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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5775_Библиотеки_им_академика_М_И_Перельмана
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Nabothiancystsarelocatedwithinthecervix,notthevaginalwall.Aurethraldiverticulumislocated
aroundtheurethraandnotwithinthevaginalwall.Ittypicallyhasahorseshoeshape.Ametastasisshould
have some internal vascularity. A necrotic metastasis could have a complicated cystic appearance but
would also have a more irregular wall. Careful scanning should show vascularity in solid mural
components.Bartholincystsare located ator belowthelevelofthepubicsymphysisand usuallyarise
fromtheposteriorvaginalwall.
16b. Answer C. Nabothiancysts, GDCs, müllerian cysts, andBartholin cysts are usually incidental
findings.
Ureteroceles mayrequire surgical repair. Asymptomatic orthotopic ureteroceles can be incidental.
Symptomaticorthotopicureterocelesmayrequirerepair,thoughthiscanusuallybedoneendoscopically.
Most ectopic ureteroceles require intervention. Those inserting on the bladder may be repaired
endoscopically; those inserting outside the bladder usually require open repair. In the congenitally
duplicatedurinarytract,theobstructingectopicureteroceleoftheupperpolemoietyusuallyalsorequires
opensurgery.
References: Lui M-W,NguS-F, Cheung VYT. Mullerian cyst of the uterus misdiagnosed as ovarian cyst on pelvic sonography. J Clin
Ultrasound2013;42(3):183–184.
SiegelmanES.BodyMRI.Philadelphia,PA:ElsevierHealthSciences,2005:291–292,329–330,418.
17a.AnswerC.Imagesshowasharplydemarcatedpartiallyexophyticsolid-appearingleftlowerpole
renal mass isoechoic to the renal parenchyma, which contains a few punctate calcifications. The
differential diagnosis for a solid renal mass includes renal cell carcinoma (RCC), angiomyolipoma,
oncocytoma,transitionalcellcarcinoma,lymphoma,andmetastasis.
Transitionalcell carcinomaand lymphomatypicallyhaveamoreinfiltrative appearance anddonot
typically result in discrete exophytic masses. Additionally, the cortical epicenter of this mass argues
againsta urothelialorigin. Angiomyolipomasare typicallyhyperechoicandrarelycontaincalcification.
Renal oncocytomas are usuallyimpossible to distinguishfrom RCCs preoperativelybut rarelycontain
calcification.Metastasiscanbeconsideredifthereisaknownmalignancy.
Although this mass should be presumed to represent a renal cell carcinoma based on its solid
appearance,aCTorMRIwouldbeanimportantstudytoperformpriortosurgeryforstaging.Renalmass
biopsyisusuallylimitedtocasesinwhichthediagnosisoflymphomaormetastasisissuspected,asthese
arenottreatedwithsurgicalresection,ortocasesinwhichthepatientisnotasurgicalcandidate.
17b.AnswerC.AlthoughthepresenceofintralesionalDopplerflowindicatesasolidrenalmassanda
renalcellcarcinomawith ahighdegreeofcertainty,theabsenceofdetectableflowdoesnotexcludea
neoplasm. One reason is that some renal cell carcinomas are hypovascular, although highly vascular
tumors will also usually exhibit less Doppler signal than the surrounding renal parenchyma. The
sensitivityfordetectionofflowisalsodecreasedwheninterrogatingdeeperlesions.Inthesettingofan
indeterminate renal mass, CT or MRI is necessary for lesion characterization and detection of
enhancement.Contrast-enhancedultrasoundisalsoemergingasahighlysensitivemethodforidentifying
bloodflowwithintumors.
References: Dyer R,DiSantisDJ,McClennanBL.Simplifiedimagingapproachforevaluationofthesolid renalmass inadults. Radiology
2008;247(2):331–343.
HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:114–120.
SiegelCL,MiddletonWD,TeefeySA,etal.Angiomyolipomaandrenalcellcarcinoma:USdifferentiation.Radiology1996;198(3):789–793.
18a.AnswerC.Deeptotheanteriorabdominalwall,atubularblind-endingstructureextendssuperiorly
from the bladder dome.Itcontains asmall amountoffluid.Close inspection reveals amucosal lining
throughoutthestructure.Findingsarecompatiblewithaurachaldiverticulum.SeeadditionalCTimages
withmultiplanarreformatsonthenextpage.Arrowsdenotethediverticulum.
Theurachusisthefibrousvestigeofthefetalallantois,atubularstructurethroughwhichurinedrains
from the bladder dometo the umbilicus during the firsttrimester of pregnancy. Normally, this channel
obliteratesafterthefirsttrimesterofpregnancy,leavingthemedianumbilicalligament,locatedwithinthe
extraperitonealspaceofRetzius.
Incompleteobliteration resultsina spectrum ofurachaldisorders.A patenturachusallowsurineto
leakfromthebladdertotheumbilicus.Aurachalcystislocatedalongtheurachuswithoutcommunication
totheumbilicusorbladder.Aurachalsinusisablindendingtractcommunicatingwiththeumbilicus.A
urachaldiverticulumisablindendingtractextendingfromthebladder.
18b. Answer B. Urachaladenocarcinomas are a rarecomplicationofurachalremnants.They maybe
located anywhere along thecourse of the urachus, including the bladder dome,and often have a large
extravesicalcomponent.Theyareoftenlargeatpresentationandoftenappearaspartiallycalcifiedmixed
solidandcysticmasses.
References: Aguirre DA, Santosa AC,Casola G, et al. Abdominal wall hernias: imaging features, complications,and diagnostic pitfalls at
multi–detectorrowCT.Radiographics2005;25(6):1501–1520.
GleasonJM,BowlinPR,Bagli DJ, et al.Acomprehensive review of pediatricurachalanomalies and predictive analysis for adult urachal
adenocarcinoma.JUrol2015;193(2):632–636.
YuJ-S,KimKW,LeeH-J,etal.Urachalremnantdiseases:spectrumofCTandUSfindings.Radiographics2001;21(2):451–461.
19. Answer D. Renal lesions, which are higher in attenuation than water but well-defined and
homogeneous,areusuallybestevaluatedwithasonogram,asmostoftheselesionsrepresentbenigncysts
andcan be effectivelyconfirmedtobe anechoicsimple cystsonultrasound.Inthisexample, the lesion
margins are indistinct, an unexpected finding given its sharply circumscribed appearance on CT. The
renalcapsuleisalsoindistinct inspiteofitsfairlysuperficial location.Thesefindingsindicatethatthe
lesion is not optimally visualized and should trigger a review of the technical parameters and scan
technique.Settingsforbothdepthoffieldandfocalzonearetoodeepandshouldbecorrected.Depthof
fieldmuchgreaterthanthelesiondepthdecreasesaxialspatialresolution.Becausethefocalzoneismuch
deeperthanthelesion,lateralresolutionisalsocompromised.Oncetheseparametersarecorrected,the
probetransmitfrequencycanalsobemaximizedtofurtherimproveimagequality.
Optimizedimageoftheleftkidneyisshown.Thelesionrepresentsasimplebenignrenalcyst.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:109–111.
20.AnswerB.Thereismildhydronephrosis,andmultiplelinearhigh-amplitudeechoeswithposterior
dirtyacousticshadowingrepresenting gas are locatedwithin therenalpelvis.Findingsare compatible
with emphysematous pyelitis, a urinary tract infection characterized bythe presence of gas within the
collectingsystem.Thisdiagnosiscanbemadeonceothercausesofgasincludingrecentinstrumentation,
trauma,andfistulouscommunicationwithbowelareexcluded.Emphysematouspyelitisusuallyresponds
toantibiotictherapywithouttheneedforaninvasiveprocedure.ItisimportanttoperformaCTinorder
toconfirmtheabsenceofrenalparenchymalgas.
Coronalreformatfromthepatient’sCTscanshowspresenceofgasinthecollectingsystem.
Emphysematous pyelonephritis (EPN) is a severe life-threatening necrotizing renal parenchymal
infectionusuallyoccurring inpatients withuncontrolled diabetes.It is characterizedbythepresenceof
renal parenchymal gas. Xanthogranulomatous pyelonephritis (XGP) is a rare chronic granulomatous
pyelonephritis resulting in a nonfunctioning kidney. Various bacteria implicated with XGP include
Escherichia coli and Proteus mirabilis. In 90% of cases, a staghorn calculus with hydronephrosis is
present.The kidneyiseventuallyreplacedbyan inflammatorymass,composedpredominantly oflipidladenmacrophages.Theinflammatoryprocessmayinvolvetheperinephrictissuesorevennearbyorgans.
The sonographic diagnosis can be challenging because of a lack of specific imaging findings, but the
possibilityofXGPshouldbeconsideredifparenchymalthinning,hydronephrosiswithstonesanddebris,
andperinephricfluidcollectionsarepresent.Inthisexample,gasandcollectingsystemdilatationarethe
onlyabnormalities.
Renalabscess usuallyappearsasa complexfluidcollectionor complex cysticmasses.In the case
shownhere,thehigh-amplitudeechoesrepresentinggasareclearlywithintherenalpelvisandnotwithin
aseparatefluidcollectionorcysticmass.
References:CraigWD,WagnerBJ,TravisMD.Pyelonephritis:radiologic-pathologicreview.Radiographics2008;28(1):255–276.
HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:124–125.
RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:336.
21. Answer A. Echogenic material within the right renal vein with adjacent color Doppler signal
representssubocclusivethrombus.Spontaneousrenalveinthrombosisismostcommonlyassociatedwith
malignancy, especially renal cell carcinoma, and nephrotic syndrome. Other causes include trauma,
biopsy, oral contraceptives, hypovolemia, and inherited hypercoagulable states. Although renal vein
thrombus in thesetting ofrenal cell carcinoma usually represents tumor thrombus, the pathogenesis of
renalveinthrombosisinthesettingofnephroticsyndromeispoorlyunderstood.
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