Radioloksabha spotters/cases series- XIII Conventional procedures Radioloksabha is a free educational website for medical students, residents and doctors to share knowledge contributing to world of Radiology Radioloksabha spotters/cases series- XIII Conventional procedures Contributing radiologists - Dr Anju Chaudhary (MD). Dr Pavankumar(DMRD, DNB) . Dr Saarah khan ( MD) . Dr Ashok(MD) we support FOAMrad - Free open access radiology education

Description The patient is placed in lithotomy position and the cervix cannulated with Leech – Wilkinson cannula under aseptic conditions. Preliminary antero- posterior film taken followed by injection of 10-20 ml non iodinated contrast under fluoroscopic visualization and spot films taken. FINDINGS: The uterine cavity well delineated with contrast. The uterine cavity is normal in outline, no irregularities noted. No abnormal filling defect noted within. Non spillage of the contrast media in the left pelvic cavity Right fallopian tube is well delineated with contrast. Evidence of spillage of contrast into peritoneal cavity noted on right side. IMPRESSION: In a known case of bilateral tubal recanalisation. The current HSG shows: Non spillage of the contrast media in the left pelvic cavity - likely left fallopian block

FINDINGS: On clinical examination one cervical os noted. Two uterine cavity is seen being well delineated with contrast. The uterine cavity is normal in outline, no irregularities noted. No abnormal filling defect noted within. Right fallopian tube is delineated with contrast. Left fallopian tube noted delineated. Right fallopian tube is normal in course and caliber. Evidence of spillage of contrast into peritoneal cavity noted on the right side. IMPRESSION: In a known case of left salphingectomy, HSG reveals -  -features suggestive of Bicornuate unicolis uterus with free spillage from the right fallopian tube

Procedure was done under aseptic precautions using non ionic contrast media (Iohexol  300 mg I/ml, mixed with equal volumes of normal saline to make 120 ml and injected through the 5F infant feeding tube into bladder). Findings SCOUT IMAGE: Bilateral renal shadows and psoas shadows are well seen.                            No evidence of radio dense opacity s/o calculus is noted in the renal shadow or in the pelvis.                              Visualized bones are normal density and contour. MCU findings: Evidence of contrast filling the bladder noted. Bladder is seen in its normal anatomical location. Urinary bladder surface shows no irregularity. No evidence of contrast entering the lower part of ureter on both sides on straining. Prostatic part of posterior urethra is well delineated with contrast. Normal in course, calibre and wall outline. No evindece of stricture/ diverticulae or abnormal hgolding up of contrast is noted. Contrast is seen beyond the prostatic urethra , membranous urethra and anterior urethra appear normal. Normal in course, calibre and wall outline. No evindece of stricture/ diverticulae or abnormal hgolding up of contrast is noted. Post void image:No significant post void residue IMPRESSION: Normal micturating cystourethrogram study.

FINDINGS: RGU Anterior urethra is well delineated with contrast . Evidence of  short segment narrowing noted at the bulbomembranous urethra  However the contrast is seen filling the bladder partially. IMPRESSION:  SHORT SEGMENT SOFT STRICTURE AT BULBOMEMBROUS URETHRA  - Suggested MCU for further evaluation

RGU FINDINGS: Complete luminal narrowing with non-passage of the contrast into the bladder noted at bulbo- membranous junction of the anterior urethra. Penile and bulbar urethra is well delineated with contrast and is normal. IMPRESSION: Stricture at bulbo-membranous junction

RGU Procedure was done under aseptic precautions using non-ionic contrast media. FINDINGS: Complete luminal narrowing with non-passage of the contrast into the bladder noted at bulbo-membranous junction of the anterior urethra. Penile and bulbar urethra is well delineated with contrast and is normal. IMPRESSION: Hard stricture at bulbo-membranous junction

Case no - 4

RETROGRADE URETHROGRAPHY       Procedure was done under aseptic precautions using non- ionic contrast media. FINDINGS: Anterior urethra is well delineated with contrast Wall appears irregular, predominantly seen in the penile and bulbar part of anterior urethra - s/o urethretis No evidence of stricture or abnormal narrowing noted in the antreior urethra Contrast is seen filling the bladder partially. IMPRESSION: Findings suggestive of: Features suggestive of urethritis

MICTURATING CYSTOURETHROGRAPHY Procedure was done under aseptic precautions using non ionic contrast media Findings Evidence of contrast filling the bladder noted. Bladder is seen in its normal anatomical location. Urinary bladder surface shows irregularity. There is evidence of an outpouching noted arising from the left lateral wall of urinary bladder. No evidence of contrast entering the lower part of ureter on both sides. Prostatic part of posterior urethra is well delineated with contrast. Contrast is seen beyond the prostatic urethra and membranous urethra is normal. IMPRESSION: Diverticulum arising from the left lateral wall of urinary bladder

MICTURATING CYSTOURETHROGRAPHY Procedure was done under aseptic precautions using non ionic contrast media. Findings There is dilatation of the prostatic part of the posterior urethra. The bladder appears elongated showing irregularities and trabeculations giving a pine cone appearance. Anterior urethra is well delineated with contrast. *On ultrasound correlation there is bilateral hydroureteronephrosis likely suggestive of bilateral vesico-ureteric junction reflux however could not be elicited on MCU due to non-cooperative patient. IMPRESSION: Features suggestive of posterior urethral valve with secondary neurogenic bladder and bilateral vesico-ureteric junction reflux.

RETROGRADE URETHROGRAPHY     Procedure was done under aseptic precautions using non-ionic contrast media. FINDINGS: Narrowing of penile urethra noted with pre-stenotic dilatation of the bulbar and penile urethra - features likely of penile urethral stricture. Anterior urethra is well delineated with contrast. Contrast is seen filling the bladder partially. IMPRESSION: Narrowing of penile urethra with pre-stenotic dilatation of the bulbar and penile urethra - features likely of penile urethral stricture. - Suggested MCU for further evaluation of posterior urethra

RETROGRADE URETHROGRAPHY   Procedure was done under aseptic precautions using non-ionic contrast media. FINDINGS: Anterior urethra is well delineated with contrast and is normal. There is evidence of contrast filled , smoothly marginated outpouching  measuring 19x9.4 mm (CcxTR) is noted in the peno-bulbar juction. However no stricture seen. No evidence of abnormal dilatation/ stricture/ filling defect noted in the anterior urethra. Contrast is seen filling the bladder partially. IMPRESSION:  In a known case of stricture urethra, post urethroplasty status, present RGU study reveals- A small outpouching in the bulbar region - likely post operative urethral diverticulum

MICTURATING CYSTOURETHROGRAPHY Procedure was done under aseptic precautions using non ionic contrast media. Findings Evidence of contrast filling the bladder noted. Bladder is seen in its normal anatomical location. Urinary bladder surface shows no irregularity. There is evidence of contrast refluxing into the left ureter and kidney. The ureter is dilated and torchuous in course. The  pelvicalyceal system is dilated with balloning of calyces with loss of fornices impressions noted in the left kidney - s/o Left Grade V vesicoureteric reflux.  No reflux of contrast is noted in the right ureter and kidney. Prostatic part of posterior urethra  are poorly delineated  due to dilted contrast. However good urinary stream and insignificant post void residue is observeed in the procedure. IMPRESSION: MCU study reveals- Left Grade Vb vesicoureteric reflux

 BARIUM MEAL    Procedure was done by administering barium sulphate suspension( 250% w/v , 135ml) orally and fluroscopic observation done. Filming done in erect, supine, prone and oblique views and spot films taken FINDINGS: The oesophagus was visualised while swallowing.  Post oesophageal dilatation- narrowing of the distal esophagus from the level of T9 to T10 noted, however the contrast is seen to flow into the stomach. Stricture noted at the pyloric end of the stomach with non passage of the contrast into the duodenum as seen in post 3 hour films. Rest of the stomach is normal in size, shape, position.. Barium is seen in the rectum- due to previous braium study performed on 16/6/18. IMPRESSION: Stricture at the pyloric end of stomach with non passage of barium in post 3 hour film.

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