Ultrasonography of the urinary system

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Authors: Mikael Häggström; Authors of Creative Commons article[1] [notes 1]


How soon


The ultrasonic renal exam does not require any preparation of the patient and is usually performed with the patient in the supine position. The kidneys are examined in longitudinal and transverse scan planes with the transducer placed in the flanks. When insonation of the kidney is obscured by intestinal air, the supine scan position is combined with the lateral decubitus position with the transducer moved dorsally. Preferably, the exam is initiated in the longitudinal scan plane, parallel to the long diameter of the kidney, as the kidney is easier to distinguish.[1]

In the adult patient, a curved array transducer with center frequencies of 3–6 MHz is used, while the pediatric patient should be examined with a linear array transducer with higher center frequencies. Artifacts of the lowest ribs always shadow the upper poles of the kidneys. However, the whole kidney can be examined during either normal respiration or breath hold, as the kidney will follow the diaphragm and change position accordingly.[1]

In cases of decreased renal function, the most relevant assessments in a renal ultrasound are renal sizes, echogenicity and any signs of hydronephrosis. Renal enlargement usually indicates diabetic nephropathy, focal segmental glomerular sclerosis or myeloma. Renal atrophy suggests longstanding chronic renal disease.[2]

Basic screening

  • Scan through the renal volumes in two projections, looking for focal changes or hydronephrosis.
Figure 1. Measures of the kidney. L = length. P = parenchymal thickness. C = cortical thickness.[1]
  • Measure renal size: The length of the adult kidney is normally 10–12 cm, and the right kidney is often slightly longer than the left kidney. The adult kidney size is variable due to the correlation with body height and age; however, normograms for pediatric kidney size are available.[1]
  • Measure cortical thickness: Cortical thickness should be estimated from the base of the pyramid and is generally 7–10 mm. If the pyramids are difficult to differentiate, the parenchymal thickness can be measured instead and should be 15–20 mm (Figure 1). The echogenicity of the cortex decreases with age and is less echogenic than or equal to the liver and spleen at the same depth in individuals older than six months. In neonates and children up to six months of age, the cortex is more echogenic than the liver and spleen when compared at the same depth.[1]
  • Evaluate the echogenicity of the kidneys, comparing to the liver on the right side, and to the spleen on the left side if possible. A hyperechoic renal cortex indicates chronic kidney disease (see section below).
  • Have at least a quick glance at the bladder for excessive distension or obvious pathology.

Findings in the normal kidney

In the longitudinal scan plane, the kidney has the characteristic oval bean-shape. The right kidney is often found more caudally and is slimmer than the left kidney, which may have a so-called dromedary hump due to its proximity to the spleen. The kidney is surrounded by a capsule separating the kidney from the echogenic perirenal fat, which is seen as a thin linear structure.[1]

The kidney is divided into parenchyma and renal sinus. The renal sinus is hyperechoic and is composed of calyces, the renal pelvis, fat and the major intrarenal vessels. In the normal kidney, the urinary collecting system in the renal sinus is not visible, but it creates a heteroechoic appearance with the interposed fat and vessels. The parenchyma is more hypoechoic and homogenous and is divided into the outermost cortex and the innermost and slightly less echogenic medullary pyramids. Between the pyramids are the cortical infoldings, called columns of Bertin (Figure 2). In the pediatric patient, it is easier to differentiate the hypoechoic medullar pyramids from the more echogenic peripheral zone of the cortex in the parenchyma rim, as well as the columns of Bertin (Figure 3).[1]

Figure 4. Doppler ultrasound (US) of a normal adult kidney with the estimation of the systolic velocity (Vs), the diastolic velocity (Vd), acceleration time (AoAT), systolic acceleration (Ao Accel) and resistive index (RI). Red and blue colors in the color box represent flow towards and away from the transducer, respectively. The specrogram below the B-mode image shows flow velocity (m/s) against time (s) obtained within the range gate. The small flash icons on the spectrogram represent initiation of the flow measurement.[1]

Doppler ultrasonography of the kidney is widely used, and the vessels are easily depicted by the color Doppler technique in order to evaluate perfusion. Applying spectral Doppler to the renal artery and selected interlobular arteries, peak systolic velocities, resistive index and acceleration curves can be estimated (Figure 4), e.g., peak systolic velocity of the renal artery above 180 cm/s is a predictor of renal artery stenosis of more than 60%, and the resistive index, which is a calculated from peak systolic and end systolic velocity, above 0.70 is indicative of abnormal renovascular resistance.[1]

Cystic renal masses

Masses are seen as a distortion of the normal renal architecture. Most renal masses are simple cortical renal cysts with a round appearance and a smooth thin capsule encompassing anechoic fluid. The incidence increases with age, as at least 50% of people above the age of 50 have a simple cyst in one of the kidneys. Cysts cause posterior enhancement as a consequence of reduced attenuation of the ultrasound within the cyst fluid (Figure 5). The simple cyst is a benign lesion, which does not require further evaluation.[1]

Complex cysts can have membranes dividing the fluid-filled center with internal echoes, calcifications or irregular thickened walls. The complex cyst can be further evaluated with Doppler US, and for Bosniak classification and follow-up of complex cysts, either contrast-enhanced ultrasound (CEUS) or contrast CT is used (Figure 6). The Bosniak classification is divided into four groups going from I, corresponding to a simple cyst, to IV, corresponding to a cyst with solid parts and an 85%–100% risk of malignancy.[1] In polycystic kidney disease, multiple cysts of varying size in close contact with each other are seen filling virtually the entire renal region. In advanced stages of this disease, the kidneys are enlarged with a lack of corticomedullary differentiation (Figure 7).[1]

Solid renal masses

Figure 8. Cortical solid mass, which later was shown to be renal cell carcinoma. Measurement of the solid mass on the US image is illustrated by ‘+’ and a dashed line.[1]
Main article: Ultrasonography of renal tumors


Kidney stone disease

Chronic kidney disease

US is useful for diagnostic and prognostic purposes in chronic kidney disease. Whether the underlying pathologic change is glomerular sclerosis, tubular atrophy, interstitial fibrosis or inflammation, the result is often increased echogenicity of the cortex. The echogenicity of the kidney should be related to the echogenicity of either the liver or the spleen (Figure 22 and Figure 23). Moreover, decreased renal size and cortical thinning are also often seen and especially when disease progresses (Figure 24 and Figure 25). However, kidney size correlates to height, and short persons tend to have small kidneys; thus, kidney size as the only parameter is not reliable.[1]

Acute renal injury

The acute changes in the kidney are often examined with US as the first-line modality, where CT and magnetic resonance imaging (MRI) are used for the follow-up examinations and when US fails to demonstrate abnormalities. In evaluation of the acute changes in the kidney, the echogenicity of the renal structures, the delineation of the kidney, the renal vascularity, kidney size and focal abnormalities are observed (Figure 26 and Figure 27). CT is preferred in renal traumas, but US is used for follow-up, especially in the patients suspected for the formation of urinomas (Figure 28).

US-guided intervention

Figure 29. (A) Percutaneous nephrostomy tube placed through a calyx in the lower pole of a kidney with hydronephrosis. (B) The pigtail catheter is placed in the dilated calyx. The tube in (A) and the pigtail in (B) are marked with white arrows.[1]

Sonography is the modality of choice for guidance when performing intervention in the kidney, whether it is kidney biopsy, percutaneous nephrostomy or abscess drainage. Historically, thermal ablation of renal tumors is performed under CT guidance, as the risk of injuring neighboring intestines during the US-guided procedure was considered too high due to poor identification of the moving bowels. However, recent guidelines for renal interventional US include radiofrequency, microwave and cryoablation with US as the ideal imaging guide.[1]

For percutaneous nephrostomy and abscess drainage, either the one-step or the Seldinger technique is used. Using the Seldinger technique, the cavity is punctured with a sharp hollow needle, called a trocar. A round-tipped guidewire is then advanced through the lumen of the trocar, and after withdrawal of the trocar, a catheter or nephrostomy can be inserted over the guidewire to ensure correct placement. The one-step technique is when insertion of the drain or nephrostomy is done without the aid of a guidewire. The interventions are performed under local anesthesia and in a sterile setup. The procedures can be carried out with or without needle guidance according to preference, experience and setup (Figure 29).[1]

CEUS, image fusion and elastography

contrast-enhanced ultrasound (CEUS) can evaluate microvasculature, which color Doppler US is unable to detect. In renal US examination, CEUS can be used to differentiate tumor and pseudotumor, such as prominent columns of Bertin. Pseudotumors enhance as adjacent renal tissue. The use of CEUS is recommended in special cases to distinguish between cystic and hypovascularized solid lesions, to characterize complex cysts, abscesses, traumatic lesions and ischemic lesions.[1]

Figure 30. Renal cell carcinoma successfully treated with thermal ablation, as no contrast enhancement is seen.[1]

Solid malignant tumors in the kidney do not exhibit specific enhancement patterns like some liver lesions, and no valid enhancement criteria between benign and malignant renal lesions have been proposed. However, CEUS is used in some patients after ablation of renal cell carcinoma to evaluate contrast uptake in the treated area (Figure 30).

Image fusion of ultrasound with a previously recorded dataset of CT or other modalities is rarely used in renal US. Reports on image fusion using CEUS or US combined with CT or MRI in the examination of renal lesions and in difficult US-guided renal interventions have been published (Figure 31). However, no recommendations have been published so far.[1]


  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.
  2. NU Hospital Group, Sweden


  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 Content initially copied from: Hansen, Kristoffer; Nielsen, Michael; Ewertsen, Caroline (2015). "Ultrasonography of the Kidney: A Pictorial Review ". Diagnostics 6 (1): 2. doi:10.3390/diagnostics6010002. ISSN 2075-4418.  (CC-BY 4.0)
  2. M Thorp (2004). "An Approach To The Evaluation Of An Elevated Serum Creatinine ". The Internet Journal of Internal Medicine 5 (2). Archived from the original. .