Send toughest Genitourinary spotters 20 images from textbook
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Here are 20 Toughest Genitourinary Radiology Spotters from Grainger & Allison's Diagnostic Radiology:
π« GENITOURINARY RADIOLOGY β 20 TOUGH SPOTTERS
1. Acute Pyelonephritis β MRI (T2W)
Fig. 26.20 β T2 weighted MRI showing striated signal in the right kidney with perinephric fluid.
Diagnosis: Acute Pyelonephritis
Key teaching: Striated nephrogram on MRI = wedge-shaped T2 hypointense areas radiating from medulla to cortex. Perinephric fluid indicates spread beyond capsule.
2. Acute Pyelonephritis in Transplanted Kidney β US + MRI + DWI
Fig. 26.21 β (A) Upper pole hyperechoic lesion on US; (B) Hypoenhancing on post-contrast T1W MRI; (C) Diffusion restriction on DWI (b=800).
Diagnosis: Acute Pyelonephritis in Transplant Kidney
Key teaching: DWI (high b-value >600) is highly sensitive β restricted diffusion distinguishes APN from ischaemia and tumour only with clinical correlation.
3. Renal Tuberculosis β CT
Fig. 26.27 β Calcification and parenchymal destruction in renal TB.
Diagnosis: Renal Tuberculosis
Key teaching: Autonephrectomy = complete replacement of renal parenchyma by calcification. Three or more of: pelvicalyceal thickening, ulceration, fibrosis/stricture β highly suggestive of TB. "Phantom calyx" = infundibular stricture obstructing a renal segment.
4. Bosniak Class II Renal Cyst β CT
Fig. 29.1 β CT showing cyst with thin septa and thin mural calcification, no enhancement.
Diagnosis: Bosniak Class II Renal Cyst (benign)
Key teaching: Bosniak classification β Class I/II = benign, no follow-up. Class IIF = surveillance. Class III = indeterminate (biopsy/surgery). Class IV = malignant. The trap: hyperdense cysts (high HU on unenhanced CT) that don't enhance are still Bosniak II.
5. Bosniak Class III Indeterminate Cystic Renal Mass
Fig. 29.2 β Thickened irregular septa, mural nodular calcification with equivocal enhancement.
Diagnosis: Bosniak Class III β Indeterminate Cystic Mass
Key teaching: <50% are malignant, but surgical exploration or biopsy mandated. Significant inter-observer variation β this is the hardest Bosniak class to call.
6. Cystic Renal Cell Carcinoma β Bosniak IV
Fig. 29.3/29.4 β Cystic mass with solid enhancing nodule.
Diagnosis: Cystic Renal Cell Carcinoma (Bosniak IV)
Key teaching: Enhancement >20 HU post-contrast = malignancy. Solid enhancing nodule within a cyst = Bosniak IV = treat as RCC.
7. Papillary Renal Cell Carcinoma β CT (Pre & Post Contrast)
Fig. 29.14 β Pre- and post-contrast CT: large solid left renal mass with characteristically low-level enhancement. Right kidney shows a simple cyst for comparison.
Diagnosis: Papillary Renal Cell Carcinoma
Key teaching: The trap β papillary RCC shows minimal enhancement, easily mistaken for a hyperdense cyst. Always compare pre- and post-contrast HU values. Papillary RCC = homogeneous, hypovascular, often multiple.
8. Medullary Renal Cell Carcinoma β CT
Fig. 29.15 β Post-contrast CT showing medullary carcinoma.
Diagnosis: Medullary Renal Carcinoma
Key teaching: Almost exclusively in sickle cell disease or trait. Arises from collecting duct epithelium, medullary location, usually metastatic at diagnosis. Young patient + sickle cell + infiltrating renal mass = medullary carcinoma until proven otherwise.
9. Renal Angiomyolipoma β CT (Macroscopic Fat)
Fig. 29.8 β CT demonstrating a mass with macroscopic fat (-20 to -80 HU) within the kidney.
Diagnosis: Renal Angiomyolipoma (AML)
Key teaching: Macroscopic fat on CT = AML (virtually pathognomonic). Beware fat-poor AML β may mimic RCC, requiring biopsy. AML >4 cm at risk of spontaneous haemorrhage (Wunderlich syndrome). Multiple bilateral AML = tuberous sclerosis.
10. Renal Oncocytoma β CT (Central Scar)
Fig. 29.12 β Homogeneously enhancing renal mass with central stellate scar.
Diagnosis: Renal Oncocytoma (benign)
Key teaching: Central scar is characteristic but NOT pathognomonic (also seen in chromophobe RCC). Cannot be reliably distinguished from RCC by imaging alone β biopsy required. Spoke-wheel vascularity on angiography is classic.
11. Autosomal Dominant Polycystic Kidney Disease (ADPKD) β CT
Fig. 25.49/25.50 β CT showing massively enlarged kidneys with innumerable cysts of varying sizes and densities (some haemorrhagic = high HU).
Diagnosis: ADPKD
Key teaching: Haemorrhagic cysts appear hyperdense on unenhanced CT β do not confuse with enhancing solid masses. Hepatic cysts in 80%. Pancreatic cysts in 10%. Increased risk of RCC. Associated with Berry aneurysms.
12. Transitional Cell Carcinoma β IVU/CT Urography (Filling Defect)
Fig. 31.2 β Irregular filling defect in the renal pelvis/ureter on CT urography.
Diagnosis: Transitional Cell Carcinoma (Urothelial Carcinoma)
Key teaching: "Goblet sign" = TCC at pelviureteric junction. Synchronous/metachronous lesions in 30β40% (field defect). CT urography = investigation of choice for haematuria evaluation.
13. Renal Calculi β Non-Contrast CT KUB
Fig. 32.1 β Non-contrast CT showing hyperdense calculi in the renal collecting system and ureter.
Diagnosis: Urolithiasis / Renal Calculi
Key teaching: NCCT = gold standard (sensitivity 96%, specificity 99%). All stones except pure uric acid are hyperdense. Uric acid stones = radiolucent on plain film but visible on CT. Staghorn = struvite (infection stones).
14. Renal Transplant Lymphocele β Ultrasound
Fig. 30.19 β US: large hypoechoic fluid collection medial to the transplant kidney causing hydronephrosis.
Diagnosis: Post-Transplant Lymphocele
Key teaching: Commonest pelvic collection post-transplant (0.6β18%). Anechoic/hypoechoic with possible septations, medial to kidney. Distinguished from urinoma by aspiration fluid creatinine. Treat by sclerotherapy or surgical marsupialisation.
15. Post-Transplant Hydronephrosis β Ultrasound
Fig. 30.20 β US: hydronephrotic transplant kidney with dilated calyces.
Diagnosis: Transplant Ureteric Obstruction
Key teaching: Always scan pre- AND post-micturition β full bladder causes false-positive hydronephrosis. Causes: ureteric stricture (ischaemia of distal ureter), blood clot, fungal ball, lymphocele compression, stone. Rise in creatinine + hydronephrosis = nephrostomy + nephrostogram.
16. Post-Transplant Urinoma β CT
Fig. 30.18 β CT (coronal + sagittal): fluid collection at transplant-to-native ureter anastomosis site.
Diagnosis: Post-Transplant Urinoma
Key teaching: Urinoma creatinine >> serum creatinine (diagnostic). Occurs at uretero-vesical anastomosis. Distinguish from lymphocele (aspiration creatinine) and haematoma (echogenic on US, +HU on CT).
17. Renal Vein Thrombosis in Transplant β Doppler US
Fig. 30.2 β Doppler US: reversal of diastolic flow in transplant kidney.
Diagnosis: Renal Vein Thrombosis (Post-Transplant)
Key teaching: Reversed diastolic flow on Doppler = RVT or severe acute rejection. Absent diastolic flow = raised renal vascular resistance (ATN, rejection, obstruction). Resistive Index (RI) >0.8 is abnormal but non-specific.
18. Acquired Cystic Kidney Disease (ACKD) with RCC β CT
Diagnosis: ACKD complicated by Renal Cell Carcinoma
Key teaching: ACKD occurs in >90% of patients on dialysis for >5 years. Small/normal-sized kidneys + numerous cysts on a background of renal failure. Increased incidence of RCC (including low-grade papillary). Persists post-transplant. Trap: do not dismiss enhancing nodule as a simple cyst in dialysis patients.
19. Alkaline-Encrusted Pyelitis/Cystitis β CT
Diagnosis: Alkaline-Encrusted Pyelitis
Key teaching: Linear hyperdense calcifications along thickened urothelium on unenhanced CT. Caused by gram-positive urea-splitting organisms. Rare, severe form of chronic UTI. Easily missed on contrast-enhanced CT β always review unenhanced series.
20. Renal Artery Stenosis β Parvus Tardus Waveform on Doppler
Diagnosis: Haemodynamically Significant Renal Artery Stenosis
Key teaching: Parvus tardus = small amplitude + delayed systolic upstroke on Doppler. RI difference >0.05 between kidneys helps identify the stenotic side. Responsible for 14% of renal failure in patients >50 years. Confirm with CT or MR angiography. One of the few treatable causes of chronic renal failure.
π Quick Reference Summary Table
| # | Diagnosis | Modality | Key Finding |
|---|---|---|---|
| 1 | Acute Pyelonephritis | MRI T2W | Striated nephrogram, perinephric fluid |
| 2 | APN Transplant | US/DWI | DWI restriction, hypoenhancing lesion |
| 3 | Renal TB | CT | Autonephrectomy, phantom calyx |
| 4 | Bosniak II Cyst | CT | Thin septa, no enhancement |
| 5 | Bosniak III | CT | Thick septa, equivocal enhancement |
| 6 | Cystic RCC (Bosniak IV) | CT | Enhancing solid nodule in cyst |
| 7 | Papillary RCC | CT | Minimal enhancement (trap for cyst) |
| 8 | Medullary RCC | CT | Sickle cell + medullary infiltration |
| 9 | Angiomyolipoma | CT | Macroscopic fat (-20 to -80 HU) |
| 10 | Oncocytoma | CT | Central stellate scar (non-pathognomonic) |
| 11 | ADPKD | CT | Bilateral massive cystic kidneys |
| 12 | TCC/Urothelial Ca | CTU | Filling defect, goblet sign |
| 13 | Urolithiasis | NCCT | Hyperdense calculi (uric acid = CT visible) |
| 14 | Lymphocele | US | Medial hypoechoic collection post-transplant |
| 15 | Transplant Hydronephrosis | US | Post-void to exclude bladder cause |
| 16 | Urinoma | CT | Anastomotic fluid (high creatinine) |
| 17 | Renal Vein Thrombosis | Doppler | Reversed diastolic flow |
| 18 | ACKD + RCC | CT | Enhancing nodule in dialysis patient |
| 19 | Alkaline-encrusted pyelitis | NCCT | Linear urothelial calcification |
| 20 | Renal Artery Stenosis | Doppler | Parvus tardus waveform, RI asymmetry |
Source: Grainger & Allison's Diagnostic Radiology (Grainger & Allison's), Chapters 26β32.
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