Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
16.1 Examination
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Scanning Protocols
..............................................................................................................
n
Ureter:
x
Transducer: 3.5–5 MHz
x
The testicular vein (or ovarian vein) may occasionally be mistaken for the
ureter at the site where the ureter crosses over the iliac vessels.
x
Scanning tip: The visualization of an obstructed ureter can be aided by
increased fluid intake, forced diuresis, or both.
n
Bladder:
x
The bladder is surveyed in longitudinal and transverse scans through the lower
abdomen, occasionally with the transducer angled slightly cephalad.
x
Scanning tip: Moving the patient to a lateral decubitus or knee–elbow position
can be a helpful maneuver in differentiating wall thickening from clots and
sediment.
x
Ultrasound cystometry: see Function Studies, p. 52.
n
Genital organs:
x
Transducer: 3.5 or 5 MHz A 7.5–10 MHz transducer is occasionally used for the
penis and testis.
x
The uterus, ovaries, prostate, and seminal vesicle are scanned from a suprapubic site with a full (not overdistended) bladder. They are surveyed in longitudinal and transverse sections.
x
For optimum visualization of the male genital organs, the beam should
be angled caudad from the bladder floor. As for the female genital organs,
the uterus is cranial to the bladder, the cervix and vagina are posterior, and
the adnexa are posterolateral.
Overview and Classification of Findings
..............................................................................................................
n
Kidney, ureter, and bladder: Section 16.2 deals with dilatations of the pyelocaly-
ceal system (PCS) and ureter (urinary tract obstruction, UTO) and with wall
changes and intraluminal changes in the bladder.
n
Genital organs: Sections 16.3 and 16.4 deal with the genital organs only to the
extent that they are involved in pathologic conditions encountered in routine
medical ultrasound.
n
Classification and overview:
x
Renal pelvis, ureter, and bladder: see Table 67, p. 380.
x
Male genital organs: see Table 68, p. 389.
x
Female genital organs: see Table 69, p. 395.
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
379
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
16
16
16
16.2 Renal Pelvis, Ureter, and Bladder
Overview (Table 67):
..............................................................................................................
Table 67.Abnormal findings in the renal pelvis, ureter, and bladder
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Renal pelvis and ureter Bladder
Urogenital Tract
Urogenital Tract
Urogenital Tract
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Pyelectasis (p. 380) Diverticula, pseudo-
Urinary stone colic (p. 380) Bladder wall thickening
Obstructive pyelocalyceal
ectasia, urinary tract
obstruction (p. 382)
Dilatation of the Pyelocalyceal System
..............................................................................................................
n
Pyelectasis (Fig. 560): ampullary renal pelvis associated with increased urinary
excretion
x
Triangular or cone-shaped hypoechoic mass in the renal sinus echo
x
Absence of calyceal ectasia
x
No ureteral dilatation
x
CDS: absence of vascularity
n
Note: It is important to exclude an obstruction.
Wall changes
diverticula (p. 384)
(p. 384)
Bladder carcinoma (p. 384) Stones (p. 387)
Polypoid bladder tumors
(p. 384)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Intraluminal findings
Ureterocele (p. 386)
Sediment, pus, clotted blood
(p. 386)
Foreign bodies (p. 387)
ab
Fig. 560 Pyelectasis (P), CDS. a A large renal vein can be excluded from the differential diagnosis. K = right kidney. b Obstructive pyelocalyceal ectasia with acute
urinary stone colic: anechoic separation of the central echo complex with mild
dilatation of the ureteropelvic junction
n
Urinary stone colic (Figs. 561–563; see also Fig. 86, p. 65):
x
Clinical features: acute, intense waves of abdominal pain caused by a kidney
stone or, rarely, by blood clots. Perirenal fluid extravasation leads to urinoma
380
formation.
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 561a, b Renal colic due to a ureteropelvic junction stone. a Hydronephrotic
kidney (K) with a dilated, fluid-filled renal pelvis and extravasated fluid (urinoma,
FL). b Ureteropelvic junction stone (arrow, U) and dilated renal pelvis (P). Oblique
upper abdominal longitudinal scan over the course of the right ureter
a
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
bc
Fig. 562a–c a High transverse scan of the right kidney (K). Posterior to the artery
is the ectatic renal pelvis (P) with no dilatation of the proximal ureter. VC = inferior
vena cava. b, c Dilated pyelocaliceal system in a patient with flank pain. Suspicion
of biliary colic. b Dilated calix (CA) communicating with the dilated and obstructed
renal pelvis (PY). c A proximal ureteral stone causing obstructive caliceal ectasia.
Scan shows tow anechoic masses in the central echo complex. The upper mass
represents an ectatic caliceal neck. The enlargement of a caliceal neck to more
than 5 mm (here 11 mm) indicates obstruction. The lower mass is the dilated renal
pelvis
381
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
ab
Fig. 563a, b Urinary stone colic with a detectable stone (arrow) in the prevesical
ureter (U). a B-mode image: high-amplitude echo with a partial acoustic shadow.
Oblique lower abdominal transverse scan. b CDS 4 days later: nonoccluding stone
in the ureteral orifice; urine jet (red); faint “twinkling artifact” in the acoustic
shadow of the stone
x
Sonographic criteria: Ureteral obstruction can be detected sonographically at
the classic sites of predilection. The level and nature of the obstruction can
be accurately determined in over 80 % of cases. If the neck of the calix is
enlarged more than 0.4 cm and the pelvis and ureter to more than 0.5 cm, urinary stasis is present.
n
Obstructive pyelocalyceal ectasia: caused by UTO, Fig. 564). As the duration of the
obstruction increases, the anechoic fluid exerts an increasing mass effect that leads
to parenchymal thinning and obliteration of the central echo complex. This chronic
process can be classified into several grades of severity (Figs.
565–568).
a
Fig. 564a, b Frequent causes of
chronic urinary tract obstruction (UTO).
a Metastasizing tumors in the lesser pelvis (ovary, uterus; here: rectal carcinoma).
b Bladder carcinoma (urothelial carcinoma, arrows), often located near the ureteral
orifice. The differential diagnosis includes metastasis from prostatic carcinoma.
U = ureter, IA = iliac artery, B = bladder
x
Mild urinary stasis (grade I, Fig. 565):
– Pyelocalyceal ectasia due to anechoic compartmentalization of the renal
sinus echo complex
– Possible anechoic dilatation of the ureteropelvic junction and ureter
– Preservation of a prominent sinus echo
382
– Normal thickness of the renal parenchyma
b
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 565 Mild urinary stasis: anechoic
splaying of the central echo band with
preservation of the sinus echo and normal thickness (1.3–2 cm) renal parenchyma (K). P = renal pelvis, U = ureter
x
Moderate urinary stasis (grade II, Fig. 566):
– Marked calyceal dilatation to 5–10 mm, pyelectasis
– Ureteral dilatation, incipient ureteral tortuosity
– Renal parenchyma is normal or slightly thinned
– Diminished renal sinus echo
Fig. 566 Moderate urinary stasis:
marked anechoic pyelocalyceal ectasia
(C) with a diminished sinus echo and
incipient thinning of the renal
parenchyma. K = kidney
x
Severe urinary stasis (grade III, Fig. 567):
– Massive calyceal dilatation, marked anechoic dilatation of the renal pelvis
– Marked ureteral dilatation and tortuosity
– Obliterated renal sinus echo
– Thinning of the renal parenchyma
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
Fig. 567 Severe urinary stasis: pronounced anechoic pyelocalyceal ectasia
(C, P) with an obliterated sinus echo,
parenchymal thinning, and ureteral
dilatation (U). K = kidney
x
Hydronephrotic sac (grade IV, Fig. 568):
– Anechoic cystic mass in the central echo complex caused by severe pyelo-
calyceal dilatation
– Complete loss of the renal sinus echo
– Complete or almost complete loss of the renal parenchyma
383
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
16
16
16
Fig. 568 Hydronephrotic sac. The
Urogenital Tract
Urogenital Tract
Urogenital Tract
calyces (C) and renal pelvis (P) have
coalesced to form an anechoic hydronephrotic sac with loss of the renal
parenchyma
Bladder: Wall Changes
..............................................................................................................
n
Bladder diverticula or pseudodiverticula (Fig. 569): high incidence of diverticular
carcinoma
x
True diverticula : anechoic, usually solitary outpouching of the bladder wall
(prolapses between muscle bundles at a site of congenital weakness)
x
Pseudodiverticula: multiple protrusions due to thickening of the bladder wall
(usually a result of obstructive or neurogenic bladder dysfunction)
a
Fig. 569a, b Bladder diverticula (D).
a True diverticulum (congenital anom-
b
aly): no wall thickening. b Pseudodiverticulum (arrows): significant wall thickening.
The patient presented clinically with benign prostatic hyperplasia. IC = indwelling
catheter
n
Bladder wall thickening (Fig. 570a): mural hypertrophy, trabeculated bladder
x
Wall thickening i 8 mm in the full bladder
x
Usually results from an infravesical outflow obstruction
n
Plaque-like bladder carcinoma (Fig. 570b; see also Fig. 564b, p. 382):
x
Relatively broad area of wall thickening
x
CDS: spot-like tumor vessels
n
Polypoid bladder tumors (Fig. 571): polypoid or polypous tumors, “bladder papil-
lomas,” mostly noninvasive carcinomas, staged according to the criteria in Fig.
x
Circumscribed wall thickening with intraluminal protrusion
x
Tumor surface is usually lobulated (and occasionally echogenic)
x
Nonhomogeneous internal echo pattern
x
CDS: spot-like tumor vessels
384
572
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 570a, b Thickening of the bladder wall. a The bladder wall is thickened to
15.8 mm (cursors) as a result of prostatic enlargement (P). b Wall thickening due
to a plaque-like bladder tumor (T; histology; papillary urothelial carcinoma,
probably a diverticular tumor). D = diverticula
ab
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
cd
Fig. 571a–d Polypoid bladder tumors. a Benign “bladder papilloma” (cursors).
b Lobulated hypoechoic mass (arrow) on the bladder floor (cystoscopy: papillary
tumor; histology: urothelial carcinoma). c Echogenic tumor with an echogenic halo
and no evidence of wall infiltration (histology: urothelial carcinoma). d Intravesical
tumor with irregular margins (papillary urothelial carcinoma). The high surface
echogenicity results from a “blooming” effect
385
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
TNM
Urothelial
involvement
L. propria
Muscle
Adventitia
Invasion
of extravesical
organs
Ti s T a T 1 T2 T3a T3b T4
Prostate,
uterus,
vagina,
pelvis wall,
abdominal
wall
Fig. 572 Staging of
bladder carcinoma.
Tis = carcinoma in situ,
Ta = noninvasive papillary
carcinoma, T1 = tumor
invades subepithelial
connective tissue,
T2 = tumor invades
muscle, T3 = tumor
invades perivesical tissue,
T3a = microscopically,
New TNM
stage
(2002)
T3a = macroscopically
IVIIIIII0
(extravesical mass),
T4 = tumor invades
adjacent organs
Bladder: Intraluminal Findings
..............................................................................................................
n
Ureterocele (Fig. 573):
x
Echogenic band bulging into the bladder lumen (invaginated ureteral orifice)
x
Ureteral obstruction
ab
Fig. 573a–c Ureteroceles. a, b Bilateral
ureteroceles (C, UC). The right ureterocele contains a stone (S = acoustic
shadow), and the left ureterocele is
associated with ureteral obstruction (U).
B = bladder. c Large ureterocele on the
right side: echogenic oval membrane
c
n
Benign prostatic hyperplasia (BPH, Fig. 574):
x
Spherical or nodular protuberance of the middle lobe of the prostate
n
Sediment, pus, blood clots (Fig. 575):
x
Sediment: sharply marginated echogenic layer that moves with position changes
within the bladder lumen (image
courtesy of Dr. K. Ringewald)
386
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
ab
Fig. 574a, b Benign prostatic hypertrophy (BPH; adenoma of the middle lobe).
a Polypoid tumor mass (T) in the bladder (B). b Angled scan demonstrates BPH,
excluding a primary bladder tumor. P = prostate
ab
Fig. 575a, b Bladder sediment and clotted blood. a Purulent sediment : echogenic
layer with a horizontal free margin (arrows). b Large polypoid clot (arrows): moves
and changes shape with position changes, shows transient swirling of clot particles.
B = bladder
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
x
Clots: round or shaggy areas of increased echogenicity; distinguishable from
polypoid tumors by noting movement or swirling in response to position
changes or irrigation (bladder tamponade by clotted blood, see Fig.
x
Both: absence of internal vessels found on CDS
n
Stone (see Fig. 563, p. 382):
x
High-amplitude echo
x
Distal acoustic shadow
x
Mobility
n
Foreign body (Fig. 576): e.g., ureteral stent, indwelling catheter
x
Ureteral stent (drain): echogenic double band in contact with the ureter
(Fig.
576a)
x
Catheter balloon: typical round, echogenic balloon wall, fluid-filled lumen,
echogenic center (tube, Fig.
576b), and double-walled tubing
177, p. 134)
387
16.2 Renal Pelvis, Ureter, and Bladder
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
16
16
16
Urogenital Tract
Urogenital Tract
Urogenital Tract
ab
Fig. 576a, b Foreign bodies in the bladder: ureteral stent and indwelling catheter.
a Echogenic ureteral stent inserted for urothelial carcinoma of the ureter.
b Indwelling catheter balloon (arrow): echogenic balloon wall surrounding a
bright central echo from the catheter tip
Evaluation and Further Testing
..............................................................................................................
n
Sonography:
x
Renal colic: Sonography is the best and simplest diagnostic study in patients
with suspected renal colic, with a diagnostic accuracy of almost 100 %. An
experienced examiner using all available aids can locate the stone with a
high degree of confidence. Most cases do not require urography. Our practice:
– The patient is referred for appropriate treatment based on the clinical pre-
sentation, laboratory results, and sonographic findings including the stone
location. Daily ultrasound follow-ups are scheduled along with regular uri-
nalysis (infection requires urologic intervention). If the stone is not passed
in 1–2 weeks, the patient is referred for further urologic therapy.
n
Note: If complications arise such as urinoma, persistent/recurrent pain, or
infection (bacteriuria, leukocyturia, fever and leukocytosis), immediate urological stenting is indicated (see p. 286).
x
Bladder: In a bladder well distended with fluid, transabdominal scanning can
clearly demonstrate lesions as small as 5 mm (fasting without prior voiding
or copious fluid intake 1 hour before the examination).
– Ultrasound is an excellent modality for locating the cause of erythrocyturia
(e.g., renal, ureteral or bladder stones, diverticula, tumors)
– Tumors 5 mm or larger can be readily detected.
– Exceptions: Tis tumors, tumors on the bladder roof, tumor staging (see
Fig.
n
572, p. 386).
Further testing :
x
Ureteral stone: If ultrasound cannot detect a stone in cases with minimal
obstruction, the stone is either located at a poorly accessible site or is very
small, in which case it generally cannot be detected even by excretory urography. Retrograde cystoscopy may be necessary.
x
Bladder: Unexplained erythrocyturia and all indeterminate findings or masses
should be investigated by cystoscopy or possibly endosonography.
388