Cystography & Retrograde Urography RDSC 233 Unit 7 Cystography & Retrograde Urography Bontrager pp. 563-574 Radiographic anatomy Film Critique Positioning of: AP cone down bladder Oblique cone down bladder Lateral cone down bladder Voiding cystourethrogram (VCUG) female male Injection urethrogram Retrograde pyelogram Exposure Factors Radiographic Pathology What in the World? Miscellaneous, but significant, odds and ends

Preparation 1. Evaluate the order 2. Greet the patient 3. Take History Routine IVU Positioning 1. Evaluate the order 2. Greet the patient 3. Take History What is pertinent Hx? Bladder diverticula, rupture, CA, incontinence, bladder infections, outlet obstructions, vesicoureteral reflux, postoperative anastomoses. 4. Remove jewelry, check attire, snaps, pins, NG tubes, etc. 5. Explain the exam in layman’s terms 6. Questions? 7. Set technique before positioning

Cystography Cystograms are obtained in two basic ways. 1. As part of an excretory IVU. The three “cone down” views may be incorporated in an IVU routine, or may be done on request. * When a patient having an IVU has a foley catheter in place, drain the bladder before the injection, then clamp it. * When working with a catheterized patient, do not raise the bag above the level of the bladder. 2. As a retrograde cystogram. Contrast is instilled via a urinary catheter. Unless there is reflux into the ureters, no other urinary structures are seen.

Retrograde cystography * Patients arrive with a urinary (urethral) catheter in place, or it is inserted in radiography room, under aseptic conditions. * The bladder is drained of urine and contrast is dipped under gravity, never injected, or the bladder could be ruptured. * The contrast is an iodine preparation of approximately 18-30%. Common brands include: Cystografin, Cysto-Conray, Hypaque-Cysto. * Filling may be monitored under fluoroscopy, or films may be taken at intervals during filling, such as 100, 200, 250, 300cc, etc. The amount of filling is determined by patient comfort.

Setup for all cystograms Routine AP bladder positioning Setup for all cystograms 40” SID, 12:1 or 16:1 grid, 70-75 kVp for iodine, expose on expiration. Film size: 11”x14” lengthwise for distal ureters (reflux on a cystogram). It is not unusual for 10”x12” or 8”x10s” to be used crosswise instead, especially in consideration of the centering. AP position 1. Supine 2. 100-150 caudad angle 3. CR 2” superior to pubic symphysis, midline

Critique criteria for AP bladder The purpose of the caudad angle is to project the pubic bones beneath the floor of the bladder. All of the bladder is included. If using an 11” x 14”, about half of the ureters will visualize should there be reflux.

Oblique positions Routine oblique bladder positioning 1. RPO & LPO: 450-600 2. CR perpendicular 3. CR 2” superior to pubic symphysis, and 2” medial to the ASIS of the side up

Routine oblique bladder positioning Characteristics of the oblique pelvis (1-3). Phleboliths – Stones in veins. Common in large division of the iliacs around the pelvic floor. Suprapubic catheter – Used when a urethral catheter cannot be inserted. 2. In this RPO position the rami on the right are superimposed, while the obturator on the left is seen in profile. 1. AP – Obturator foramen are symmetrical, symphysis pubis is midline. 3. Also an RPO: the left SI joint is demonstrated, and the left ala is foreshortened

Critique criteria for oblique of bladder ASIS The most shallow angled cystogram is taken with a 14”x17” oblique of the kidneys (IVU). The film shown here is a 300 RPO, as evidenced by the excellent demonstration of the left SI joint When the bladder is filmed alone, 45 to 600 is used. Notice the position of the ASIS relative to the obliquity. Distance to bladder is much greater than 2” in a shallow oblique No specific structures are demonstrated on the 450 oblique. All of the bladder is included.

Critique criteria for oblique of bladder The 600 oblique is designed to demonstrate the ureterovesicle (UV) junction of the side up. All of the bladder is included, and the thigh of the independent leg is not superimposed on the bladder In a steep oblique position the ASIS is close to the center of the bladder The above obliques show diverticula at the UV junctions. The AP film is seen on the left

Lateral position Lateral bladder positioning (not routine) 1. True lateral position 2. CR perpendicular 3. CR 2” superior and 2” posterior to pubic symphysis.

Critique criteria for lateral bladder The lateral demonstrates the anterior and posterior walls of the bladder, and parts of the superior and inferior aspects not as well seen on the frontal views. All of the bladder is included. kVp will be above the optimal range, and may need to be 90 or more in larger patients. Quality will be compromised. Increased scatter also lessens the value of this view, and the gonadal dose is higher. For these reasons the lateral is most often done on special request.

Voiding Cystourethrograms (VCUG) female & male In addition to being a cystogram, the VCUG s is a functional study to examine the urethra for strictures, obstructions, diverticula, and reflux into the ureters. The patient may be recumbent or upright. Filming may be done using a spot film camera, or overhead tube. The bladder is filled retrograde via a urinary catheter (Foley). After filling the bladder the retention balloon is deflated, and the catheter is removed. The patient is instructed to begin urination into a radiolucent receptacle or absorbent padding (chux) while filming. Deflation port Foley urinary catheter. Retention balloon is inflated with sterile water or NS.

Female Voiding Cystourethrogram (VCUG) AP position 1. Supine 2. CR perpendicular 3. CR to pubic symphysis All of the bladder is included. The entire urethra is seen during micturition (micturate)

Male Voiding Cystourethrogram (VCUG) RPO 1. 300 RPO 2. CR perpendicular 3. CR to pubic symphysis 4. Superimpose urethra on thigh to act as filter All of the bladder is included. The entire urethra is seen during micturition (micturate)

Injection (retrograde) Urethrogram male only Injection urethrography is done when an obstruction hinders the insertion of a catheter, or trauma prevents urination. Brodney Clamp, (or catheter) Extravasation of contrast from ruptured bladder. Extravasate = escape out of, vs. Infiltrate = passing, or forced into.

Retrograde Pyelography: female & male Retrograde pyelograms are minor surgical procedures that are performed is a “cysto room” that is often in the surgical suite. Patients are sedated, or given general anesthesia. A cystoscope is inserted by the urologist, and the visible interior of the bladder is visually examined. Ureteral catheters are advanced through the cystoscope, and the ureteral orifice is catheterized unilaterally, or bilaterally, as indicated. The lithotomy position Used for urological procedures. In the stirrups

Retrograde Pyelography: the filming sequence ureteral catheter Scout 0900 #1 0907 #2 0912 cystoscope 3 to 5 cc of contrast is injected by the urologist. A film demonstrating the renal pelvis and calyces is taken The urologist withdraws the catheters and film of the contrast filled ureters it taken. A scout film is taken to check the technique, position, and placement of the ureteral catheters. These three films are a typical routine, though more may be taken at the urologist’s discretion. All films must be marked by the technologist: order and time.

Exposure Factors 75 kVp for optimal visualization of iodine contrast All other technique computations are the same as for the abdomen 1. 40-60% increase for oblique positions 2. 2x kVp (15% rule) and 2x mAs for lateral. 3. 25% increase of mAs when using 10”x12” for cone down views

Significant Pathologies of the kidneys and bladder and their Radiographic Appearances Calcified prostate Renal calculi Bladder stones Hydronephrosis Cystocele

Calcified Prostrate Gland With age the prostrate gland atrophies (atrophy), and sometimes calcifies. Both conditions lead to a narrowing of the prostatic urethra and the inability to completely empty the bladder. The surgical remedy is a transurethral resection of the prostate (TURP) Seen on these films is a severely calcified prostate. Though rare, bladder stones may look similar on a plane film. On a cystogram the calcifications are seen to be in the prostate.

Bladder Stones Once prevalent, stones in the bladder are rarely seen today, unless they pass from the kidneys. Stones that form in the bladder are typically large and numerous. Prior to the 20th century, bladder stones were a common malady that were so painful, due to obstructions, people subjected themselves to a procedure called “cutting for stones,” that was performed without anesthesia, antibiotics, or aseptic techniques.

Cystocele A hernia of the bladder, into the vagina, caused by a weakening of the vesicovaginal fascia during delivery. Causes urinary frequency, urgency, and dysuria. The cystocele on this upright postvoid is completely below the superior rim of the pelvic bones, and would have been missed with routine centering.

Renal calculi Kidney stones are formed in the parenchyma, calyces, pelvis of the kidneys. They may remain in place and be asymptomatic, or they come loose and travel down the ureter. Though often small, renal calculi are sharp and jagged. They cut the inside of the ureters which are rich in sensory nerves, causing intense pain. Hematuria may be a sign of passing stones. Lithotripsy is an alternative to surgery that pulverizes stones by using shock waves. An obstructed ureter caused by a kidney stone shows dilation of the ureter above the obstruction, tapering to the lodged calculus.

Renal calculi parenchyma Calculi in A thin stream of contrast is slipping by, seen to the UV junction. If the pressure were not relieved the ureter would continue to dilate. Caculi filling large parts of the calyces are called staghorn calculi A similar example is seen on this postvoid upright of the bladder. This delayed film shows that excretion of contrast is complete on the left, but a column of contrast remains in the right ureter.

Hydronephrosis When a ureter is obstucted from calculi or other causes, urine (or contrast) causes the renal pelvis and calyces to dilate as long as the kidney is functioning. A build up of fluid in the collecting system is hydronephrosis.

What in the World? Miscellaneous, but significant, odds and ends

What in the World? Review What was this? And these?

What in the World? Guess what this is

What in the World? A stent is a device that holds tissue in place, or holds open a hollow organ or vessels. These ureteral stents create an open channel from the renal pelvis to the bladder, to bypass and obstruction. What in the World?

What in the World? A percutaneous renal puncture is performed under fluoroscopy. A needle is inserted into a calyx, or the renal pelvis. A catheter is inserted into the collecting system for access to the kidney. This procedure is called a nephrostomy.

What in the World? An ectopic kidney is one that is in an abnormal position. In this case it is a transplanted kidney. Transplants are turned backwards, and placed in the pelvic cavity. The renal artery and vein are sutured to the iliac vessels. Adding a kidney, rather than replacing one, often results in a damaged kidney regenerating its function.

What in the World? A pelvic mass, seen by displacement of the bladder.

38. Excretory urograms are antegrade studies of the kidneys, ureters, and bladder. Cystograms (not IV injection) are studies of the bladder. 39. When urine (or contrast) from the bladder, flows back into the ureters, this condition is called . 40. What is the angle and direction of the CR for an AP cone down view of the bladder? 41. What is the range of obliquity for the RPO and LPO of the bladder? 42. What specific anatomy will a steeper oblique demonstrate?

38. Excretory urograms are antegrade studies of the kidneys, ureters, and bladder. Cystograms (not IV injection) are retrograde studies of the bladder. 39. When urine (or contrast) from the bladder, flows back into the ureters, this condition is called reflux. 40. What is the angle and direction of the CR for an AP cone down view of the bladder? 10-150 caudad 41. What is the range of obliquity for the RPO and LPO of the bladder? 45-600 42. What specific anatomy will a steeper oblique demonstrate? The ureterovesicle, or, ureterocystic junction.

43. What is the name, and acronym, for a functional study of the bladder and urethra? 44. What is the term that describes contrast media that has escaped from (out of) the bladder, due to a leakage or rupture? 45. What physician (

Oblique position degree of obliquity what is demonstrated RAO stomach 40 asthenic -70 hyper profile view “GI”