All about radiological perspective in Intravenous urography Also called as intravenous pyelography. Few spotters to help in tha cause.

1. DrVishal Ladage
JR 2 Radiodiagnosis,
RKCH, RAIPUR

2. Presentation Outline
⦁ Introduction
⦁ Indications
⦁ Contraindications
⦁ Patient preparation & Technique of IVU
⦁ Non routineprojections in IVU
⦁ Modificationsof IVU
⦁ Complications
⦁ Aftercare
⦁ CT-IVU
⦁ IVU Images

3. Introduction
⚫IVU is the imaging investigation of the urinary
tract following the introduction of a water-
soluble intravenous contrast medium.
⚫Helps in “structural & functional evaluation of
urinary tract”.
⚫Contrast is excreted by kidneys, rendering the
urine opaque to x-rays and allowing visualization
of the renal parenchyma togetherwith the calyces,
renal pelvis, ureters and bladder

4. In recent years, there has been a
decline in the intravenous urogram
because of:
Developmentof newer imaging modalities like
CT Scan, USG, MRI
Adverseeffectsof contrast media.
Costcontainment.

5. Indications
In Adults
⚫Suspected urinary tract pathology
⚫Investigationof persistentor frank hematuria
⚫Renal /uretericcalculi (prior toendourological
procedure)
⚫Complex urinary tract infection (including Renal TB)
⚫Ureteric fistulasand strictures
⚫Suspected transitional cell carcinoma

6. In Children:
Evaluationof VATER anomalies- 90% has Renal
anomalies.
Malformation of urinary tract –PCKD,PUJ obstruction
Constantor intermittentdampness in girls toruleout
ectopically inserted ureter.

7. Contraindications
Absolute CIs:
⚫Past h/o severe adverse reaction to contrast media.
HOCM carries 20% risk and LOCM decrease risk to
5% , and in thosecases radioisotope scan , USG, CT,
MRI providealternative meansof investigations
⚫Proven hypersensitivity to iodine.
Relative CIs: (@ABCD MS)
⚫Asthma /significant allergic history.
⚫B-blockers

8. ⚫Chronic Renal insufficiency
⚫Cardiac disease –Cardiac failure /arrhythmias may be
precipitated and in thesecases lowerrisk with LOCM
⚫Diabetes Mellitus
⚫Dehydration
⚫Multiple Myeloma
⚫Metformin therapy: Co-administration of metformin
(glucophage)+ iv contrast to diabetics may lead to
acute alteration of renal function and lactic acidosis,
therefore metformin is withheld
⚫Sicklecell anemia

9. ⚫Thyrotoxicosis
⚫Pregnancy
⚫A contrast material is excreted by a similar
mechanism to creatinine, a serum creatinine level
above 200micromol/l would indicatea patientwho
would unlikely toexcretecontrast satisfactorily.
⚫So, cautions in diabetics and patientswith severe
disturbances of liverand kidneys.

10. Contrast medium and injection data
⚫ Ionic and non-ionic are available, both of which are
excreted by different mechanisms. The ionic group is
excreted mainly by glomerular filtration causing a
peak concentrationof iodine in the renal cortex faster
compared to nonionic which is mainly excreted by
proximal tubules
⚫The timing for first radiograph todemonstrate
parenchymal phase bestwill thusdiffer.

11. HOCM or LOCM 370 areacceptable but the following
“high risk” group should receive LOCM.
⚫Infants/small children/elderly.
⚫Poorly hydrated patients
⚫Thosewith renal /cardiac failure
⚫Patientswith diabetes, myelomatosis, sicklecell
disease
⚫Patientswith previouscontrast medium reactions/
strong allergic history

13. ⚫Contrast agent: Iohexol (omnipaque)
Ultravist ( Iopramide)
LOCM: 300-600mg Iodine meq/kg bodyweight
⚫Rapid - <60 sec – better nephrogram.
⚫Slow – 2-3 min – less side effects.
⚫Standard Dose:
Adult Dose : 50-100 ml Pediatric
dose: 1 ml/kg

15. Patient Preparation
⚫Bowel preparation is important as abdomen
should ideally be freeof radio-opaque fecal matter
and gas
⚫NPO (No food for 4-6 hr prior toexamination)
⚫Laxatives- Dulcolax 2-4 tabs at bed time for 2
days prior to procedure.
⚫ Bowel preparation is now generally regarded as
unhelpful and it is unpleasant to the patient.

16. Is fluid deprivation indicated?
⚫Traditionally fluid was restricted prior to IVU in order
to improveopacification of collecting system.
⚫However, dehydration increase risk of nephrotoxicity
which may be permanent in patients with DM,
Multiple Myeloma, Hyperuricemia, Sickle Cell Disease
and pre-existing renal disease.

17. ⚫Risk of irreversible renal damage to renal function in
previously healthy kidney due tocontrastagent is very
low
⚫Also, with the advent of modern non-ionic contrast
agents which do not provokean osmoticdiuresis,
degree of opacification is unlikely to be significantly
altered bydehydration.
⚫So, fluid restriction should be avoided and if there
is a risk that the patient is dehydrated before the IVU,
this should be corrected first.

18. Radiation protection
⚫“Pregnancy rule” should beapplied.
⚫If whole of renal tract is to be visualized, no gonad
shielding is possible for the females, but for males
the testis can be protected by placing a lead rubber
sheet over upper thighs below lower edge of
symphysis pubis.
⚫When bladderand lowerureters are not included
then female can also begiven gonad protection.

19. Technique
⚫Informed consent
⚫Median ante-cubital vein-preferred injection site.
⚫18,20 G needle is advanced upto thevein and kept
there during entire procedureduration.
⚫IV cannula in place
–provides ER treatment if required
-for further injection of contrast if opacification is
inadequate

20. ⚫Mostadverse reactionsare likely tooccurwithin few
minutes after injection. So, Emergency drugs (eg.
Adrenaline), Oxygen and Resuscitation equipments
should also be readilyavailable.

21. Stereotypical appearances of normal
IVU are as follows
⚫Takes 12-20 seconds for contrast to reach renal
arteries following iv injection
⚫At this stage, itsconcentration is maximum in the
vascularcompartment.
⚫However, this falls rapidlyas contrast medium begins
to escape into extracellular compartment and
undergoes rapid glomerular filtration and enters the
renal tubules

22. ⚫In first minute of IVU, healthy kidneys (assuming a
normal cardiovascular system) show diffuse
enhancement. This is referred as Nephrogram.
⚫During this phase renal size (normally at least 3
vertebrae in length but no more than four) and outline
are seen.

23. ⚫In roughly 1st half minute – contrast in the
vascular compartment dominates and therefore
cortex is more enhanced than the medulla
⚫This differentiation is sometimes visible in
immediate film of IVU series (but regularly visible
on CT performed at this stage)
⚫In second half of minute - contrast in the
tubules increasesand enhancementof kidneys is
morediffuse

24. ⚫At 1 minute: Contrast begins toappear in
calyces
⚫After 1 minute: Contrast in the normal calyces
will begin todrain immediately into the pelvisand
ureterand this phased referred as Pyelogram
⚫After compression is released ,there is transient
increase in flow down the ureters and release film
offers the best chance of demonstrating the
ureters.
⚫Normal ureters exhibit peristalsis and on a single
film it is uncommon todemonstrate entire length
of both (oreven either ) ureters.

25. Classic series of plain films
⚫Preliminary postvoid full length film (control film).
⚫Immediate film (Nephrogram)
⚫5-min film
⚫15-min compression film
⚫15-min release film
⚫Post-micturition film

26. Preliminary/Control film
⚫Plain film is todemonstrate the urinary tract priorto
administrationof contrast medium
⚫kVp= 70-80 (low kVp), mAs= 60-70
⚫Centering: thevertical central ray is directed to the
centreof thecassette
⚫Supine full length AP view of theabdomen in
inspiration.
⚫Pelvis should be adjusted so that the anterior
superior iliac spines are equidistant from table
top.
⚫Lower border of cassette is at level of symphysis
pubis.

29. Why to take preliminary/control film?
⚫To check exposure factors, centering
⚫Stateof bowel preparation
⚫Obviouspre-existing pathology, particularly urinary
tractcalculi/calcification.

30. Calcification on the KUB
In the Urinary tract
⚫Renal: calculi, renal cell carcinoma, tuberculosis,
arterial (atheromaoraneurysm)
⚫Ureter: calculi, tuberculosis, schistosomiasis
⚫Bladder: calculi, tuberculosis, schistosomiasis,
transitional cell carcinoma

31. Outside the urinary tract
⚫Musculoskeletal: calcified tipof 12th rib
⚫Hepatobiliary: gallstones, hepaticgranuloma
⚫Pancreas: chronic pancreatitis
⚫Adrenal: tuberculosis, Addison'sdisease
⚫Spleen: granuloma
⚫Aorta: atheroma, aneurysm
⚫Venous: phlebolith
⚫Uterine: fibroid
⚫Lymphatic: calcified lymph nodes (presumed
postinfective)

32. Immediate film (Nephrogram)
⚫AP film of renal areas.
⚫This film isexposed 10-14
secondsaftercontrast
injection (arm to kidney
time)
⚫Renal parenchyma is
opacified by contrast
medium in the renal tubules.
⚫Aim is to see Renal
outlines

33. ⦁ Normal size: 9-13cm
cephalocaudally, left
is 0.5-1 cm larger
than right.
⦁ Normal kidney size
should not more
than 3 times the sum
of the height of L1
vertebraand height
of L1-L2
intervertebral disc.
Measurement of Kidney

34. ⚫Right kidney is more than 1.5cm larger than left kidney
⚫Left kidney is more than 2cm larger than right kidney
Significant Discrepancies in size if

35. ⦁ Average thickness 3-
3.5cm in polar region
and 2-2.5cm in
interpolar region
⦁ Decrease in
parenchymal thickness
seen in post
inf lammatoryorstone
related scarring.
⦁ Increase in parenchymal
thickness is seen in
renal mass.
Measurement of Parenchymal thickness
Interpapillary line

36. 5-min film
⚫AP of Renal areas
⚫Film is taken to
determine if excretion is
symmetrical and for
assessing if need to
modify technique e.g- a
further injection of
contrast medium if poor
opaification.
⚫Tosee Pelvicalyceal
system

37. ⚫Compression band is now applied around the
patients abdomen and balloon is positioned
midway between the anteriorsuperior iliac spine
i.e preciselyoverthe ureters as theycrosses pelvic
brim.

38. Why compression technique?
⚫Compression inhibits ureteric drainage and
promote distension of pelvicalyceal system,
optimising theirvisualization

39. Before compression After compression

40. Contraindications of compression
⚫Recentabdominal surgery
⚫Abdominal AorticAneurysms
⚫Acutepainful abdomen/ renal colic
⚫Largeabdominal mass
⚫Urinary tract trauma
⚫Presence of Urinary diversion
⚫Presence of Renal transplant
⚫When 5-min film showsalreadydistended calyces.

41. 15-min compression film
⚫AP viewof renal areas
⚫There is usuallyadequate
distension of pelvicalyceal
system with opaque urine.
⚫Compression removed
when satisfactory
demonstration of
pelvicalyceal system has
been achieved.

43. 15-min Release film
⚫Supine AP film
⚫This film is taken to
show whole urinary
tract.

45. Post-micturition film
⚫Based on clinical findings and
radiological findings on earlier
films, this will be either a full
length abdominal film or a
coned view of the bladderwith
tube angled towards bladder
and centered 5cm above the
symphysis pubis.
⚫Main aim of films is to
- Assess bladderemptying

46. ⚫Aid diagnosisof VUJ calculi
⚫Diagnosisof bladdertumors
⚫Demonstrateurethral diverticulum.

47. Non-routine projections
Postero-anterior (prone)-abdomen
⚫Projection is to promoteemptying of contrast from the
pelvicalyceal system into the ureter.
Right or left posterior oblique
⚫This is toshow the relationshipof theopacities to the
kidneys, ureters, and bladder.

48. Lateral Projection
⚫May be used as an alternative tooblique projection in
relative position of theopacities near toor in the
kidneys.
⚫Opacities in the kidneys will overshadow, or be very
near thevertebrae. Opacitiesoutside the kidneys are
usuallyshown anterior to thevertebrae

49. Modifications
⚫To increase sensitivityand to reduce radiation dose
to the patient
⚫3 circumstances:
1. When significant obstruction due to calculi,
there is delay in opacification of collecting system.
Thedelay may be considered upto 24 hror more.
In this case, it is necessary to perform
additional films and time interval between
film traditionally is doubled, with films taken at
0.5, 1, 2, 4, 16 & 24 hours

50. ⚫However, in order to minimize radiation exposure, if no
opacification of an acutely obstructed kidney at 30
minutes it is usually unhelpful to perform next film
before around 4hr after contrast injection.

51. 2.A further maneuver to minimize radiation dose in
strong clinical suspicion of ureteric colic is to omit all
films after contrast until a full length 15min film is
performed.
3.In pregnant patients, if very necessary to perform an
IVU, then radiation exposureshould be minimised. So,
single length preliminary film and a delayed full
length film around 30-45min may bewell enough

52. IVU Modifications

53. • Plain film – additional oblique views to differentiate intrarenal
or extrarenal opacities
5 min film – to know whether extra contrast is needed if
contrast is inadequate to visualize renal pelvis
Delayed films – 3,6,12,24 hours for delayed opacification
early nephrogram but collecting system is not visualized.
Immediate after micturition – to see for VUR
Rapid sequence urography – 2,4,6 mins
to see renal atery stenosis,
to compare rate of excretion of both kidneys.

54. Prone films-
to visualize those ureteral areas () which are not opacified on
supine position
lesions on anterior bladder wall, bladder herniation

55. Frusemide IVU Administration of
20 mg of
later
If suspected PUJ
obstruction is being
Frusemide iv after investigated and
15 min film with a there is no e/o of
further film 15min this on standard
IVU this maneuver
performed. This
provokes
hydronephrosis and
pain. other choice
is radionuclide
renography

56. ⚫Tailored Urogram.
⚫Hypertensive Urogram.
⚫Drip infusion urogram
⚫Limited urogram
⚫High doseurogram
Other Modifications

57. ⚫Modifies the urogram to provide the information
needed to includeorexclude theclinical problem.
⚫Study is terminated as soonas the desired information
is available.
Tailored Urogram

58. ⚫Alsocalled as minutesequence urogram.
⚫Workup for hypertensive pts of age < 50 years
⚫Obsolete now
⚫Filmsare taken 1,2,3,5 minutesafter injectionof
contrast media.
⚫Findings – small kidney, delayed nephrogram,
hyperconcentration on subsequent late films
Hypertensive urogram

59. ⦁ Contrast is given in 500ml of normal saline.
⦁ Advantages
- Nephrogram persists for longer time.
- PCS and ureters are visualized for longer time.
- Nosignificant increase in contrastreactions.
- Administration is easy.
Drip infusion urography

60. ⚫Overload the patientwith more iodine than necessary.
⚫Calyceal blunting may be produced suggesting
abnormal dilatation.
⚫May precipitate CCF in patient with borderline
cardiac complaints.
⚫Initial vascular nephrogram is not obtained.
Disadvantages

61. ⚫Useful for followup forearlierpathology
⚫Limited films are taken - KUB , 15 minsand postvoid.
@{limited phases are taken}
Limited Urography

62. ⚫Indications:
 Renal impairment
 Poor bowel preparation
 Emergency urography
 Vesical fistula
Butshould beverycautious in Diabetes, Dehydration
and in elderly patient.
High dose urography

63. Due tocontrast
⚫Minorreactions- Nausea, vomiting, mild rash,
headache, mild dyspnea
⚫Intermediate reactions- Extensive urticaria, facial
edema, bronchospasm, laryngeal edema, hypotension.
⚫Severe reactions- Circulatorycollapse, pulmonary
edema, MI, cardiac and respiratoryarrest
Complications

64. Due toTechnique
⚫Upperarm orshoulderpain.
⚫Extravasationof contrastat injection site.

65. ⚫Observation for 6 hrs
⚫Watch for latecontrast reactions
⚫Preventionof dehydration
⚫In high risk patients – RFT should bedone towatch
deterioration.
After care

66. CT Protocol

67. Phase Timing Range
Slice
Thickne
ss
What to
Detect?
Nonenhanc
ed
Precontr
ast
Lung bases to
pubic
symphysis
5 mm Calculi,
calcifications,
hemorrhage/he
morrhagic
cysts
Nephrogra
m
100 sec Lung bases to
pubic
symphysis
3 mm Renal tumors,
renal vein
thrombosis
Excretory 5-8 min Lung bases to
base of
bladder
2 or 3
mm
Papillary
necrosis,
urothelial
carcinoma

68. Contrast CT
⚫3 Phases:
1. Cortico-medullary phase (25-70 seconds)
2. Nephrographic phase (80-180 seconds)
3. Excretory phase (after 180 seconds)

69. Corticomedullary phase
⚫ Renal cortexcan be differentiated from renal medulla
at this stage because (1) thevascularityof thecortex is
greater than that of the medulla, and (2) contrast
material has notyet reached thedistal aspectof the
renal tubules
⚫Useful fordiagnosisof aneurysm or an arterio-
venous malformation or fistula

70. Nephrographic Phase
⚫Offers the best opportunity for discrimination
between the normal renal medulla and a renal
mass.
⚫ Mostvaluable fordetecting renal massesand
characterizing indeterminate lesions

71. Excretory phase
⚫Helpful to better delineate the relationship of a
centrally located masswith thecollecting system.
⚫ Alsouseful forevaluating urothelial masses.

72. CT-IVU
⚫Progressivelyreplacing conventional intravenous
urography (IVU).
⚫Hybrid CT urography is acombinationof CT and
IVU that uses projection radiographs along with
acquisition of CT images after intravenous contrast
injection
⚫IVU abdominal compression is applied after the
intravenouscontrast medium injection for better
opacification and distention of the intrarenal
collecting system and the ureter

73. ⚫Ten-minute decompressed film images help to
visualizealmost theentire ureters. Twenty-minuteand
postvoiding films are useful for bladderevaluation.
⚫Role of MRI:
1. Determining the Renal vein thrombosis &
cephalic extent of an intracaval tumor in a
patient with renal cell carcinoma (RCC)
2. Characterization of small renal masses
3. Evaluation of donors & transplanted kidneys

74. IVU Images

75. Unilateral
renal
agenesis

76. Ectopic kidney

77. Crossed
fused ectopic
kidney

78. Horse shoe
kidneys

79. ureterocele

80. Retrocaval
ureter

81. Right
hydronephrosis

82. Grading of hydronephrosis

84. Puj
obstruction

85. Spider leg sign
⚫Thecalyces havea
classical stretched
appearancedue to
the presence of
multiplecysts

86. Staghorn
calculus

87. BPH

88. Ureter cut
extravasation
Pt. With Stab
injury

89. Papillary tip
necrosis
Pt with sickle cell anemia
Or analgesic abuse
BALL ON TEE

90. Maiden waist sign - RPF

93. CONGENITAL MEGAURETER

95. Ectopic Ureter: Drooping lily appearence
⚫The lower pole moiety
is displaced
inferolaterally by an
upper pole
hydronephrosis.
⚫This usuallyoccursdue to
obstruction of the upper
pole moiety ureterat its
orifice associated with
ectopic insertion or a
ureterocele.

96. Thank You