1. Intravenous Urography
ZMDA MRD450

2. Intravenous Urography
Introduction
Terminology
Patient preparation
Contrast
Scout films
Compression
Tomography
Routine procedure/filming sequence
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3. 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
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4. Terminology
ZMDA MRD450

5. 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
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6. Describes visualization of the bladder Urethrography
Cystography
Describes visualization of the bladder
Urethrography
Visualization of urethra
Cystourethrography
Combined study to visualize bladder and urethra
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7. 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!
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8. 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
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9. Contrast Will be covered later
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10. Scout Films
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11. 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
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13. Abnormal Soft Tissue Renal outlines Spleen Liver
Loss of psoas margin may indicate retroperitoneal pathology
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14. Air
Within urinary tract may indicate fistula or gas forming infections
If patient has Foley, may have been introduced thru Foley
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15. Bony abnormalities Osteoblastic metastases due to prostate cancer
Spine abnormalities may be associated with neurogenic bladder
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16. 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
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17. Proper scout
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21. Ureteral Compression films
ZMDA MRD450

22. 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
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24. Contraindications to compression
Abdominal Aortic Aneurysm
Ureteral obstruction
Acute abdominal/flank pain
Recent abdominal surgery
Abdominal stomas
Colostomy, ileostomy, ileal conduit
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25. 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
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28. Tomograms
ZMDA MRD450

29. Scout tomograms
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30. 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
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31. Tomograms Average patient-- tomos at 8, 9, 10 cm
Heavier patients– tomos at 9, 10, 11
Thinner patients– tomos at 7, 8, 9
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32. 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
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33. 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
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34. Value of tomograms with barium on scout
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35. Value of tomograms to get rid of overlying bowel gas
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36. Routine procedure/ filming sequence
ZMDA MRD450

37. 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
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38. 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
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39. Additional views Oblique Views Good for questionable ureteral lesions
For differentiating extrinsic and intrinsic renal and ureteral masses
Visualization of posterolateral aspect of bladder
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40. Value of oblique views to move ureter from spine
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41. Delayed Views 1 hour to 48 hours- in cases of obstruction
Better to CT patient for immediate diagnosis
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42. 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
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43. 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
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44. Example of prone view in patient whose left ureter was not filling on supine views
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45. Postvoiding films
To determine residual urine in bladder—especially in older male patients
To look for bladder neoplasms
Must be obtained immediately after voiding
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46. Transitional cell carcinoma
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47. Images from Normal IVU Studies…
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48. 1,3,5 minute tomo images
1 min.
3 min
5 min
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49. Examples of compression images
10 min with compression
15 min without compression
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50. immediately after release of compression
Film with compression
immediately after release of compression
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51. Value of fluoroscopy
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52. Normal Bladder, pre and post-void
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53. The End
ZMDA MRD450