Acute renal infections.

Most adults with uncomplicated acute pyelonephritis pose no diagnostic or therapeutic problems and recover fully. When imaging is requested in these cases, CT scan with and without contrast enhancement is preferable; however, depending on the condition of the patient and preference of the clinician an IVU, sonogram, or radionuclide scan may also provide adequate information. Patients at higher risk for complications, such as renal or perinephric abscesses with or without PHN and EPN, require aggressive and vigorous clinical and radiologic monitoring. CT scan is superior to other imaging modalities in the investigation of these complications. Interventional percutaneous procedures are established as safe and effective means of controlling or curing the infection in many patients and are often chosen over traditional surgical technique. The radiologist thus is an indispensable member of the management team and should be available for consultation and intervention.

Adrenal cysts: imaging and percutaneous aspiration.

Six patients with primary adrenal cysts were encountered during a period of 3 years. Multiple imaging modalities were used to characterize these lesions, including magnetic resonance imaging in one case. Percutaneous aspiration was performed on four of the six cysts - in one case, in the operating room prior to excision of the cyst. Cholesterol was detected in four cysts and cortisol in one cyst. Cytologic findings from aspiration biopsy were benign in all five cases. Two cysts were removed, one of them after reaccumulation of the fluid after needle aspiration. The findings in this small series of adrenal cysts suggest that in certain cases, complete cyst aspiration, rather than surgical excision, may be carried out initially for diagnosis and management of indeterminate suprarenal cystic lesions and symptomatic cysts of the adrenal gland.

Percutaneous, large-bore, suprapubic cystostomy: technique and results.

A technique to insert large-bore suprapubic cystostomy catheters (18-French or larger) percutaneously, under radiologic imaging guidance, is described in 15 men who required long-term drainage of the bladder. This single-stage procedure is carried out under local anesthesia with optional IV sedation. It consists of rapid enlargement of the percutaneous track by means of a balloon dilatation catheter followed by insertion of a self-retaining Foley cystostomy catheter through a peel-away sheath. No complications associated with the placement of the catheters occurred, and long-term patient compliance has been satisfactory. Our results suggest that percutaneous, large-bore suprapubic cystostomy may be a preferred alternative to surgical cystostomy.

Migratory lobar nephronia.

Lobar nephronia or focal bacterial nephritis is a pre-abscess stage of localized cellulitis and has been shown to represent a focal imaging manifestation of what is frequently a diffuse renal process. To the best of our knowledge, although multi-focal bacterial nephritis has been described, a migratory pattern has not been observed. This report describes a previously healthy 32-year-old woman with pathologically proven lobar nephronia that exhibited a migratory pattern on serial computed tomography (CT) and a prolonged course on antibiotic therapy. Possible etiologies for this unusual course, along with the CT, sonographic and needle biopsy features of this disease are discussed.

Fat-filled postoperative renal cortical defects: sonographic and CT appearance.

Surgical filling of renal cortical wedge resection defects with vascularized retroperitoneal fat resulted in postoperative sonographic and CT appearances that simulated focal renal masses in four patients. Correct identification of this abnormality is important in order to avoid unnecessary further evaluation to exclude renal neoplasm.

Urinary extracorporeal shock wave lithotripsy: equipment, techniques, and overview.

Second generation urinary lithotriptors are characterized by extensive technical alterations and significant equipment improvement in the functional, logistical, and medical aspects of shock wave lithotripsy (SWL). These newer devices feature a water bath-free environment, a reduced anesthesia requirement, improved imaging, functional uses in addition to lithotripsy, or combinations thereof. Shock wave generation by spark gap, electromagnetic, piezoelectric and microexplosive techniques are related to their peak energy, frequency, and total energy capabilities which impacts on both anesthesia needs and the length and number of treatment sessions required to pulverize calculi. A master table summarizes the types of SW energy, coupling, imaging systems, patient transport, functional features, cost, and treatment effectiveness of 12 worldwide lithotriptors in various stages of investigative and clinical trials as monitored by the Food and Drug Administration (FDA) of America.

Seminal vesicle abscess after vasectomy: evaluation by transrectal sonography and CT.

PIP: A case of staphylococcal seminal vesicle abscess after vasectomy was diagnosed by transrectal CT (computed axial tomography) and sonography. The patient was a 43-year old man who was transferred to Massachusetts General Hospital after being treated unsuccessfully at another hospital with gentamicin and carbenicillin for a pelvic infection. He had developed fever, hematuria, dysuria and purulent drainage from the scrotal incision site 3 weeks after vasectomy. A CT scan done at the previous institution showed a mass in the prostatic region. On admission a transrectal linear array sonogram delineated a 5 cm lesion in a enlarged left seminal vesicle. The lesion was drained of purulent material by transurethral endoscopy. Staphylococcus aureus was cultured from the exudate. A follow-up transrectal sonogram 2 months later was normal. Seminal vesicle infections are very rare, except when associated with prostatitis.^ieng

Significant renal hemorrhage following extracorporeal shock wave lithotripsy: imaging and clinical features.

Extracorporeal shock wave lithotripsy (ESWL), either alone or in combination with percutaneous or retrograde techniques, has rapidly become the procedure of choice for the treatment of intrarenal and upper ureteral calculi. Complications have been few so far and usually have been urinary obstructions or hemorrhages. Most fluid collections observed after ESWL are asymptomatic and their detection usually does not prolong hospitalization or alter therapy. In five patients out of 2,149 patient treatments symptomatic renal hematomas developed within a few hours after ESWL for renal calculi. In two of these patients the partial thromboplastin time was mildly prolonged. In four patients blood volume replacement was required to treat a falling hematocrit reading or hypotension. Diagnosis of the hematomas was initially made with sonography, although computed tomography and magnetic resonance imaging were used to further define the distribution and extent of retroperitoneal hematomas. Severe ipsilateral flank pain and rapid decrease in the hematocrit reading after ESWL strongly suggest significant bleeding from the treated kidney and require prompt radiologic confirmation and careful clinical treatment until there is evidence that the hemorrhage has stopped.

Needle puncture of cystic renal masses: a survey of the Society of Uroradiology.

A survey of 114 members of the Society of Uroradiology provided data on the results of needle punctures of cystic renal masses in approximately 16,000 cases. The 73 respondents reported that cyst puncture is currently performed only for specific indications, that opacification is only occasionally performed after puncture, and that cytology is the laboratory procedure of choice for aspirated fluid. While all respondents accepted sonographic confirmation of cysts seen on nephrotomography, only 92% accepted sonography alone as diagnostic, compared to 100% for CT alone. Aspiration of clear fluid (usually an indicator of benignity) with positive or negative cytology, occurred in 19 cystic renal malignancies. Thus, gross and laboratory characteristics of aspirated fluid are not conclusive in diagnosing cystic lesions. CT should be the final arbiter in suspicious lesions.

Life-threatening hypotensive reactions to contrast media administration: comparison of pharmacologic and fluid therapy.

Nine patients were studied retrospectively and 21 prospectively to ascertain the effectiveness and complications of three therapeutic regimens for life-threatening hypotensive reactions (systolic blood pressure 50 mm Hg or less) to intravenous (IV) contrast media. Initial treatment was pharmacologic in nine patients, with fluid in 14 and combined fluid-pharmacologic in seven. All nine patients treated initially with epinephrine required fluid volume administration to restore blood pressure. Thirteen of 14 patients initially treated with fluids (0.5-3 liters) required no other therapy. All patients treated with the combined regimen responded satisfactorily. Complications of drug therapy included six-beat ventricular tachycardia and ventricular bigeminy (epinephrine) and exacerbated hypotension (diphenhydramine hydrochloride). No pulmonary edema was encountered as a complication of fluid therapy. Fluid therapy, alone or with drugs, with electrocardiographic monitoring appears to be a safe and effective method of treating severe IV contrast agent-induced hypotension. Pharmacologic therapy alone in the doses the authors used is often ineffective and may cause major complications.

Diagnostic morphologic and urodynamic antegrade pyelography.

Diagnostic antegrade pyelography, with a thin needle, is basically a simple procedure that can be performed relatively rapidly under local anesthesia with few complications of significance. Its role, however, is frequently crucial to subsequent patient management. During morphologic antegrade examination, aspirated urine can be analyzed for tumor cells (cytologic examination), infection (smear, culture), or other biochemical alterations. The use of antegrade pyelography in the demonstration of internal diversion, ureteral fistula, and the site and cause of obstruction is well established. Dynamic antegrade study is crucial in the assessment of many pyeloureteral units in which the issue of current obstruction is equivocal or uncertain. Absolute renal and bladder pressures are obtained simultaneously; these and the calculated differential pressure provide objective data relative to ureteral resistance to urine flow and renal nephron preservation.

Spontaneous and traumatic rupture of renal cysts: diagnosis and outcome.

Twenty-five patients with spontaneous or traumatic rupture of known renal cysts were encountered over an 18-year period. Blunt abdominal trauma and iatrogenic trauma during retrograde endoscopy accounted for four traumatic ruptures. In 21 patients, spontaneous communication occurred between the cyst and the collecting system or the perinephric space. Hematuria was the most frequent manifestation (21 patients [84%]), followed by flank pain (17 patients [68%]). The diagnosis was made by means of infusion nephrotomography in 22 patients, computed tomography in two, and retrograde pyelography in one. Follow-up information was obtained in 21 patients. The communication of the cyst with the collecting system closed spontaneously in 11 patients and persisted in two. Six patients were operated on because of coexisting stones, persistent hematuria, infection, or the uncertain nature of the cyst, and two underwent cyst evaluation by percutaneous needle aspiration. Renal cyst rupture is an infrequent, usually self-limiting event that may sometimes pose diagnostic dilemmas.

Academic uroradiology: the future.

Radiologic education, research, and the practice of radiology will be of the highest quality in the future if academic departments stress organ-system subspecialization while continuing to integrate and interface with technique-based specialists. Planning should begin now to effect an orderly progression to an organ-system-based subspecialty structure for radiology training in general and for uroradiology specifically. Uroradiologists should remain as central consultants to their clinical counterparts, working collaboratively with urologists in clinical endeavors of mutual relevance. More fellowships in uroradiology should be offered that attempt to incorporate all imaging methods and procedures into the curriculum. These issues are addressed in the context of patient care, service, education, and cost containment.