1. Direct contrast investigations

2.  In this group of investigations water-soluble
contrast is injected via some form of catheter
directly into part of the urinary tract.

4.  All of these procedures may potentially
introduce infection into the urinary tract and
care should he take to use a sterile technique,
 broad-spectrum antibiotics should be
administered prior to the procedure.

5. Retrograde pyelography
 This investigation aims to optimally opacify the pelvicalyceal
system and ureter.
 It usually follows an IVU with non functioning kidney
 further Improve demonstration of the collecting system,
either when there has been inadequate demonstration of part
or all of the system with ivu
 when the IVU is normal but the abnormal laboratory findings
persist.
 It is occasionally used to demonstrate the lower end of an
obstructed ureter.

6. procedure
 The urologist positions catheters within one or both
ureters cystoscopically and the patient is transferred
to the radiology department.
 Under screening control 5-20 ml of a 150 strength
water soluble iodine-containing contrast agent is
injected via each catheter in turn.
 It is important to avoid injecting air bubbles, which
can be mistaken for filling defects.
 The pelvicalyceal system and ureter should be
adequately opacified but not over distended.

7.  Spot plan film taken
 And then of opacified pelvicalyceal system and ureter
 Catheter can be withdrawn to inject contrast in particulur site
of concern
 Overvigorous injection of contrast may lead to reflux of
contrast into the collecting ducts (pyelotubular reflux) and
forniceal rupture with contrast extravasation into the renal
sinus (pyelosinus extravasation)
 more extensively into the regional lymphatic or veins
 pyelolymphatic and pyelovenous extravasation.

8. Ureteropelvic Junction Obstruction

9. Retrograde ureterogram reveals smooth narrowing and
medial shift of the ureter due to Retroperitoneal Fibrosis

10. Right retrograde pyelogram demonstrates large filling defect in
midureter due to transitional cell carcinoma

12. Loopography
The standard investigation for ileal conduits is
the loopogram

13.  It can be performed in the immediate
postoperative period to demonstrate
 The integrity of the surgical anastamoses, or
later (after months or years) to differentiate
between reflux (common) or obstruction
 ureteroconduit anastamoses

14.  A Foley catheter (12-16 gauge) is positioned so
that its balloon lies a couple of centimeters into the
conduit
 then cautiously inflated so as to produce a
reasonable seal without over distending the
conduit.
 Between 20 and 40 ml of contrast is injected
under direct screening to outline the conduit,
 which is normally of the order of 12-15 cm long.

15.  Usually there is free reflux into the ureters and
pelvicalyceal systems.
 A series of spot films are taken to record this.
 most important areas to study are the ureteroconduit
anastamoses
 A rare complication of this procedure in patients
with spinal injuries is the development of severe
hypertension (autonomic dysreflexia) due to over
distension of the ileal loop.

16. Loopogram showing the ileal conduit-enteric
fistula in patient

18. Stentography
 Urologists routinely leave narrow gauge hollow
stents running from the ureters into reconstructed
bladders or ileal conduits in the immediate
postoperative period.
 The stents run to the exterior either via the urethra
or a cutaneous stoma.
 Stentography is frequently requested to demonstrate
the integrity of the distal ureteric anastamoses within
a few days of surgery.

19. procedure
 10 and 20 ml 150 strength contrast is injected
under direct screening via each stent in turn,
which opacities the upper tracts
 followed by drainage around the stents down
into the bladder or diversion
 Spot films are taken, again paying particular
attention to the distal ureteric anastamoses

21. Cystography
Cystography can be classified into three groups:
 micturating cystourethrography (MCUG)
 dynamic cystography
 simple cystography

22. Simple cystography
• Simple cystography is used to assess the
integrity of the bladder following trauma or
surgery
• or to investigate suspected fistulas involving
the bladder (usually into the gastrointestinal
tract, occasionally elsewhere such as the
vagina).

23.  Approximately 250 ml contrast is infused into the
bladder
 should be done under frequent intermittent screening
control so that extravasations can be identified as
soon as it occurs.
 When the bladder has been filled or when
extravasation is identified a spot film is obtained in
the supine position. Ideally 45° oblique lateral spot
films should be obtained

24.  When a patient has undergone radical prostatectomy
or cystectomy, with preservation of the sphincter and
reconstruction of the bladder using small bowel
 a cystogram is often performed around 10 days
postoperatively to demonstrate the integrity of the
surgical anastamoses prior to removal of the urethral
catheter.

26. Urethrography
 This can be performed via an ascending or
descending approach.
 Descending urethrography is usually part of
the micturating cystogram and is rarely
indicated in adults.

27.  When it is performed in adults the bladder
should be adequately filled (with at least 200
ml of contrast).
 The screening table should be positioned
erect.
 Imaging is performed directly anteroposterior
in females,45° oblique projection in males

28.  Ascending urethrography is essentially confined to the male.
 It is used in the investigation of trauma, stricture and fistulas.
 The patient is positioned in a 45° oblique position
 dependent hip partly flexed to provide stability and ensure the
urethra is not projected over hone.
 A 12-16 gauge Foley catheter is positioned with its balloon a
Couple of centimeters into the distal urethra.
 The balloon is gently partially inflated to provide a seal without
undue trauma

29.  Between 5 and 10 ml 150 strength contrast is injected gently
into the urethra under direct screening and spot filets are
taken.
 The urethra is usually easily opacifed back to the urogenital
diaphragm.
 In a minority of patients contrast will reflux into the posterior
urethra and bladder.
 Usually ascending urethrography the prostatic urethra is not
demonstrated.
 Overenthusiastic instillation of contrast into the urethra can
be painful and produce extravasation of contrast into the
corpora cavernosa

30. there is transection of the urethra and extravasation of
contrast

31.  Female urethrography is rarely required
virtually all urethral pathology being better
demonstrated on urethroscopy or transvaginal
sonography.

32. voiding cystourethrogram. The urethra is short
indicating this is a female patient.

36. THANK YOU