Intravenous Urography ZMDA MRD450
Intravenous Urography Introduction Terminology Patient preparation Contrast Scout films Compression Tomography Routine procedure/filming sequence LearningRadiology.com
Intravenous Urography Aka excretory urography Use decreased significantly in recent years CT, US, MR is replacing Remains primary modality for visualization of pelvocalyceal system and ureter LearningRadiology.com
Terminology ZMDA MRD450
Terminology Urogram Visualization of kidney parenchyma, calyces and pelvis resulting from IV injection of contrast Pyelogram Describes retrograde studies visualizing only the collecting system So, IVP is misnomer, should be IVU LearningRadiology.com
Describes visualization of the bladder Urethrography Cystography Describes visualization of the bladder Urethrography Visualization of urethra Cystourethrography Combined study to visualize bladder and urethra LearningRadiology.com
One more word about terminology…. Contrast is what we give intravenously Dye is used on clothes and in cooking to change the color of things—it is not given IV to patients! LearningRadiology.com
Preparation of patients for IVU Bowel Prep Controversial Eliminates fecal material and reduces amount of gas in bowel Dehydration Now thought to be unnecessary Improves degree of opacification of contrast Patients now kept NPO to decrease chance of vomiting as well as producing slight dehydration LearningRadiology.com
Contrast Will be covered later ZMDA MRD450
Scout Films ZMDA MRD450
Scout films for IVU Evaluate technique Look for calcifications Abnormal soft tissue Air within urinary tract Bony abnormalities Determine if a contraindication to abdominal compression exists LearningRadiology.com
LearningRadiology.com
Abnormal Soft Tissue Renal outlines Spleen Liver Loss of psoas margin may indicate retroperitoneal pathology LearningRadiology.com
Air Within urinary tract may indicate fistula or gas forming infections If patient has Foley, may have been introduced thru Foley LearningRadiology.com
Bony abnormalities Osteoblastic metastases due to prostate cancer Spine abnormalities may be associated with neurogenic bladder LearningRadiology.com
Proper scout radiograph Supine Should extend from upper renal poles to 2 cm below the inferior margin of pubic symphysis Often difficult to fit this large area on a single radiograph, may need…. 14 x 17 of abdomen 10 x 12 of lower pelvis LearningRadiology.com
Proper scout LearningRadiology.com
LearningRadiology.com
LearningRadiology.com
LearningRadiology.com
Ureteral Compression films ZMDA MRD450
Value of ureteral compression Normal peristalsis may leave portions of ureters empty of contrast With compression, ureters are compressed against pelvis and are temporarily obstructed As a result, the proximal ureters and intrarenal collecting system are optimally distended LearningRadiology.com
LearningRadiology.com
Contraindications to compression Abdominal Aortic Aneurysm Ureteral obstruction Acute abdominal/flank pain Recent abdominal surgery Abdominal stomas Colostomy, ileostomy, ileal conduit LearningRadiology.com
Proper compression Ureters are compressed against pelvis Place belt and pneumatic balloons at upper edge anterior superior iliac spine Paddles should nearly meet at the midline LearningRadiology.com
LearningRadiology.com
LearningRadiology.com
Tomograms ZMDA MRD450
Scout tomograms LearningRadiology.com
Estimated midcoronal kidney level is determined as… Anterior abd is 27 cm Example 27/3 = 9 9+1 =10cm Tabletop is 0 cm position Estimated midcoronal kidney level is determined as… ( Distance in cm from table top to ant abd wall / 3) +1 LearningRadiology.com
Tomograms Average patient-- tomos at 8, 9, 10 cm Heavier patients– tomos at 9, 10, 11 Thinner patients– tomos at 7, 8, 9 LearningRadiology.com
Remember upper pole of kidney is more posterior than lower pole Think about kidney lying on psoas muscle that gets larger more inferiorly so in average patient Upper pole best seen at 8 cm from table top Mid kidney best seen at 9 cm from table top Lower pole best seen at 10 cm from table top LearningRadiology.com
Tomograms May not need tomos If study is a repeat of a study from short time ago when kidneys have been evaluated by other modality and were shown to be normal LearningRadiology.com
Value of tomograms with barium on scout LearningRadiology.com
Value of tomograms to get rid of overlying bowel gas LearningRadiology.com
Routine procedure/ filming sequence ZMDA MRD450
General principles of IVU No universally accepted filming sequence Best examination is monitored by radiologist and modified to answer clinical question However, certain views are essential to every examination Scout Film Early Nephrogram films Excretion films LearningRadiology.com
Example Preliminary scout (patient should void before study) Inject contrast Immediate tomograms at 2,3,4 minutes 10 x 12 over kidneys 5 minute film 14 x 17 Inflate compression paddles 10 minute supine film with compression 15 minute film (14 x 17) immediately after release of compression Bladder image Optional—delayed, oblique, prone or post-void LearningRadiology.com
Additional views Oblique Views Good for questionable ureteral lesions For differentiating extrinsic and intrinsic renal and ureteral masses Visualization of posterolateral aspect of bladder LearningRadiology.com
Value of oblique views to move ureter from spine LearningRadiology.com
Delayed Views 1 hour to 48 hours- in cases of obstruction Better to CT patient for immediate diagnosis LearningRadiology.com
Additional views Remember that contrast opacified urine is heavier than nonopacified urine, so use gravity… Prone film Helps fill ureteral areas not seen in supine position since upper ureters more anterior than kidney LearningRadiology.com
Erect film Promotes emptying of collecting system Optimal for showing bladder hernias Shows layering of calculi in cysts Demarcates areas of ureteral obstruction better than prone views LearningRadiology.com
Example of prone view in patient whose left ureter was not filling on supine views LearningRadiology.com
Postvoiding films To determine residual urine in bladder—especially in older male patients To look for bladder neoplasms Must be obtained immediately after voiding LearningRadiology.com
Transitional cell carcinoma LearningRadiology.com
Images from Normal IVU Studies… LearningRadiology.com
1,3,5 minute tomo images 1 min. 3 min 5 min LearningRadiology.com
Examples of compression images 10 min with compression 15 min without compression LearningRadiology.com
immediately after release of compression Film with compression immediately after release of compression LearningRadiology.com
Value of fluoroscopy LearningRadiology.com
Normal Bladder, pre and post-void LearningRadiology.com
The End ZMDA MRD450