jurnal akut obstruksi uropati

7/24/2019 Jurnal Akut Obstruksi Uropati

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Unequivocal Obstructive UropathyUnequivocal Obstructive UropathyRadiologic AssessmentRadiologic Assessment

Sarah P. Psutka

Harvard Medical School Year III

Gillian Lieberman MD

March 2006Sarah Psutka, 2007



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Sarah P. Psutka, 2007


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GoalsGoalsReview Anatomy: Urinary Tract

Define Unequivocal Obstructive UropathyPathophysiology

Pathology

Clinical PresentationPatient KA

Patient JL

Patient JM

Radiologic Work-up Modalities

Management


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Anatomy: Urinary TractAnatomy: Urinary Tract

Medline Plus: Medical Encyclopedia: Female Urinary System

http://www.nlm.nih.gov/medlineplus/ency/imagepages/1122.htm

http://www.urostonecenter.com/images/p1.gif

CortexCortex

MedullaMedulla

SuperiorSuperior

OperculumOperculum

InferiorInferior

OperculumOperculum

PelvisPelvis

CalyxCalyx

FornixFornix

Renal CapsuleRenal Capsule

PapillaPapilla


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Unequivocal Obstructive UropathyUnequivocal Obstructive Uropathy

= Urinary tract obstruction

Unequivocal: clear etiology

Obstruction may be atany site within GU tract

Evidence of post-renalfailure

Variable presentationbased on etiology

Hydronephrosis

http://www.merck.com/media/mmhe2/figures/fg148_1.gif

Sign: Hydronephrosis = dilatation of renal pelvis and ureters

Hydronephrosis

http://www.e-radiography.net/ibase5/Renal/slides/

Renal_ca_bladder_hydronephrosis_rt_ivu.jpg


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PathophysiologyPathophysiology of Obstructive Uropathyof Obstructive Uropathy

Initial increase in ureteral peristalsis & pelvic

muscle hypertrophy

Mechanical or functional obstruct ion

Back up of urine flow = increased renal pressure

Initial increase in renal blood flow

Decrease in renal blood flow

Increase in renal lymphatic flow

Muscle stretched & atonic Aperistalsis

Tubular dilatation

Dilatation of ureters and renal collecting duct system

Parenchymal Atrophy

Renal failure

Pathogenesis of unilateral hydronephrosis. Smiths Urology p.181

Hydronephrosis


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How Acute Obstruction leads toHow Acute Obstruction leads to

Dilatation and Decreased TubularDilatation and Decreased Tubular

FunctionFunction

http://asia.elsevierhealth.com/home/sample/pdf/314.pdfBlandino et al., AJR 2002; 179: 1307 -1314
http://www.ajronline.org/content/vol179/issue5/images/large/11_AC0308_10A.jpeg


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PathologyPathology

http://www.smbs.buffalo.edu/pth600/IMC-

Path/images/Year1/Hydronephrosis_Gross-_Robbins.jpg

Dilated pelvis & calyces, renal atrophy, cut surface

http://www.smbs.buffalo.edu/pth600/IMC-

Path/y1case/y1ans21.htm#Obstructivelesionsintheurin

arytract

Dilated renal pelvis (arrow), external view


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Clinical Presentation: Obstructive UropathyClinical Presentation: Obstructive Uropathy

Renal insufficiency Consider UTO in all patients with unexplained renal insufficiency

Urine Output ChangesAnuria = complete bilateral UTO

Partial obstruction normal to elevated UO

Hyperkalemic renal tubular acidosis

Hypertension

Lab Abnormalities: normal, microscopic/gross hematuria, pyuria, azotemia, uremia,anemia (2/2 chronic infection, ACD), leukocytosis

Lower and Mid Tract

(Urethra and Bladder)

Hesitancy in starting urination

Lessened force

Weak stream

Terminal dribbling

Hematuria

Burning on urination

Cloudy urine (infection)

Acute urinary retention

Upper Tract

(Ureter and Kidney)

Flank pain radiating along ureter

course (distension)

Gross hematuria

Nausea/Vomiting

Fever/Chills

Burning on urination

Cloudy urine with infection

Bilateral uremia

N/V/weight loss


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Presentation: Patient KAPresentation: Patient KA65 yo male c/o several days of

hematuria and back pain.

Exam: MM dry, enlargedprostate, difficult foleyplacement, minimal urineoutput (30cc following 1 L IVF)

U/A: Large blood, + nitrite,protein > 300mg/dL, glucose100, ketones 15 mg/dL, largebilirubin, Urobilin 4 mg/dL, pH

6.5, large leukocytesWBC: 6.2

Hgb: 11.2

Cr: 8.4 (baseline 1.4)

Renal Failure

Oliguria

Infection

Hematuria


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Presentation: Patient JLPresentation: Patient JL57 yo male with history of bladder

CA, renal stones, presents with

severe L flank pain. s/p TURBTfor bladder CA.

Exam: no CVA tenderness, no

abdominal tenderness, normalsized prostate

Labs:

Cr = 1.3

Hgb = 15.4 WBC = 11.7

U/A: large blood

Hematuria

Flank PainRenal function

unperturbed


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Presentation: Patient JMPresentation: Patient JM

27 yo male with h/o leftureter stenosis presentswith severe left sided flankpain.

Exam: unremarkableU/A: clear yellow urine, neg

dipstick

WBC: 12.8

Flank Pain

Renal function

unperturbed


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Differential Diagnosis: Obstructive UropathyDifferential Diagnosis: Obstructive Uropathy

In The Lumen

Sloughed papillae/blood clots

Urinary calculi

Infection

Intrinsic/Congenital

Urethral valves

Urethral stricturesMeatal stenosis

Bladder neck obstruction

Ureteropelvic junction stenosis/obstruction

Ureterovesical junction stenosis/obstruction

Ureteric Strictures : infectious, iatrogenic, XRT, TB

Severe vesicoureteral reflux

Extrinsic

Benign prostatic hypertrophy (BPH)

Tumors - carcinoma of the prostate, bladder tumors, contiguous malignant disease,transitional cell carcinoma of renal pelvis/ureters/bladder, squamous carcinomaof the cervix, retroperitoneal lymphomas

Inflammation

prostatitis, ureteritis, urethritis,

retroperitoneal fibrosis

Idiopathic, B-blocker/methysergide use, malignancy, connectivetissue disorder

Uterine prolapse or cystocele

Endometriosis

Fibrosis around renal transplant

Dilatation without obstructionGram neg cocci in pyelonephritis dilatation due endotoxin

Pregnancy

Chronic obstruction post-release

Mega-ureter

Children

Young Adults

Older patients


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13Obstructive lesions of the urinary tract that cause hydronephrosis from Robbins & Cotran, 7th Ed, Chap 20, p 1013

Think Anatomically:Think Anatomically:

Where is obstruction?Where is obstruction?

Systemic or

Distal etiology

Bilateralhydronephrosis

Proximaletiology

Unilateral

hydronephrosis

Series: 53 of 380 patients

52/53 in lower 1/3 of the ureter.

Causes:Ureteral stones 64%

Ureteral edema or lucent

stones 30%

Neoplasms 4%

Inflammatory disease 2%

Chen et al., J Emerg Med, 1997: 15; 3. 339 343.

Most Common in Distal Ureter


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Acute Obstruction andAcute Obstruction andAnuriaAnuria

Patients may die from acute

renal failure witholiguria/anuria

Requires prompt

recognit ion and

possible surgicalintervention

CT examination: Postcontrast axial scan: The retroperitoneal giant tumor mass compresses the

right ureter and causes hydronephrosis (arrows).

http://www.szote.u-szeged.hu/radio/panc/alep8c.htm

Acute complete, bilateral obstruction

= Medical Emergency


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DiagnosisDiagnosis

Early diagnosis and decompression iscritical to prevent renal failure

Continue to Radiologic work-up


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UltrasonographyUltrasonographyTest of Choice for Suspected Urinary Tract ObstructionScreening test

Indications: Renal failure of unknown origin/Hematuria/Signs of UTO/Urolithiasis

Sensitivity for detection of chronic obstruction: 90%

Sensitivity for detection of acute obstruction: 60%

Advantages :

No allergic/toxic complications of radiocontrast media

Fast, inexpensive

Diagnose other causes of renal disease in patient with renal insufficiency ofunknown origin

Polycystic Kidney Disease

Disadvantages

NonspecificRarely identifies cause

False positive rate: < 25% with minimal criteria (operator dependent)

Any visualization of collecting systems

False negative with acute obstruction, dehydration, sepsis

Bowel Gas decreases sensitivity


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UltrasoundUltrasound Normal KidneyNormal Kidney

Pt. AK, PACS, Courtesy of Dr. AC Kim

Normal renal fat,

no dilatation of

collectingsystem,

hyperechoic

Normal renal

parenchyma,

hypoechoic,normal function


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UltrasoundUltrasound Obstructive UropathyObstructive Uropathy

Pt. AK, PACS, Courtesy of Dr. AC Kim

Compressed

renal fat,hyperechoic

Renal

parenchyma,

hypoechoic

Dilated collectingduct, hypoechoic

(fluid)


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Abdominal CT & Plain FilmAbdominal CT & Plain Film1. CT***Noncontrast***

Urolithiasis test of choice in ED

Size

Location

Identi fy masses/Inflammation causingextrinsic obstruction

Identify obstructive atrophy

Quick

Post Trauma

2. Plain Film

Enlarged renal shadows

Heavy metal densities renal stones

Tumor metastases to bones ofspine/pelvis

Osteoblastic? Likely prostatemetastases

CT/Plain fi lm + ultrasound will make thediagnosis of ureteral obstruction in ~90% cases

Limitations of Plain Film and CT

Obstruction due to radiolucent

stones (indinavir), sloughing of

renal papillae, small blood clot

Radiation doses

Need Fat to see soft t issue

Contraindications to Contrast

Pregnancy, children, nursing

moms

Renal failure/insuff iciency

Allergy

Multiple Myeloma

CHF

Gout


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CT: normal renal parenchyma withCT: normal renal parenchyma with

proximal stone, no obstructiveproximal stone, no obstructive uropathyuropathy

Kawashima et al., RadioGraphics 2004;24:S35-S54

Noncontrast

CT

Enhancingcalculus in

interpolar

portion of R

Kidney


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CT: Hydronephrosis due toCT: Hydronephrosis due to

retroperitoneal fibrosis (soft tissue)retroperitoneal fibrosis (soft tissue)

CT (postcontrast):

Giant retroperitoneal

tumor mass

compressing the rightureter, causing

hydronephrosis with

compression of renal

parenchyma (arrows).

http://www.szote.u-szeged.hu/radio/panc/alep8c.htm


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CT: Obstructive UropathyCT: Obstructive Uropathy

PACS, Courtesy of Dr. D. Brennan

CT (postcontrast):

Obstructive left-sideduropathy with

proximal ureteric

stone

Dilated Renal

Pelvis

Proximal

Stone


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IVU: Intravenous UrogramIVU: Intravenous UrogramIntravenous Pyelogram = Excretory Urogram

1. Scout film calculi?

2. IV bolus of radiocontrast dye (ionic contrast)

3. Series of plain films demonstrate kidneys, ureters,urinary bladder

4. Upright film post-void to evaluate for obstruction

Advantages

Anatomy

Pathology Location

Rough indicator of function bilaterally

Low false positive rate

Detects associated conditions

Papillary necrosis intralumenal filling defect

Caliceal blunting from previous infection

Disadvantages

Cumbersome

Requires radiocontrast

Need bowel prep with conventional IVU

Radiation dose

Need cross-sectional imaging follow up

http://www.e-

radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hy

dronephrosis_rt_ivu.jpg


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CTCT UrographyUrographyEvaluate urinary tract for flow defects

Noncontrast Scout first: Urolithiasis

Coronal reconstructions: visualize entire urinary tract

Advantages over Conventional IVU

Speed

Sensitive to renal parenchyma abnormalitiesSimultaneous evaluation of both renal parenchyma and

urinary tract

Cross-sectional imaging

DisadvantagesRadiation dose

Ionic Contrast reactions/cannot be used in patients in

renal failure

Kawashima et al., RadioGraphics 2004;24:S35-S54


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Normal CT UrogramNormal CT Urogram

Pt. JL, PACS, Courtesy of Dr. AC Kim

CT Urography

Total Body

Opacificantion

Nephrogram

Pyelogram


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Normal CT UrogramNormal CT UrogramCT Urography

Total Body

Opacificantion

Nephrogram

Pyelogram


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Total Body

Opacificantion

Nephrogram

Pyelogram


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Total Body

Opacificantion

Nephrogram

Pyelogram


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Total Body

Opacificantion

Nephrogram

Pyelogram


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Total Body

Opacificantion

Nephrogram

Pyelogram


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Total Body

Opacificantion

Nephrogram

Pyelogram


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Contraindications for IVU/CTUContraindications for IVU/CTUHistory of allergy to IV contrast

Bronchospasm, laryngeal edema, anaphylactic shock

May use with history of minor allergic reactions with preprocedural steroids,

antihistamines (diphenhydramine) 12 hours prior to studyRenal insufficiency

Pregnancy = relative contraindication (radiation exposure)MR Urogram can be used

Likewise: children minimize radiation doses

Pts taking oral hypoglycemics (metformin) should stop taking meds prior tostudy

May resume after renal function is confirmed normal

Risk of lactic acidosis

Must be Physician-Supervised

- Contrast reactions

- Minimize no. of images

- Minimize radiation- May use Fluoroscopy


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MRMR UrographyUrography

A. Unenhanced MR urography

Heavily T2 weighted

B. Gadolinium-enhanced excretory MR urographyC. Excretory MR urography + diuretic

10 mg furosemide IV

Gadopentetate dimeglumine

Advantages:

Distinguishes adjacent soft tissue abnormalities

With Gadolinium: functional information

No ionic contrast OK in renal failure

No radiation children, pregnancy women

Drawbacks

High cost

Low sensitivity in detecting calcifications

Time intensiveMetallic implants/Foreign Body = Contraindications

Blandino et al., AJR 2002; 179: 1307 -1314

Sagittal contrast-enhanced excretory

MR urography obstruct ing r ight

sided papillary TCC
http://www.ajronline.org/content/vol179/issue5/images/large/11_AC0308_09.jpeg


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Excretory Urogram/CTU/MRUExcretory Urogram/CTU/MRU

AcuteAcute ObstructionObstruction

Kidney minimally enlarged

Dense Nephrogram

Preferential absorption of Na and

water from diseased tubules =

concentration of contrastDelayed appearance of contrast in

collecting system

= delayed function

Poor concentration of contrast in thecollecting tubules

No ureteral dilatation acutely

Ureters not tortuous

Mild Moderate Marked

http://asia.elsevierhealth.com/home/sample/pdf/314.pdf


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Excretory Urogram/CTU/MRUExcretory Urogram/CTU/MRU

ChronicChronic ObstructionObstruction

Progressive dilation of col lecting system

and ureters/tortuous

Urectasis = dilated ureter

Decrease number of nephrons

6-12 weeks: irreversible loss of renalfunction

Shell nephrogram parenchymal

atrophy

Collecting system: blunt calyces/forniceal

angles

Partial Complete


Calyceal Clubbing
http://www.ajronline.org/content/vol179/issue5/images/large/11_AC0308_19.jpeghttp://www.ajronline.org/content/vol179/issue5/images/large/11_AC0308_19.jpeg


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Evaluation of Renal Function: Renal ScanEvaluation of Renal Function: Renal ScanRenal scan = Renogram =

Nephrogram

Nuclear medicine examinationusing radioisotopes (Tc-99mDPA) to measure kidney filtrationof blood

Findings indicative of decreased renalfunction

Delayed appearance ofradionuclide

Diminished uptake compared

with normal side Dilated collecting system and

ureter to point of obstructionon delayed scans

Advantages

No contrast

Lasix Renogramhttp://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.html

Prompt excretion of activity from

the right kidney, but an obstructedpattern on the left side


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Evaluation of Renal Function: Renal ScanEvaluation of Renal Function: Renal ScanRenal scan = Renogram =

Nephrogram

Nuclear medicine examinationusing radioisotopes (Tc-99mDPA) to measure kidneyfunction

Findings indicative of decreased renalfunction

Delayed appearance ofradionuclide

Diminished uptake compared

with normal side Dilated collecting system and

ureter to point of obstructionon delayed scans

Advantages

No contrast

Lasix Renogramhttp://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.html

Prompt excretion of activity from

the right kidney, but an obstructedpattern on the left side


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Patient KA: WorkPatient KA: Work--upup

Ultrasound

Bilateral Mild Hydronephrosis

Right Kidney 11.9 cm (baseline 10.6 cm)

Left Kidney 12.7 cm (baseline 11.0 cm)Normal flow bilaterally (seen on Doppler)

Hypoechoic fluid

fil ling renal pelvis

Pt. KA, PACS, Courtesy of Dr. AC Kim


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Patient KAPatient KA

Bilateral Hydronephrosis with

dilatation of renal pelvis

Perirenal fat

stranding



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Patient KA: NSAID overdose leading to papillaryPatient KA: NSAID overdose leading to papillary

necrosis and UTO, with secondary infectionnecrosis and UTO, with secondary infection

Hydroureter

No evidence of stone

Diagnosis:

65 yo M with mild bilateral

hydronephrosis, hydroureter,and fat stranding in the setting

of acute post-renal failure and

oliguria. Believed to be

secondary to excessive NSAID

use, causing renal papillaenecrosis and sloughing and

acute prostatis.

Management

Admitted

Cystoscopy: R UO Sludge

Ureteral stents placed

Pain ManagementAntibiotics for UTI and

Prostatitis



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Patient JL: WorkupPatient JL: Workup

Enlarged

kidney

Mild hypoechogenic

renal pelvis



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Patient JLPatient JL Left HydronephrosisLeft Hydronephrosis


Small cystLeft Hydronephrosis

Mild Fat Stranding


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Patient JLPatient JL Bladder MassBladder Mass

Left Bladder mass

surrounding UO


Diagnosis:

57 yo M with known Bladder

CA with left hydronephrosis

secondary to left bladder

cancer.

ManagementFoley placement for

immediate decompression.

Pt urinated following

catheter removal and wascleared for d/c

Urology consult for possible

stent placement


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Patient JM: WorkupPatient JM: Workup

Pt. JM, PACS, Courtesy of Dr. AC Kim

Massive

Hydronephrosis

S h P P tk 2007


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Patient JMPatient JM

Fat

stranding

Proximal renalpelvis dilatation

without dilatation

of distal ureter


S h P P tk 2007


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Fat

stranding

Proximal renalpelvis dilatation

without dilatation

of distal ureter


Sarah P Psutka 2007


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No

visible

stone

Parenchymal

thickness

preserved

Sarah P Psutka 2007


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Patient JM: Severe HydronephrosisPatient JM: Severe Hydronephrosis

SecondaySeconday toto UreterUreter StenosisStenosisDiagnosis:

27 yo M with severe right

hydronephrosis likely due tocongenital left ureter

stenosis

Found to have

simultaneous UTI

Management

Pain Control

Antibiotics

Referred to Urology for out-

patient ureteral stentplacementPt. JM, PACS, Courtesy of Dr. AC Kim

Sarah P Psutka 2007


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Urinary Tract ObstructionUrinary Tract Obstruction

Without HydronephrosisWithout Hydronephrosis

CAVEAT:

UTO can occur withouthydronephrosis or dilatation

of the urinary tract

1. Acute: Days 1 - 3 Duplex Doppler U/S

detect increased resistive

index vs. contralateral

kidney2. Mild obstruction without

impairment of renal

functionPt. AK, PACS, Courtesy of Dr. AC Kim

Normal Kidney Appearance in the

setting of acute obstruction

Sarah P Psutka 2007


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Hydronephrosis without Obstruction/Hydronephrosis without Obstruction/

with Asymptomatic Obstructionwith Asymptomatic Obstruction

Presentation: Back/flank pain, hematuria,hydronephrosis and ureteral dilatation

EtiologiesPregnancy (normal finding)

Megaureter due to previous Vesicoureteral reflux

Dilated but unobstructed extrarenal pelvis

Gram Negative Cocci infection (Endotoxin)Goal: Rule out obstruction

1. Diuretic Renogram

2. Diuretic IVU3. Whitaker Test/Perfusion pressure flow

studies


21 yo M with L Megaureter,

No obstruction

Sarah P Psutka 2007
http://www.ajronline.org/content/vol179/issue5/images/large/11_AC0308_08.jpeg


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Radiologic WorkRadiologic Work--up for Urinary Tractup for Urinary Tract

Obstruction: RationaleObstruction: Rationale

Is there

hydronephrosis?

What is renal

function?

Final Diagnosis

Management:

Decompression

Urology Consult

Cystoscopy

Yes/Equivocal with

High Clinical

Suspicion

Is there mechanical

obstruction?

Ultrasound CT

Plain Film

Answer

Where is it?

IVU/CTU/MRU

Renal scan/Nephrogram

No:

Alternate

Work-up

Obstructive

Symptoms

Flank pain

Hematuria

Renal failure

Dysuria/FrequencyUrgency



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Management of Urinary Tract ObstructionManagement of Urinary Tract Obstruction

Obstructive lesions of the urinary tract that cause hydronephrosis from Robbins & Cotran, 7th Ed, Chap 20, p 1013

Surgery

Nephrectomy

Partial Nephrectomy

Resect extrinsic masses

Foley Catheter

Prostate resection/TURP/PVP

Cystoscopy

TURB

Ureteral Stents

Percutaneous Nephrostomy Tube

Emergency Drainage

Intraureteral Stone removal

Extracorporeal Shock Wave LithotripsyLaser Lithotripsy

Percutaneous Ultrasonic Lithotripsy



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ReferencesReferencesAlpers CE. The Kidney in Robbins and Cotrans Pathologica Basis of Disease. Eds Kumar, Abbas, Fausto. Elsevier-

Saunders 7th Ed. Pennsylvania 2005. pp. 955 1021.

Barbaric ZL. Urinary Tract Obstruction in Principles of Genitourinary Radiology. Thieme Medical Publishers, Inc. NewYork. 1999. p 111 151.

Blandino et al., MR Urography of the Ureter: Pictoral Essay. AJR 2002; 179: 1307-1314.

Chen, M et al., Radiologic findings in Acute Urinary Tract Obstruction. J Emerg Med 1997; 15:3: 339 343.

Kawashima et al., CT Urography. RadioGraphics 2004;24:S35-S54

Rose BD. Diagnosis of urinary tract obstruction and hydronephrosis. UpToDate 2006.

Tanagho JW and McAninch EA. Urinary Obstruction and Stasis in Smiths General Urology. Lange MedicalBooks/McGraw Hill 16th Ed. New York, 2004. p 175 187.

Weissleder R et al. Obstruction of Collecting System in Primer of Diagnostic Imaging. Mosby 3rd Ed. Boston, 2003.

Zagoria RJ and Tung GA. The Renal Sinus, Pelvocalyceal System and Ureter in Genitourinary Radiology TheRequisites. Mosby Publishers, Inc. St. Louis, Missouri. 1997. p.152 191.

Websites:Hematuria Cases Liebermans Primary Care Radiology: Dr. G. Lieberman

http://www.primarycareradiology.com

Hydronephrosis Medline Plus

http://www.nlm.nih.gov/medlineplus/ency/article/000509.htm#Alternative%20NamesDiuresis Renogram Joint Program in Nuclear Medicine

http://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.html

Hydronephrosis Pathology Cases

http://www.smbs.buffalo.edu/pth600/IMC-Path/y1case/y1case21.htm

OReilly, P. Upper Tract Obstruction Benign Disorders of the Upper Urinary Tract.

http://asia.elsevierhealth.com/home/sample/pdf/314.pdf

Hydronephrosis

http://www.e-radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hydronephrosis_rt_ivu.jpgCT Urographyhttp://www.szote.u-szeged.hu/radio/panc/alep8c.htm

http://www.primarycareradiology.com/http://www.nlm.nih.gov/medlineplus/ency/article/000509.htm#Alternative%20Nameshttp://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.htmlhttp://www.smbs.buffalo.edu/pth600/IMC-Path/y1case/y1case21.htmhttp://asia.elsevierhealth.com/home/sample/pdf/314.pdfhttp://www.e-radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hydronephrosis_rt_ivu.jpghttp://www.e-radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hydronephrosis_rt_ivu.jpghttp://www.szote.u-szeged.hu/radio/panc/alep8c.htmhttp://www.szote.u-szeged.hu/radio/panc/alep8c.htmhttp://www.szote.u-szeged.hu/radio/panc/alep8c.htmhttp://www.e-radiography.net/ibase5/Renal/slides/Renal_ca_bladder_hydronephrosis_rt_ivu.jpghttp://asia.elsevierhealth.com/home/sample/pdf/314.pdfhttp://www.smbs.buffalo.edu/pth600/IMC-Path/y1case/y1case21.htmhttp://www.med.harvard.edu/JPNM/TF96_97/Nov26/WriteUp.htmlhttp://www.nlm.nih.gov/medlineplus/ency/article/000509.htm#Alternative%20Nameshttp://www.primarycareradiology.com/


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Many Thanks!Many Thanks!

Darren Brennan, MD, BIDMC

AC Kim, MD, BICMC

Andrew Bennett, MD, BIDMC

Gillian Lieberman, MD, BIDMC

Pamela Lepkowski, BIDMC

Larry Barbaras, Webmaster, BIDMC

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