery (arrowheads), the transplant renal artery (long arrow), and the interlobar arteries (short arrow) Lower right: Spectral Doppler analysis reveals an elevated resistive index of 0.84 These findings are compatible with, but not specific for, acute rejection In the nonacute setting, cyclosporin toxicity or chronic rejection may also show elevated arterial resistive indices cross-sectional images, and relative operator independence Carefully tailored examinations are essential Reformatted helical image data in different planes and in three dimensions have made renal CT imaging, with renal angiography and urography, valuable in preoperative planning, such as for partial nephrectomy Limitations of CT include restriction to the transaxial plane for direct imaging, tissue nonspecificity, low soft-tissue contrast resolution, and the need for contrast media (both oral and intravenous) Even with careful use of contrast media, tissue contrast is sometimes unsatisfactory Finally, radiation exposure is a consideration with multisequence CT imaging McAninch_CH06_p063-p106.indd 86 (Hricak et al, 2011) Ongoing studies evaluating reduced exposure, and modifying protocols, are under way MAGNETIC RESONANCE IMAGING (FIGURES 6–34 TO 6–41) ▶▶Basic Principles Clinical MRI is based on the nuclear properties of the hydrogen atoms in the body Hydrogen nuclei, when considered as aggregates, and sometimes referred to as “protons,” behave 07/02/20 5:06 PM www.freebookslides.com RADIOLOGY OF THE URINARY TRACT CHAPTER 87 ▲▲Figure 6–27. CT scans: adrenal glands Upper left: Normal adrenal glands (arrows) have inverted arrowhead or Y shape Upper right: CT densitometry Thin-section CT of incidental right adrenal mass (M) performed without intravenous contrast Region-of-interest density measurement was