 Sonography of Calculate and Calcifications of the Urinary Tract Part 2, Ureter and Urinary Bladder. So, whenever there is a dilated collecting system or a hydrogen of process, then we can trace the pelvis and the ureter and see the level and this calculus is a cause of obstruction. It may be seen as an echogenic lesion in the line of dilated ureter with acoustic shadow that is typical of a ureter calculus. Now, here it is in the upper ureter with dilated ureter above and the dilated pelvic elixil system. So, here tracing the dilated ureter we can find out the ureter calculus. So, here there is dilated pelvic elixil system upper ureter and mid ureter. So, you go down and you see a calculus at the ureter vesicle junction. So, when there is dilated ureter it can be traced and the cause of obstruction can be found out and if it is a calculus it is seen as an echogenic lesion in the ureter line of the ureter with shadowing. So, that is there is no difficulty. Now, this is a case where you trace the ureter that is the upper ureter mid ureter it is being traced you see the mid ureter dilated and the lower ureter and you see a calculus at the lower ureter distal most ureter. So, this is how a ureter calculus is diagnosed when there is that is the calculus when there is dilated ureter there is no difficulty. And here another example dilated akelesis pelvis and 80 percent of ureter calculate are at the ureter vesicle junction. So, you once you see hydranophoresis with a patient with a chronic you go to the immediately to the ureter vesicle junction and the lower ureter here it is not dilated then you come back and trace the ureter and you see the calculus in the upper ureter. By tracing the upper ureter you find out a calculus in the actually in the junction of the upper and mid ureter. That is the protocol. So, you go to the you see dilation of the pellicle system go to the lower ureter you get no calculus. So, you trace the ureter and you find the calculus in the mid ureter. It is generally told that HRCT is the best term investigation for ureter calculate because of some myths about sonography ultrasound is blind for dilated mid ureter and because of bubble gas because of the deep retroperitoneal location of the ureter, but we know that it is at the same level as appendix. So, appendix can be seen ureter can be seen and you need a full bladder for distal ureter. Non-dilated ureter is not seen and calculate at multiple levels will be missed by ultrasound and when there is non-obstructive dilation it may be misleading that it is due to calculus and ureter may be dilated below the calculus also because of the common cause of over distanted bladder. So, these are the some more myths of about sonography. In acute obstruction ureter need not be dilated acute obstruction bladder will not be full and anuria when there is anuria due to bilateral calculus collecting system may not be dilated and in the follow up of a calculus ureter may not be dilated. So, u calculus may not be seen there may be a calculus along with the stent and there may be a recently passed out calculus with the dilated collecting system which may be misleading and in pregnancy there is a dilatation of collecting system due to gravid ureterous which has to be differentiated from calculus when the patient presents with pain. So, these are the myths we will see whether it is true or not. Now patient in acute pain and bladder is not full so you cannot wait for full bladder to diagnose. But here you see the bladder is empty but still you are able to see the ureter and there is a calculus of the ureterovesicle junction. This is on right side and another similar case you see the bladder is almost empty but still you see a calculus in the UVJ with the ureter seen proximally. So, if it is bilateral then ureteric alkylate patient may be in anuria or oliguria. So, now we know that even with acute colic when the bladder is empty calculus may be seen. Now, so in that case if suppose you would not seen by abdominal scan you can try indovational scan you will see the distal ureter and the calculus in the distal ureter and in men we can try a transfector ultrasound you see the bladder the distal ureter and the calculus in the distal ureter and non dilated ureter with calculus how to pick it up. So, patient presents with history of ureteric colic or hematuria and X-ray shows a calculus and because of acute obstruction the ureter is not dilated but still you see the kidney and you see the ureter and there is a calculus. So, that is the ureter but even if this ureter is not made out you can wait for some time there will be ureteric peristalsis. So, the ureter will distant and you will confirm that there is a calculus in the upper ureter ok. So, that is shown in the video you see the calculus you see the ureter and you see of the typical moment of the calculus with the peristalsis of the ureter. So, that again confirms that it is in the ureter this is the eye frequency scan you see the ureter and you see the calculus here and you see the calculus moves with the ureteric peristalsis. This is a very important clue in the diagnosis of calculus in a non dilated ureter. So, here you see patient with colic, kidney is normal and there is no hydrogen of roses and when you see the lower ureter there is no calculus of the ureter vesicle junction or the lower ureter. So, you try to trace a non dilated ureter. So, when you try to trace you see wait for some time you see the ureteric peristalsis with that you see the calculus in the upper ureter with shadow. So, that ureteric peristalsis is useful. Now here you see again normal kidney, no hydrogen of roses, no calculus of the uvj, but there is a calculus in the mid ureter with a distinction of the ureter above due to peristalsis and this can be further seen with high frequency you see the dilated or distended ureter above with the calculus within the ureter. Now here you see a calculus in the region of the ureter but you are not able to confirm that it is in the ureter. So, wait for some time you will see the ureteric peristalsis with the peristalsis you nicely see that the calculus is within the ureter. So, wait for the ureteric peristalsis which is shown on real time you see the calculus you confirm with the ureteric peristalsis that it is within the ureter. Again with high frequency you see the calculus here with the ureteric peristalsis ureter distance above around the calculus and also the calculus also moves so that it confirms that it is ureteric calculus. Coming to the lower ureter again there is no hydrogen of roses, no calculus of the uvj but there is a suspicious calculus in the distant ureter lower ureter and you wait for some time you see the ureteric distance and then you see the calculus in the distant ureter confirming that it is ureteric calculus. Distal most ureter again here no hydrogen of roses no calculus at the uvj and we wait for some time you see the distance of the distal ureter and you see the calculus within the distal most ureter because of ureteric peristalsis. So, you can see the real time you see the ureter distance and you see the calculus and here again you see the calculus and if you see wait for some time you see the calculus moves with ureteric peristals. So, here the ureter distance and you see the calculus in the line of the ureter and here the calculus moves with ureteric peristalsis. So, both signs confirm ureteric calculus and helps us to pick up calculate in non dilated ureters. I hope you all will be convinced that we can see non dilated ureters in the non dilated ureter. Now, here you see ureteric calculus on the x-ray you see the calculus in the line of the upper ureter and when you do ultrasound there is no hydrogen of roses, but when you see at rest the ureter you see the peristalsis ureter is seen and you see the calculus in the upper ureter confirming that it is calculus in the upper ureter. You see the real time you see the no hydrogen of roses you try to trace the ureter. So, now you see the upper ureter and as you trace it you see the calculus within the upper ureter and you see that movement also. So, that confirms that it is calculus in the non dilated upper ureter. Now, here there is lift ureteric calculus on the x-ray and there is mild hydrogen of roses when you trace the ureter as actually the calculus is in the upper ureter not in the lower ureter. So, that is the flip bullet. So, ultrasound confirms actually the upper ureteric calculus. Now, here you see the real time you see the mild hydrogen of roses and you see the calculus here and the mid ureter is not dilated and you go to the lower ureter where you suspect calculus by the x-ray it is normal and so you go back and see that it is actually in the upper ureter. You see the ureter here and in the you see the calculus here in the upper ureter it is not in the lower ureter. So, ultrasound can look for calculus in the non dilated. The patient presenting with acute colic and there is no hydrogen of roses and you see the ureter is not dilated and the bladder is empty. You can trace the non dilated ureter because of ureteric pedestals and you see the calculus at the ureteroacycl junction. So, you can pick up even with empty bladder. Our patient presenting with pain abdomen and anemia and both the kidneys so normal and the ureter mid ureters are not dilated but we are able to see by the pedestals and when you calm down you see the bladder is empty and you see calculus by tracing the non dilated ureter. There are calculus at the ureteroacycl junction on both sides that has resulted in anemia right side and left side. So, in the transverse scan you see the empty bladder and both the calculate at the ureteroacycl junction. So, here ultrasound can pick up calculate in spite of anuria in spite of empty bladder and spite of non dilated ureter. In this cases we can also use the individual scan or trust to your advantage to look for calculate in the distal ureter with an empty bladder. So, calculus with the stent. So, here there is stent in the renal pelvis and in the ureter and you see calculate by the side of the stent. This particular issue comes up when patient presents with acute pain or without anuria and they put a stent temporarily and later on a patient is asymptomatic. So, before going for ureterscope they would like to have whether the calculus still remains there. So, there ultrasound is really helpful you can trace the stent and look for calculate by the side of the stent which are easily seen by the side of the stent. Another example patient had colic scan revealed ureter calculus comes after a few days no pain now. So, send for check scan to go for ureterscope to confirm that this calculus still remains. Now, what are the possibilities in this clinical scenario? So, you may see a dilated ureter with calculus or no calculus in the follow-up scan or you may see non-dilated ureter still you may trace and you may find a calculus or no calculus or you may see a small calculus in the urinary bladder. Now, you see in such a scenario you know hydranophrosis you trace the ureter there is no calculus, you trace the ureter with ureter there is no calculus and go to the urinary bladder to the lower ureter and still there is no you can see the peristalsis of the ureter and here you see the lower ureter again you see the peristalsis it confirms that it is ureter. So, you do not see a calculus. So, the calculus has been passed out that is normal. Now, here you see the same clinical scenario you see non-dilated ureter and no calculus, but you see edema of the ureter vesicle junction confirming that it is a passed out calculus. Now, here you see the same scenario non-dilated ureter no calculus in the ureter, but you see a small calculus in the urinary bladder that is the calculus has escaped from the ureter into the urinary bladder confirming that it has passed out into the urinary bladder and the patient will pass out this calculus during next week duration. Now, here you see in the same clinical scenario dilated collecting system you trace it you see the dilated upper ureter and then you come to the mid ureter which is also dilated and you come to the lower ureter it is also dilated but you do not find any calculus. So, again here the calculus is recently passed out and the dilatation has not collapsed. So, it is still remaining vestibule dilatation that is also possible. Another myth is calculus at two sites may not be picked up on ultrasound. Now, here you see mild hydro ureter nephrosis and you see a calculus in the mid ureter not much dilatation and there is also calculus in the lower ureter. So, sites calculate can be easily diagnosed on ultrasound. Now, here you see the dilated ureter below the calculus. So, that is the calculus the line of ureter that is dilated ureter below the calculus there is no calculus down. So, this is possible because of the over distended urinary bladder. Now, in the ureter calculate also you can use the tinkle artifact to confirm that it is calculus many times it may not be necessary. Now, here you see mild hydro ureter nephrosis and you see the upper ureter calculus with shadow, but the history is poorly controlled diabetes mellitus. So, it may be something else we will see. Now, here if you see carefully the images of this kidney there is dilated chelises, but there is parenchymal cavity. You see the communication of the cavity with the calyx and so they are papillary necrotic cavities. Multiple papillary necrotic cavities. So, with this picture the calculus seen in the that is the real time you see the collecting system and you see the parenchymal cavities. So, the parenchymal cavities are in the parenchema not away from the central echogenic area as explained in the papillary necrosis in infection. So, papillary necrotic cavities may be containing sloughed papilla like that they are called the ring sign and when they pass out you see the papillary necrotic cavities are empty communicating with the renal pelvis. This is what we saw in this case. So, you see multiple parenchymal papillary necrotic cavities. So, with this this may be a calcified sloughed papilla in the ureter which is causing obstruction. It may not be a calculus. How to differentiate papillary necrotic cavity versus hydronephrosis. The hydronephrosis the chelises are dilated chelises are symmetric and they are contained within the central echogenic area and you see the parenchema outside. Whereas in papillary necrotic cavities the cavities are outside the central echogenic area in the parenchema with asymmetric dilatation as opposed to symmetric dilatation of hydronephrosis. You can see the schematic and hydronephrosis with all much progression. The dilatation mind moderate, severe, gross. The dilatation of the echelises is symmetric contained within the central echogenic area and you see the parenchema. Even though thinned out you see the parenchema and very severe you may not see parenchema you see a bag of fluid. So, however much the progression the hydronephrosis you don't see the cavities in the parenchema as opposed to papillary necrotic cavities. Sometimes you may have to trace the ureter from below, retrograde fashion. This is an example you see IVP. The left kidney is a 6-year-old girl presenting with dribbling of urine. IVU non-visualized left kidney and isotopes can also non-visualized left kidney. Sent for ultrasound you see the right kidney normal. The spleen and the left kidney in the area is empty and there is no suggestion of ectopic kidney, left kidney. And as described earlier whenever there is empty renal fossa I use uretric jet to say before that the kidney is absent. Because ectopic kidney there may be uretric jet and you can look carefully for the ectopic kidney. But here you see the jet on the right side you don't see a jet on the left side confirming that the left kidney is absent. But because of dribbling of urine a perineal scan shows fluid in the vagina. So fluid in the vagina with dribbling then the suspicion is ectopic uretric opening. So going back to the jet image you see the uretric jet on the right side but you see a small round of cystic structure there whether it is ureter. So how to confirm? You turn the transducer longitudinally you see that it is tubular structure so it may be ureter. Then you trace from this proximally to look for a kidney ectopic kidney and you see a small atrophic left kidney in the lumbar region confirming that it is an ectopic atrophic kidney with the ectopic uretric opening into the vagina and which is resulted in dribbling. So this is how tracing the ureter sometimes retrograde patient gives a better diagnosis and that was the removed atrophic kidney. Another example of tracing the ureter from below this is a 37 year old woman representing a subdominal pain non-specific the left renal fossa was empty so jet was looked for and there is uretric jet on left side there is normal kidney on the right side absent kidney on left side but the jet is seen on the left side so there was no jet on the right side so what is happening? So they search for ectopic left kidney it was not found so what has happened? Then you do a transverse scan of the pelvis you see the uterus ovary and you see a small cystic structure medial to the left ovary whether it is left ureter then a little above you see that the continuation of the cystic structure and between there are two IVCs and the iota between the iota and left IVC you see that cystic structure which is continuous with it when we make a sweep and that in a little upper section you see that it is crossing to the right side in front of the iota so this is actually the ureter so what is actual picture is when you see the IVP normal right kidney and the absent left kidney but you see the ureter the right ureter is crossing to the left and then opening on the left side of the bladder so this is a condition called solitary crossed renalectopia so what has happened? this is the schematic right kidney normal the ureter crosses to the left side so when you take a section here you see the ureter medial to the left ovary little above you see between iota and left is IVC and little above you see the left ureter crossing to the right and joining the right kidney so this is solitary crossed renalectopia and this is an example where the ureter is traced from below to arrive at a better diagnosis tumor versus calculus in the ureter now here this is a planix ray IVP in a patient with hematuria the IVP is normal 58 for an year old man hematuria IVU normal and ultrasound shows the right kidney mild distention of pelvic muscle system and in the line of ureter you see an echogenic lesion and the shadow is not very good so whether it is calculus or tumor you would have a doubt and you look for the shadow so acoustic shadow is present you can see the acoustic shadow responding to the echogenic lesion so that confirms that it is a calculus and not a tumor whereas in tumor you see here the ureter and you see a soft tissue mass distancing the ureter and there is no shadow actually there is enhancement so that is a mass so that is a tumor so the shadow helps us to say whether it is tumor or calculus ureter calculus may be asymptomatic to a degree that there may be complete loss of function but still patient may be asymptomatic now here a patient coming for something else you see gross hydronephrosis of the right kidney ureter dilated up to UVJ where there is a calculus with shadowy so calculus at the UVJ has resulted in gross hydronephrosis and atrophy of the parenchyma and loss of function of the kidney but the patient was all along asymptomatic a calculus due to stasis can happen there is an example of ureterosil with stasis of urine with calculus in the ureterosil due to stasis so what is the solution to pick up ureteric calculus trace the entire length of the ureter whether it is dilated or not dilated so trace the entire length of the ureter dilated or not dilated ureter can be traced by ultrasound the protocol is to first see the upper ureter lower ureter because most of the calculus are at the lower ureter and then again go back to the upper mid ureter and pelvic brim and look for peristalsis so if you are not able to identify the ureter anywhere you can identify easily at the level of pelvic brim sometimes with high frequency scan and the clue is peristalsis either you will see the calculus within the distended fluid distended ureter or the calculus will move with the ureteric peristalsis confirming that it is ureteric calculus and you can use the individual scan or trust to your advantage then we come to a cycle calculus a cycle calculus can be asymptomatic or it may present with suprapubic pain, hematuria or foul smelling urine due to infection with dysuria or it can cause obstruction with acute retention so in the cycle calculus you see the urinary bladder fluid build with an echogenic lesion in the lumen of the urinary bladder here it is a smooth echogenic lesion it is peculiar with the classical acoustic shadow confirming that it is a cycle calculus and another feature of confirmation is the mobility of the calculus so you can see the supine the calculus lying near the base of the bladder and put the patient in left lateral decupitus the calculus shift to left lateral wall confirming that it is a mobile vesicle calculus which is shown on the real time you can see from the left lateral with patient moving to supine it falls back into the base of the bladder so mobility confirms that it is a vesicle calculus now vesicle calculus may be due to migration of ureteric calculus into the bladder or due to urinary stasis urinary bladder due to urinary bladder outflow obstruction, neurogenic bladder or cystocene or a foreign body now the wall of the urinary bladder may be normal or it may be thickened in a case of calculus it may be diffuse thickening that is global thickening of the urinary bladder it is due to obstruction by the calculus or it may be focal thickening due to nonspecific thickening or it may be due to ascoma cell carcinoma due to constant irritation by calculus or you may see a polypoid mass in the bladder associated with calculus if it is polypoid then it may be an associated transitional cell carcinoma with calculus now vesicle calculus due to stasis may be due to benign hypertrophy of prostate as seen here you see the enlarged prostate with a calculus proximal in the urinary bladder or it may be due to neurogenic bladder features of neurogenic bladder or the thick walled, trabaculated bladder and you see the calculus in the bladder due to neurogenic bladder stasis now vesicle calculus the characteristic finding I told you is mobility now here you see a calculus the ecogenic lesion with shadow in supine and left lateral decubitus it does not fall so it is immobile so when it is immobile that means it is either struck on the vesicle wall which is very very unusual or it may be a concretion and a tumor you see the kidney with a calculus and in the bladder immobile but the patient gives history of surgery for a stone 5 years ago and you see a stint in the ureter when you look for the ureter you see a stint in the ureter so it is a forgotten stint with calculus formation on the ends of the stint in the kidney as well as in the urinary bladder how to make out you make a sweep of the probe you see some part of the stint and some part of the calculus in section confirming that it is a calculus formation on the ends of the stint again I did not calculus or calcifer tumor you see the calculus in the bladder and it does not shift with position you do because it is a male patient trust helps to use the obligation of ultrasound to your advantage now here this is the calculus because of shadow we are not able to see this area so what you aim of the trust is to see the mass from the opposite side so from the rectum you see the mass so you see that there is the prostate and transsector ultrasound and that is the bladder and you see a polypoid mass in the bladder with the concretions on the surface which is seen here as a calculus fixed and color Doppler you see flow in the mass confirming that it is actually a transsexual carcinoma with concretions on the surface and not a calculus there may be calculus in the diverticulum a cycle diverticulum as seen here that is the bladder and that is the diverticulum with the communication with the bladder and there is a calculus within the diverticulum another example of a periodic diverticulum with calculus in it Eureka vesicle calculus another cause of calcification in the bladder you see the bladder you see a calcification with shadow in the anterior wall fixed to the anterior wall of the bladder it does not shift with shifting the patient and when you see frequency you see type of calculus one part of the calculus in the lumen and part of it in the wall of the urinary bladder this is near the dome of the bladder so this is the typical appearance of a Eureka vesicle calculus that is the persistent Euracal diverticulum the dome of the bladder with calculus in part of it in the bladder and part of it in the patent Euracus and that is the systoscopy picture the calculus portion in the lumen and portion within the wall which is seen on systoscopy and after removal of the calculus you see the typical dumbled shaped lumenal calculus and the part of the calculus within the patent Euracus so this is Eureka vesicle calculus another example of an adherent calculus now this is a child you see the bladder and you see an echogenic lesion in the lumen with dense shadowing typical of a calculus but here the history is Eurotric re-implantation done 3 months ago for reflex so urinary tract infection since then so within 3 months you cannot expect such a big calculus forming in the urinary bladder so you have to think laterally and this is actually a leftover pad in the urinary bladder due to surgery it is a foreign body now here you see echogenic lesion in the lumen of the bladder with shadowing but another section shows that it is appearance is like this this is typical appearance of a prosthetic mesh so the history this is 66 year old man hematuria 3 years dysuria for 3 years and there is history of surgery for hernia 3 years back so this is the appearance of the bladder and when you look at the bladder there is a bubble of air in the bladder so this is a mesh plus a gas so must think of a fistula with the bubble the history of surgery for inguinal hernia makes a diagnosis of a migrated mesh so how to confirm you see the real time you see the bladder you see the part of the mesh which is extending outside the bladder wall into the bubble typical appearance of the bubble and with that we may diagnose a migrated mesh with a vesicointestinal fistula and you see the mesh extending outside and you see that is extending within the small bubble and that is the bubble so you can carefully look for the fistula you can see that there is gas movement between the bladder lumen and the small bubble loop confirming that it is vesicointestinal fistula a migrated mesh that is the appearance of the mesh which was removed and the patient became alright now calculus can get impacted in the neck of the bladder and cause acute retention you see the over distended bladder and you see the calculus impacted of the neck the calculus can get impacted in the prostatic urethra now this is at the neck distal to the neck you see the prostate in the prostatic urethra you see calculus this is subdominal scan sagittal and the transverse you see the bladder and the calculus in the prostatic urethra and which you can also see on the perennial scan now just distal to the prostate you can get calculus impacted in the membranes urethra this is the sagittal scan that is the prostate just distal to the prostate you see the calculus transverse scan also this you can confirm by perennial scan this is the perennial scan you see urethra due to the prostate so at the junction the membranes urethra you see the calculus and the calculus may impacted in the penile urethra also anterior urethra this is the penile scan you see the urethra in the corpus spondiosum and in the line of urethra you see the calculus so patients will have intense dysuria and the calculus may be also impacted in the region of ocean avicularis and that is the penile scan and you see the urethra and you see the glands penis and in the region of ocean avicularis you see the calculus with shadow so ultrasound can pick up urethra in calculus also thank you very much for your patient attention