intravenous urography

Intra venous urographyDr Irfan Elahi

Consultant Nephrologist Mayo Hospital Lahore

Indications

1) Persistent or frank hematuria.

2) Renal & ureteric calculi. (Especially prior to endourological procedures)

3) Ureteric fistulas & strictures.

4) Complex urinary tract infections.

o Consists of series of film after IV administration of contrast.

Traditional preperation

4 hours starvation & liquid deprivation along with bowel purgation with laxatives.

Recent Recommendations

o Bowel preparation: unhelpful & is unpleasant for patient.

Food should be avoided 2-4 hrs before procedure.

o Fluid restriction: better opacification of collecting system.

Fluid restriction increase risk of nephrotoxicity

High risk conditions › DM › Multiple Myeloma › Hyper urecemia › Sickle cell disease › Pre existing renal disease.

Risk of contrast induced injury to previously healthy kidney is very low.

Fluid restriction should be avoided in high risk patients

If dehydration is present it should be corrected.

Classical Series

1) Pre contrast film “scout” film. (full length)2) Immediately post contrast film. (Cross

kidney)3) 5 mins after contrast film (Cross kidney).

(apply abdominal compression) 4) 15 mins after contrast. (Cross kidney)5) Immediately after release of compression

full length film. (full length)6) Post Micturation film. (full length)

Immediately post contrast film. (Cross kidney)

5 mins after contrast film (Cross kidney).(apply abdominal compression)

15 mins after contrast. (Cross kidney)

Immediately after release of compression full length film. (full length)

Post Micturation film. (full length)

Compression is omitted in : Children. Aortic aneurysm. Tender abdomen. Recent abdominal surgery. Acute abdomen including renal colic. If patient can not tolerate.

Modifications to deal with different circumstances.

o To increase the sensitivity of the procedure.

o To reduce the radiation dose.

Acute Obstruction:

There is delay in opacification of the collecting system.

Delay may be considerable up to 24 hrs or more.

It is then necessary to perform additional films

Time interval b/w films is doubled0.5 hrs/ 1 hr/ 2 hrs/ 4 hrs/ 16 hrs/ 24 hrs

as necessary.

To minimize the radiation exposure If there is no opacification at 30 mins it is usually unhelpful to perform next film before 4 hrs

In patient with strong suspicion of ureteric calculi omit all films after contrast until a full length film is performed at 15 mins.

Patients with proven ureteric calculus for follow up IVU there should be a full length plain film & 15 mins post contrast film

Pregnant female

Very rarely necessary to perform IVU. If required minimize radiation

exposure. Single full length film pre contrast. Solitary full length film at 30-45 mins.

Rapid sequencing IVU

Taken in cases of suspected renal vascular hypertension to evaluate differential rates of contrast uptake.

Several time-spaced films of kidneys within 1st several minutes after contrast.

IV Frusemide

20 mg after 15 mins with a further film 15 mins later.

In suspected obstruction if no evidence on 15 min film , it provokes hydronephrosis & pain.

Sterotypic appearance of Normal IVU

Contrast takes 12-20 sec to reach the renal arteries after iv injection.

Nephrogram : diffuse enhancement which healthy kidneys show In the 1st min of IVU.

Renal size 3-4 vertebrae in length no > 4 vertebrae

Out lines best seen in 1st 30 sec.

Medullary or pyramidal blush: Contrast may be visible as fine linear

opacities running along the medullary pyramids

Pyelogram: Excretion of contrast into the pelvis &

ureter Compression impedes ureteric

drainage & distends PCS at12-15 mins

On releasing compression increase flow in ureters making them prominent in post release film.

Normal ureters have contractions & are not seen entire length.

There are smoothly narrowed areas esp at PUJ and as the ureters cross ilial vessels in pelvis.

IVU at SZH

History taking

IVU at SZH

Weight of patient for dose of Urografin

IVU at SZH

IV Urografin

1mg/Kg Body Wt

IVU at SZH

X ray films 1) Pre contrast 2) 5 mins 3) 25 mins 4) Post void

IVU at SZH

Editing & printing of films

Caseno 1

Scout film shows radio opaque densities bilaterally in renal areas.Post Contrast films show normal renal out lines both kidneys excrete contrast promptly. Lt urogram confirms position of above mentioned calculus at lower pole moiety no hydronephrosis. Rt urogram shows double collecting system the two ureters unify in mid part it confirms the presence of above mentioned calculi in mid and lower pole of PCS, there is mild fullness of PCS

Caseno 2

Normal collecting system

Showing poorly developed papillae and smallcommunicating calyceal diverticula on IVU.

Renal dysplasia in Laurence-Moon-Biedlsyndrome

Case no 3

Pelvic kidney seen on IVU

case no 4

Intrathoracic kidney seen on IVU

Caseno 5

Normal collecting system

IVU demonstrating a horseshoe kidney

Case no 6

Duplex ureters on IVU: complete bilateral

Caseno 7

IVU demonstrating the characteristic stretching of calyces bycysts in polycystic kidneys

Case no 8

Medullary sponge kidney on IVUshowing: linear and saccular ectasia of the collecting ducts.

Case no 9

Caseno 10

Caseno 11

The plain film demonstrates calcification within distended upper pole calyces

IVU

(B) Strictures at the calyceal necks with hydrocalyces and fibrous stricturing of the renal pelvis and the ureter.

(C) shows a stricture at the neck of the upper pole calyx.

(D). Distal ureteric strictures are also present.

(E) Chronically obstructed PCS is filled with calcified material associated with complete renal parenchymaldestruction.

Urinary tract tuberculosis. . In Classical end-stage upper tract tuberculosis the result is autonephrectomy.

Case 12

(A) Normal kidneys preoperatively (fashioning of an ileal conduit)

right upper pole compound calyxnoted incidentally.

(B) Six months later showing non-obstructivedilatation of the pelvicalyceal systems and ureters due to reflux from the conduit.

(C) 3 years later showing non-obstructivedilatation of the PCS and ureters due to reflux from the conduit & progressive cortical loss, especially on the left.

Reflux nephropathy developing following fashioning of an ilealconduit

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