Ureterocele and Duplicated Collecting System
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A Case Presentation and relative topic review regarding ureterocele and duplicated collecting system during my clerkship in Image Diagnostic Department
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Ureterocele and Duplicated Collecting System
- 1. Ureterocele l Duplication of Collecting System Presenter: Clerk 陳佳菁 Date: 2017-06-22
- 2. Patient’s profile 31y/o Mrs. 康 •Chief complaint UTI for 3-4 times in the past year
- 3. Patient’s profile •PMH Patient was told to have a bladder septum in the midline by trans-vaginal ultrasound •Lab data Urinalysis: RBC 0-2, WBC 0-2 BUN/sCr: 13/0.65
- 4. Recurrent UTI Definition ≥2 infections in 6 months or ≥3 infections in one yearRelapse 依感染菌種和間隔時間判斷 Same infectious strain and the recurrence occurs within two weeks of the completion of treatment for the original infection. Re-infection 依兩次感染間的尿液培養判斷 Sterile urine culture is documented between the two UTIs in a patient off antibiotics.
- 8. KUB
- 9. Nephrogram
- 10. Ureter – Bladder
- 12. IVU Findings •Dilated left renal pelvis •Comparatively dilated left ureter •Suspicious mass lesion with lateral displacement of left kidney
- 13. Dynamic CT study Non - Enhanc ed CT Late Arteria l Phase Nephr o - genic Phase Delaye d Phase 0 sec 30 sec 90 sec 300 sec
- 14. Non - Enhanced CT Fat in liver tumors Adrenal adenoma Myelolipoma Stones Calcifications (liver and pancreas)
- 21. Early Arterial Phase Dissection of Aorta Arterial Bleeding
- 22. Late Arterial Phase Liver - HCC FNH Adenoma Bowel Ischemia Enhancement of Renal Cortex Pancreas - Adenocarcinoma Insulinoma
- 31. Hepatic Phase Hypovascular Lesions - Cyst Abscess Most Metastases
- 42. Cholangiocarcinoma Transitional Cell Carci Fibrotic metastases (Breast Ca.) Delayed Phase
- 49. CT Findings •Complete duplication of left collecting system •Upper moiety obstruction at the lower end, forming a ureterocele just behind the urinary bladder Diagnosis: Left complete ureteral duplication with a ureterocele behind the urinary blad
- 53. WHEN MUST SUSPECT CYSTIgnore Follow Excise Wall thickening ALL (unless infection) Hyperdens Sharp margin < 3cm, not completely intrarenal, homogeneous Totally intra- renal, > 3 cm + no enhancing Poorly defined heterogeneous enhancement Enhancem ent <10 HE 10 – 15 HE >15 HE Nodularity Very small non- enhancing nodules All others Multiloculat ed ALL(unless infection)
- 56. Embryology of the renal system
- 57. Embryology of the renal system
- 58. Duplication occurs when two separate ureteric buds arise from a single Wolffian duct (mesonephric
- 60. Epidemiology Incidenc e: 0.8%~5 % Most common congenital anomaly of the kidney and urinary tract Incidence: 0.02%
- 61. Classification
- 62. Weigert-Meyer law Upper 輸尿管開口相對在膀胱 內下側 ．Ectopic insertion ．Medial and inferior ．Ureterocoele Lower 輸尿管開口相對在膀胱 外上側 ．Orthotopic insertion ．Lateral and superior ．Vesicoureteral reflux
- 64. Ureterocele • Breakdown of the ureteral membrane • Developmental delay of the ureteral bud insertion into the bladder • Abnormal development of the bladder trigone
- 65. Classificatio n Almost associated with a duplicated collecting system simple ectopic Bilateral in about 30% of cases. 25% 75%
- 67. Associated Symptoms Asymptomatic Obstruction or VUR Infection Hydronephrosis
- 68. Management Observati on Prophylatic antibiotics Upper pole heminephrectomy Excision of ureterocele Ureteral reimplantation
- 69. TAKE Home Message •Proper intravenous urographic technique and rules of urographic interpretation •Four phases of Dynamic CT Urography •Features indicate that a cyst is NOT simple (WHEN Must Suspect Cyst) •Symptoms of duplicated ureter and Weigert-Meyer law
Editor's Notes
- Duplication：兩套集尿系統，可能兩套都有功能，會充滿藥物；沒功能者便不會充滿藥物。IVP 要診斷很難 Ureterocele：Cobra Head
- 身體裡有一灘不流動的死水，久了細菌可能醞釀其中，尤其是女性
- Standard: Preliminary imaging: KUB radiograph（定位腎臟，也要包含 Pubic Synthesis） -> 打顯影劑，推藥 -> Nephrogram (1-3 min p.i.，從不同方位照腎臟，optimal renal parenchymal visualization) -> KUB radiograph (5 min p.i., assess temporal symmetry and progress of opacification) -> Abdominal Compression -> Pyelogram (10 min p.i.，從不同方位照 Pelvis & Ureter) -> Ureter bladder images (15 min p.i.) -> Bladder image Delayed Phase: Neurogenic Bladder / 嗑藥～尿不乾淨，一般人餘尿量 <100c.c.
- distention of the collecting system is significantly improved Contraindications for the use of abdominal compression include evidence of obstruction on the 5-minute image, abdominal aortic aneurysm or some other abdominal mass, recent abdominal surgery or severe abdominal pain, suspected urinary tract trauma, and presence of urinary diversion or a renal transplant
- Finding: 1. sclerotic change noted over the SI joint bilateral. 2. degenerative change of the spine with spur formation. (L5右側)
- Finding: 兩側的腎臟的 Calyx fornix 沒有 blunting，代表沒有 Hydronephrosis. *左邊腎臟有 Lateral displacement，原因可能因為有mass or lesion推擠。 *兩側腎臟的 Contour 大致上明顯，axis 也正常(interpapillary line和psoas muscle算是平行) *有顯影的是正常的輸尿管，Ureter本身就不太好Trace
- 輸尿管因為會蠕動，所以理論上看不太到整條完整的輸尿管。如果看到整條完整的輸尿管顯影，反而代表可能有hydroureter, obstruction等問題。 Findings: Dilated left renal pelvis and ureter *膀胱左方有filling defect (顯影的輸尿管其實不是Cobra head，第一是因為其insertion在膀胱三角(orthotopic)，第二是Cobra head能夠看得到通常是比較delayed 的影像，此時異常輸尿管會顯影，正常輸尿管已經把尿液排出) *左腎有extra renal pelvis 左腎的upper pole有疑似mass lesion DDx: Oncocalyx, papillay necrosis (a long extension of contrast material from the fornices into the renal substance)
- Contrast medium smoothly define 有 Uterine impression on sup. Wall Post Voiding: collapsed bladder 腎盂還有顯影 PV 用來看 Neurogenic bladder, bladder mass lesion 等問題。
- Non-enhanced CT (NECT) 打藥之前的樣子，亮暗表示本身的性質，水=0，空氣、脂肪比較暗，骨頭比較亮 Detection of: (1) Stones in kidney, ureter and sometimes in CBD; (2) Calcifications in liver, pancreas; (3) Fat in liver tumors; (4) Fat in adrenal adenoma or myelolipoma
- ５ｍｍ 一切；明顯一包水，最常見是 Cyst；Findings: HU=-3 suggest a cystic lesion, without 下述的狀況，DDx: hydronephrosis, simple cyst, cystic renal cell carcinomas (10% of all renal cell carcinomas) 比較不像 看到下列狀況不能視為簡單的Simple cyst，要切除 Calcification Hyperdense / high signal (=high attenuation) 代表有血管 Septations Multiple lobules Enhancement Nodularity / wall thickening
- Early arterial phase (immediately after bolustracking)：較大、較前面的動脈會顯影 15-20 sec p.i. or immediately after bolustracking Demarcation 劃界 of vessels Detection of: (1) Dissection of aorta; (2) Arterial Bleeding
- Late arterial phase - 35-40 sec p.i. or 15-20 sec after bolustracking Enhancement of: (1) Hypervascular Lesions; (2) Stomach; (3) Bowel; (4) Pancreas parenchyma; (5) Spleen; (6) Kidney outer cortex Detection of: (1) Liver: HCC – FNH – Adenoma; (2) Pancreas: Adenocarcinoma – Insulinoma; (3) Bowel Ischemia 又稱作“arterial phase” or “early venous portal phase”, because some enhancement of the portal vein can be seen. All structures that get their blood supply from the arteries will show optimal enhancement. 補充 Hepatic or late portal phase - 70-80 sec p.i. or 50-60 sec after bolustracking. Although hepatic phase is the most accurate term, most people use the term “late portal phase”. In this phase the liver parenchyma enhances through blood supply by the portal vein and you should see already some enhancement of the hepatic veins. FNH: Focal nodular hyperplasia
- 因為輸尿管會Peristalsis，一般不會從頭到尾皆看到，否則可能是不太動或是塞住
- 70-80 sec p.i. or 50-60 sec after bolustracking Enhancement of: Hepatic parenchyma Detection of: Hypovascular liver lesions: Cyst, abscess, most metastases
- ***這套比較重要，可以偵測到 Filling Defect～ Nephrogenic phase - 100 sec p.i. or 80 sec after bolustracking. Enhancement of: All renal parenchyma including medulla Detection of: Renal Cell Carninoma This is when all of the renal parenchyma including the medulla enhances. Only in this phase you will be able to detect small renal cell carcinomas. 補充 [RCC] On non-contrast CT the lesions appear of soft tissue attenuation. Larger lesions frequently have areas of necrosis. Approximately 30% demonstrate some calcification. During the corticomedullary phase of enhancement, 25-70 seconds after administration of contrast, renal cell carcinomas demonstrate variable enhancement, usually less than the normal cortex. Small lesions may enhance a similar amount and be difficult to detect. In general small lesions enhance homogeneously, whereas larger lesions have irregular enhancement due to areas of necrosis. The clear cell subtype may show much stronger enhancement. The corticomedullary phase is also best for assessing vascular anatomy, both for renal vein involvement, and for arterial variation if partial nephrectomy is being contemplated. Intraluminal growth into the venous circulation, in particular, the renal vein, occurs in 4-15%. The prognosis is significantly worse for those with IVC involvement compared to renal vein involvement alone, making identification on CT important. The nephrogenic phase (80-180 seconds) is the most sensitive phase for detection of abnormal contrast enhancement. Excretory phase is of less worth, but important in assessing the collecting system anatomy especially if the candidate is a potential candidate for a partial nephrectomy. Follow-up imaging after treatment is typically done with CT, with dual-phase imaging of the abdomen advocated to maximise the detection of solid organ metastases. Renal cell carcinoma typically causes hypervascular metastases, best appreciated on arterial phase imaging of the upper abdomen.
- Delayed phase - 6-10 minutes p.i. or 6-10 minutes after bolustracking Enhancement of: (1) Fibrotic Lesions; (2) Still enhancement of kidney and urinary collecting system Detection of: (1) Liver – Cholangiocarcinoma; Fibrotic metastases, most commonly breast cancer; (2) Kidney – Transitional cell carcinoma Sometimes called "wash out phase" or "equilibrium phase". There is wash out of contrast in all abdominal structures except for fibrotic tissue, because fibrotic tissue has a poor late wash out and will become relatively dense compared to normal tissue. This is comparable to late enhancement of infarcted scar tissue in cardiac MRI.
- 正常Middle Third 和 Lower Third的地方有時候輸尿管不會顯影 此圖的輸尿管交叉三次！！正常的輸尿管先insertion到膀胱！！
- Onco-central scar Transitional cell ca- collecting system Infection-mottled sygn perfusion decrease
- *17. Renal cell carcinoma (increased parenchymal thickness and distorting the collecting system) *18. Simple cyst (nephrographic defect in the midportion of the left kidney (arrow) with increased parenchymal thickness and distortion of the underlying collecting system.) *19. Simple cyst. (Nephrotomogram shows build-up of normal parenchymal tissue (cortical “beaking”)) *20. Renal cell carcinoma. (Nephrotomogram shows a double contour within the kidney (arrows).)
- Bosniak 看到一大堆脂肪比較放心，AML轉為惡性很少
- 看到一包 Cystic Lesion 時會給一個分數，告訴你這個東西可能是 Cyst 還是別的，比方說 Wall Thickening、厚的 Septum、裡面有亮亮的肉… Enhancement 表示裡面有血管
- 在腎的發育過程中，主要分成三個階段、cranial-to-caudal(從頭往尾巴的方向)，分別是pronephros(前腎)、mesonephros(中腎)以及metanephros(後腎) Pronephros 前腎在第四周初期的時候發育而成，最後會退化、消失。 Metanephros (後腎) 即為最終的永久腎(permanent kidney)，在第五周開始發育。 可分為 excretory system 和 collecting system 1. excretory system 是由 metanephric mesoderm 的中胚層細胞形成的，其發育源頭又稱為 metanephric tissue cap (metanephric blastema) 2. collecting system 則是由 ureteric bud 所形成，ureteric bud 是 mesonephric duct接近 cloaca (泄殖腔) 連接處的小突起。 collecting system 和 excretory system 會相互誘發形成 metanephros Collecting System 由 ureteric bud (輸尿管芽) 開始發育，穿入 metanephric tissue cap (後腎組織帽；又叫 metanephric blastema) 圖 A：ureteric bud 變寬形成 primitive renal pelvis (原始腎盂) renal pelvis 分岔成頭尾兩端，形成 major calyces (大腎盞) 圖 B：芽繼續分岔，會分岔 12 次以上，越來越細 圖 C：第 2、3、4 級融合（第２級膨大,吸收第３、４級），形成 minor calyces (小腎盞) 圖 D：第 5 級後持續拉長，形成 1~3 百萬條 collecting tubules (收集小管)，從 minor calyces 之後組合成 renal pyramid (腎錐體)
- A：ureteric bud 由 mesonephric duct 分支出來，而 mesonephric duct 尾端在發育中會被膀胱壁吸收，和 ureter 分開 C、D：腎臟往腹腔(上方)移動，同時 ureter 也被往上拉，跑到 mesonephric duct 的上方 男生：mesonephric duct→ejaculatory ducts(射精管)，連結 prostatic urethra(紅圈處) 女生：遠端的 mesonephric duct 退化 Trigone(圖 C、D 淡藍色三角地帶)：兩個 ureter 開口與內尿道開口形成的三角型區域。 →urogenital sinus 吸收了 mesonephric duct(中胚層)的尾端，並隨著mesonephric duct 下拉，而使此三角處屬中胚層，但胚胎發育的過程中，會被周圍的 endodermal epithelium 漸漸覆蓋，所以最後膀胱的內壁還是內胚層，外側肌肉則是中胚層
- 有function的那條 但功能不是很好的duplication