Given his hematuria, a screening abdominal ultrasound was also performed (Discussion Videos 4, 5). Renal ultrasound revealed a right-sided isoechoic lesion, not well demarcated from the kidney, that was consistent with a mass. Solid renal masses are heterogeneous, isoechoic, or hypoechoic, which can vary in size and are present adjacent to normal renal parenchyma. Ultrasonography can be used to differentiate between cystic and solid masses. All solid renal masses in adults should be considered malignant until proven otherwise. In addition to the renal mass, diaphragmatic metastasis was seen. The presence of a mirror artifact reflected across the diaphragm is shown. Areas of very high acoustic impedance, such as the diaphragm, may serve as an acoustic mirror and deflect ultrasound beams to the side. Mirror artifacts will always be deeper to the true reflector because the redirected beam takes longer to reach the transducer.