IVP INTERPRETATION Dr. Jaturat Kanpittaya

Introduction IVP has long been cornerstone of imaging evaluation of urinary tract disease Global , important in diagnosis of KUB disease Evaluation in hematuria , stone disease , post therapeutic evaluation of stone Good technique , understanding limitation , basic rule of interpretation Relate with other imaging modality U/S , CT , MRI

Contrast material Excrete by glomerular filtration Concentration in the postglomerular nephron and progressive opacification Of the urinary tract

Standard procedure for IVP Scout film ( technique 65-75 kVp , level ) Nephrotomogram (1-3 min film ) 5 min KUB film Abdominal compression Pyelographic image ( 10 min film ) Ureter-bladder image ( release compression , 15 min film , supine , prone , oblique , upright ) Bladder image ( delay , oblique , post void )

Middle ureteric calculi

Lower ureteric calculi

Plain film , cover symphysis pubis: urethral calculus ..\Intravenous Urography\Figure\f1.gif

Plain film : left flank pain , Sriated gas within renal parenchyma , perirenal , RP , URGENT INTERVENTION Emphysematous pyelonephritis

IVP normal size kidney

Abdominal compression Optimal evaluation of ureter and pelvicalyceal system , distension of collecting system Contraindication; *Presence of obstruction *Abdominal aortic aneurysm *Abdominal mass *Recent abdominal surgery *Severe abdominal pain *Suspected of urinary tract trauma *Urinary diversion or renal transplant

Value of abdominal compression distended collecting system

Value of oblique film , posterior papillary tip

Value of fluoroscopy , demonstrate entire ureter

Bladder image Distend and opacity , oblique image , evaluate bladder disease Post void image may be useful for evaluate filling defect

Collapse urinary bladder

Urographic interpretation Nephrotomographic phase; Evaluate renal parenchyma , smooth contour, renal size ( 9-13 cm ) Pyelographic and ureteric image; Evaluate renal collecting system Bladder image ; Early , delay , post void film assess bladder pathology

Renal size Related with age 9-13 cm in length (cephalocaudal) Kidney slightly larger in men than women LK >RK 0.5 cm Significant discrepancies RK >1.5 cm larger than LK LK >2 cm larger than RK

Polycystic kidney disease LK enlarge Swiss cheese nephrogram

Renal contour abnormality Contour abnormality associate with change in parenchymal thickness ( interpapillary line ) interprete underlying collecting system Parenchymal thickness : average 3-3.5 cm polar region 2-2.5 cm interpolar region

Normal interpapillary line

Parenchymal thickness Indentation or increase thickness : * Congenital anatomic variation * Predictable location Increase parenchymal thickness , calyceal distortion : * Mass Decrease parenchymal thickness , calyceal changes : * Post inflammation * Stone–relate scar Parenchymal loss , without calyceal distortion: * Renal infarction

Indentation , cortical hump

Nephrotomographic image Require adequate * Renal blood flow * Normal parenchymal excretory function * Normal venous outflow

10 min film : persist nephrogram small size RK hypotension , CM reaction

Renal artery stenosis RK nephrotomogram , 15 min small size RK with decrease density

1min asym nephrogram 80 min dense nephrogram RK , high grade obstruction , Rt UV stone 2mm

Nephrotomogram Absence of nephrotomographic enhancement within the lesion : suggest a simple cyst , parenchymal beaking ( margin of unenhanced tissue )

Renal cyst : cortical beak

Reflux nephropathy ; clubbing calyces , parenchymal loss

Mass Increase parenchymal thickness Calyceal distortion Double contour at tomography CT is suggested for solid lesion

Renal cell carcinoma mass mid portion of LK , distortion collecting system

Position of kidney Alteration of axis and position : RK is lower than LK ( liver ) Vertical axis parallel upper 1/3 of psoas Alteration of axis and position : * Congenital renal anomaly * Abdominal or RP mass

Horseshoe kidney

HORSESHOE KIDNEY

Renal cell CA mass upper pole of RK axis deviation parallel with psoas m. distortion collecting system

RCC lower pole of LK

Pyelographic and ureteric image IVP , CT urogram good for evaulation of collecting system , urothelium-line surface: * TCC urinary tract * Pyelitis cystica

Transitional cell CA ; renal pelvis irregular papillary filling defect

Pyeloureteritis cystica

Calyces Compound calyces : polar region Simple papillae , classic calices : interpolar Obstruction : * Round forniceal margin , * Loss of papillary impression , * Clubbing calices

Left distal UC with obstruction

Papillae Papillary blush Contrast within papillae Tubular ectasia : Medullary sponge kidney

Papillary blush

Medullary sponge kidney; tubular ectasia microscopic hematuria , cavity fill with CM “ growing calculus sign “

Renal papillary necrosis ; sickel cell anemia, analgenic abuse

Aberrant papilla , benign

Calyceal diverticulum with stone

Phantom calix Usually number of calices 7-14 Phantom calix : * Benign -TB * Malignant process -Oncocalix

Tuberculosis ; phantom calices lower pole LK , moth-eaten calices D/DX TCC

TCC ; Oncocalyx ( tumor filled calix) upper pole of LK

Impression on collecting system Vascular compression Renal sinus cyst

Vascular impression

Renal sinus cyst , (not hydronephrosis) narrow displacement of collecting system and renal pelvis

Ureter collecting system dilatation Segmental nonvisualization of ureter due to peristalsis Persistence column of contrast along course of ureter on several image indicate obstruction : collecting system dilatation

Stone at right UV junction , edema interureteric ridge ( normal < 3mm )

Ureteric course From renal pelvis , lateral to psoas m. About L3 pass ventral to psoas m. Upper RP course , pass along lateral ½ of transverse process of upper lumbar vertebrae Cross anterior to iliac vessel ( medial ) Pelvic course , parallel inner margin of iliac bone and enter bladder at UV junction

Abnormal ureteric course Medial deviation of ureter : * Overlying pedicle, medial to pedicle * Separation of ureter <5 cm Lateral deviation : * Ureter lie >1cm beyond tip of transverse process Abrupt changes in ureteric course

RP and iliac adenopathy ; lateral proximal medial distal ureteral deviation pear bladder splenomegaly

Internal iliac aneurysm ; acute medial deviation of right ureter

Circumcaval ureter ; reverse J hydronephrosis

Psoas muscle hypertrophy: distal ureter central locate straightened abrupt transition of mid ureter over belly of m.

Ureteric diameter Diameter > 8 mm consider dilatation : * Obstruction * Ureterocele * Nonobstructive dilatation , high urine flow ( fluid diuresis , DI ) * Reflux * Inflammatory process

Orthotopic ureterocele , cobra head ureteral dilatation

Megaureter ; dilatation distal 1/3 ureter taper narrow at UV junction

Ureter Normal peristalsis Anatomic narrowing : * UPJ junction * Iliac vs transition * UV junction Vascular impression of gonadal vein , prominent in female

Ureteric nothching extrinsic vascular narrowing gonadal vein

Ureter Ureteral pseudodiverticula : Ureteric filling defect : narrow with outpouching ureteric wall increase of TCC , especially in bladder Ureteric filling defect : TCC , patient present with hematuria

Ureteral pseudodiverticula, narrow risk of TCC , especially bladder

TCC left renal pelvis and ureter goblet filling defect lower ureter

TCC distal ureter with filling defect on fluorocopy , persist hematuria

Bladder image 15-30 min or delay film distend lumen evaluate the bladder , wall thicken Post void film may be helpful for evaluation mucosal lesion

Hemorrhagic cystitis; lobulate irregular thick wall bladder

Neurogenic bladder ; bladder diverticula, irregular thick wall bladder

Bladder Bladder is tether only at the lower aspect of anatomic pelvis Position and appearance can be significant distort by * Mass ( intrinsic , extrinsic ) * Hematoma * Pelvic lipomatosis

Ovarian cyst ; smooth impression posterolateral aspect of bladder

Pelvic trauma hematoma pear deviate, elongate bladder , blood clot in lumen

Pelvic lipomatosis medial deviation of ureter distortion of bladder

Bladder outlet obstruction Bladder base defect ( prostatic disease) with bladder wall irregular thickened , contour abnormality with cellule or diverticulum formation * Cellule – early herniation of bladder mucosa usually as wide as tall

Prostatic enlargement ; bladder base defect with bladder outlet obstruction, thickened wall , cellule

Anterior vaginal wall mass , bladder base , female prostate defect uterine superior impression

Bladder Early filling image and post void film : most sensitive image for evaluate filling defect

Bladder transitional cell CA; irregular filling defect , stipple sign

TCC Urinary bladder

TCC ; visible in postvoid film

Conclusion Tailored urographic study allow *Optimal visualization of urinary tract *Provide diagnostic detail Important : * Good technique * Understanding limitation * Basic rule of interpretation * Correlate with other imaging modality

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