Intravenous pyelogram Intravenous urogram IVP - IVU Intravenous pyelogram Intravenous urogram

Urinary Anatomy Two kidneys Two ureters One urinary bladder One urethra Note: the suprarenal glands are part of the endocrine system.

Kidney anatomy Kidneys are located posteriorly in the abdomen The right kidney is lower than the left due to the position of the liver. Kidneys and ureters are primarily retroperitoneal. Distal ureters, the bladder and the urethra are infraperitoneal.

Kidney position The psoas major muscles cause the longitudinal plane of the kidneys to form a 20° angle with the midsagittal plane. The muscles expand as they progress inferior causing the upper poles to be closer to the midline than the lower pole which create about a 20° angle. The inferior vena cava and the aorta are anterior to the kidney.

Kidney position The large psoas muscles and spine cause the kidneys to also rotate backwards approximately 30° to the coronal plane

Radiographic view RPO and LPO visualize the up-side kidney RPO – left LPO – right RAO and LAO visualize the downside kidney RAO – right LAO – left

Kidney position Normally the kidneys will be situated halfway between the xiphoid process and the iliac crest. The average right kidney is 1cm lower than the left. In the erect position the kidneys will drop approx. 2 inches. Nephroptosis – kidneys drop lower than normal.

Microscopic Structure Collecting System Cortex: Nephrons ▼ Medulla: Renal pyramids (8-18) Renal papilla (openings) Minor calyces (4-13) Major calyces (2-3) Renal pelvis Ureter

Kidney Anatomy Renal papilla – opening in the collection tubules from the renal pyramid Renal pyramid – part of the collecting system found in the medulla (made of 8-18 conical masses) Major and minor calyces – hollow flat tubes Renal pelvis – major collection area Ureter – connect kidneys to bladder.

Renal parenchyma Cortex – layer of tissue containing the nephron (functional unit of the kidney). Under the cortex is the medulla which contains the structures responsible for channeling the filtrate from the nephrons to a series of tubules and collection reservoirs. The term used to describe the total functional portion of the kidney is the renal parenchyma.

Microscopic anatomy Nephron – responsible for filtering blood; there is over 1 million of them in each kidney. The loop of henle Glomeruli – small capillary tufts in the cortex Afferent vessels carry blood to the glomerus Efferent vessels carry blood away from the glomerus Bowman’s capsule – surrounds the glomerulus and is also called the glomerular capsule.

Urinary flow Filtration takes place in the glomerulus and then it is transported to the proximal convoluted tubules Then to the loop of Henle, collecting tubules and the major then minor calyces. The filtrate is collected into the renal pelvis and transported to the bladder through the ureters.

Urine production Average daily input of water is about 2.5 liters 100% is filtered; 99% is reabsorbed and returns to the blood to help control the pH and electrolytes of the body. 1% is eliminated from the body, which equals about 1.5 liters (1500 cc).

ureters Length is 28 – 34 cm in length and 1mm to 1cm in diameter Positioned on the anterior aspect of the psoas muscles, extending posteriorly until they enter the back of the bladder.

Vesicle junctions UPJ – ureteropelvic junction (junction of renal pelvis and proximal ureter) Pelvic brim – iliac blood vessels cross over the ureter. UVJ – ureterovesical junction (junction between the distal ureter and the bladder). Urine is directed downward by the process of peristalsis and gravity.

Bladder Musculomembranous sac that serves as a reservoir for urine. The bladder will flatten when empty and greatly expanded when full. Ureters enter the posterior aspect of the bladder at the ureteral opening. Trigone – triangular shaped muscular portion of the bladder formed at the entrance of the two ureters and the proximal opening of the urethra. It is attached to the pelvic floor by connective tissue. The prostate gland is found inferior to the male bladder and surrounds the proximal urethra Prostate-produces fluid to improve motility of sperm

Bladder terms Micturition – to urinate or to void; elimination of urine Incontinence – uncontrolled leakage or urine from the bladder Retention – inability to void or eliminate urine Average bladder capacity is about 350 – 500 mm liters; around 250 mm liters (1/2 to 2/3rd full gives you the urge to void)

Male organs Urinary bladder is anterior to the rectum and posterior to the symphysis Prostate gland is inferior to the urinary bladder Urethra is approximately 17.5 – 20 cm in the average male. It travels from the bladder to the prostate gland and then exits at the glans penis. Penis has two functions: passage for semen and the eliminations of urine.

Female organs Ovaries are superior to the uterus; the uterus is anterior to the rectum and posterior and superior to the urinary bladder. Fundus is superior and lies onto the bladder, the cervix is posterior but still anterior to the bladder. The female urethra is approximately 3.84 to 4 cms (1-1 ½ inches) long in the female. The shorter urethra makes woman more susceptible to UTI.

Female organs

Radiographic Anatomy Minor calyces Major calyces Renal pelvis Ureteropelvic junction Proximal ureter Distal ureter Urinary bladder

Radiographic Anatomy Distal ureter Urinary Bladder Region of trigone Region of the prostate gland Urethra

Urinary procedures IVP/ IVU Hypertensive IVU Retrograde Urography Retrograde cystography Voiding cystourethrography Bead Chain Cystogram

Excretory Urography—IVU Correct term Intravenous urogram (IVU): Radiographic examination of the urinary system Purpose of IVU ( Visualize the collecting portion of the urinary system. Assess the functional ability of the kidneys (a timed procedure). See pathology

Patient Preparation for an IVU Light evening meal prior to the procedure Bowel-cleansing laxative NPO after midnight (minimum of 8 hours) Enema on the morning of the examination Voiding prior to procedure

Ureteric Compression A method to enhance filling of pelvicalyceal system

IVU—Basic Routine Scout radiograph Injection Sample imaging routine Note time at beginning of injection. Sample imaging routine 1 min nephrogram or nephrotomography 5 min AP supine 10-15 min AP supine 20 min posterior obliques Postvoid (prone or erect)

Hypertensive IVU Performed to see if the kidneys are the cause of high blood pressure. Tomograms of the kidneys (nephrotomogram) are done starting at 1 minute post injection.

Retrograde Urography Nonfunctional surgical examination of the urinary system to check for the location of calculi and/or other reasons for obstruction. Retrograde means backward or against the flow.

Retrograde urethrography A non-functional study of the male urethra. A device known as a Brodney clamp is attached to the distal penis and allows for the injection of contrast media. The 30° right posterior oblique prevents superimposition of the bony pelvis over the urethra.

Retrograde cystography Nonfunctional examination of the urinary bladder used to rule out trauma, calculi, tumor and inflammatory disease. Bladder can hold about 350 – 500 mm liters of contrast. Contrast media is allowed to flow in by gravity only, so as not to accidentally rupture the bladder.

A combined retrograde urethrogram and cystogram, obtained via a suprapubic catheter, showing a posterior urethral disruption with extravasation of contrast dye from the transected urethra. Cystogram with dumbbell shaped urinary bladder in a sliding inguinal hernia

Voiding Cystourethrography Purpose: Functional study of the bladder and urethra Performed after routine cystogram Catheter removed and imaged while voiding Female—AP Male—30° RPO

Bead Chain Cystogram This is a special kind of voiding cystourethrogram on females with a diagnosis of stress incontinence or involuntary loss of urine. The purpose is to determine anatomical relationship of the bladder and the urethra