1. IVP INTERPRETATION
Dr. Jaturat Kanpittaya

2. 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

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

4. Standard procedure for IVP
Scout film ( technique 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 )

5. Middle ureteric calculi

6. Lower ureteric calculi

7. Plain film , cover symphysis pubis: urethral calculus
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8. Plain film : left flank pain , Sriated gas within renal parenchyma , perirenal , RP , URGENT INTERVENTION Emphysematous pyelonephritis

9. IVP normal size kidney

10. 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

11. Value of abdominal compression distended collecting system

12. Value of oblique film , posterior papillary tip

13. Value of fluoroscopy , demonstrate entire ureter

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

15. Collapse urinary bladder

16. 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

17. 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

18. Polycystic kidney disease LK enlarge Swiss cheese nephrogram

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

20. Normal interpapillary line

21. 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

22. Indentation , cortical hump

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

24. 10 min film : persist nephrogram small size RK hypotension , CM reaction

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

26. 1min asym nephrogram 80 min
dense nephrogram RK , high grade obstruction ,
Rt UV stone 2mm

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

28. Renal cyst : cortical beak

29. Reflux nephropathy ; clubbing calyces , parenchymal loss

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

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

32. 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

33. Horseshoe kidney

34. HORSESHOE KIDNEY

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

36. RCC lower pole of LK

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

38. Transitional cell CA ; renal pelvis irregular papillary filling defect

39. Pyeloureteritis cystica

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

41. Left distal UC with obstruction

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

43. Papillary blush

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

45. Renal papillary necrosis ; sickel cell anemia, analgenic abuse

46. Aberrant papilla , benign

47. Calyceal diverticulum with stone

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

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

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

51. Impression on collecting system
Vascular compression
Renal sinus cyst

52. Vascular impression

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

54. 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

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

56. 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

57. 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

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

59. Internal iliac aneurysm ; acute medial deviation of right ureter

60. Circumcaval ureter ; reverse J hydronephrosis

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

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

63. Orthotopic ureterocele , cobra head ureteral dilatation

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

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

66. Ureteric nothching extrinsic vascular narrowing gonadal vein

67. 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

68. Ureteral pseudodiverticula, narrow risk of TCC , especially bladder

69. TCC left renal pelvis and ureter goblet filling defect lower ureter

70. TCC distal ureter with filling defect on fluorocopy , persist hematuria

71. 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

72. Hemorrhagic cystitis; lobulate irregular thick wall bladder

73. Neurogenic bladder ; bladder diverticula, irregular thick wall bladder

74. 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

75. Ovarian cyst ; smooth impression posterolateral aspect of bladder

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

77. Pelvic lipomatosis medial deviation of ureter distortion of bladder

78. 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

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

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

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

82. Bladder transitional cell CA; irregular filling defect , stipple sign

83. TCC Urinary bladder

84. TCC ; visible in postvoid film

85. 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

86. Thanks you