IVU

1. Intra venous
Urography

2. Definition
It is the radiographic examination of the urinary
tract including the renal parenchyma , calyces and
pelvis after the intravenous injection of the
contrast media.

3. Introduction of excretory urography
was done in 1929, by American
urologist Moses Swick.
He injected an organically bound
iodide compound—later named
Uroselectan and took X-rays, as the
material cleared the body through the
urinary tract.
Moses Swick

4. 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

5. Indications
1. demonstration of renal collecting system and
ureters.
2. Investigation of level of ureteral obstruction.
3. Demonstration of Intraop opacification of collecting
system during ESWL or percut acess to collecting
system.
4. Demonstration of renal function during emergent
evaluation of unstable patients.
5. Demonstrate renal and ureteral anatomy in special
situations(ptosis, transureteroureterostomy, urinary
diversion)

6. Contraindications
No absolute contraindication
Relative contraindications
Renal failure (raised serum creatinine level >1.5 mg/dL)
Hepatorenal syndrome
Previous allergy to the contrast agent/iodine
Generalized allergic conditions
Multiple myeloma
Pregnancy
Infancy
Thyrotoxicosis
Diabetes
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7. Advantages
• Clear outline of the entire urinary system so can see even mild
hydronephrosis.
• Easier to pick out obstructing stone when there are multiple pelvic
calcifications.
• Can show non-opaque stones as filling defects.
• Demonstrate renal function and allow for verification that the
opposite kidney is functioning normally.

8. Disadvantages
• need for IV contrast material
• may provoke an allergic response
• multiple delayed films (Can take hours as contrast passes
quite slowly into the blocked renal unit and ureter.)
• May not have sufficient opacification to define the anatomy
and point of obstruction.
• Requires a significant amount of radiation exposure and
may not be ideal for young children or pregnant women

9. RENAL ANATOMY

10. Internal structure
• The parenchyma of the kidney is divided into two
major parts: superficial is the renal cortex and deep
is the renal medulla.
Grossly, these structures take the shape of 8 to 18
cone-shaped renal lobes, each containing renal
cortex surrounding a portion of medulla called a
renal pyramid (of Malpighi).
Between the renal pyramids are projections of
cortex called renal columns (of Bertin).
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11. • Nephrons, the urine-producing functional structures
of the kidney, span the cortex and medulla.
• The tip, or papilla, of each pyramid empties urine
into a minor calyx
minor calyces empty into major calyces, and major
calyces empty into the renal pelvis, which becomes
the ureter.
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20. Contrast
• High osmolar contrast media
• Low osmolar contrast media
• Iso osmolar contrast media

21. • All currently used CM are chemical
modifications of a 2,4,6-tri-iodinated benzene
ring.
• They are classified on the basis of their physical
and chemical characteristics, including their
chemical structure, osmolality, iodine content,
and ionization in solution.
• In clinical practice, categorization based on
osmolality is widely used.

23. HOCM
• High-osmolar contrast media (HOCM) are the
oldest agents.
• They are relatively inexpensive, but their
utility is limited.
• They are monomers (single benzene ring) that
ionize in solution with a valency of -1.
• Their cation is either sodium or meglumine.

24. LOCM
• major advancement was the development of
non ionic compounds.
• They are monomers that dissolve in water but
do not dissociate.
• Hence, with fewer particles in solution,

25. LOCM
• Hydrophilic
• Non-ionise
• Osmotic load<50%
• <complications

26. Iso -osmolar contrast media
• The most recent class of agents is dimers that
consist of a molecule with two benzene rings
(again, each with 3 iodine atoms) that does
not dissociate in water(nonionic).

27. Administration of CM
• Dose of 200mg of iodine per pound body wt-
dose of 20-30g.
• Injection completed within 60 sec-rapidly
injecting as bolus with 50 ml syringes.
• Slow injections decrease side effects but
provides less dense nephrogram
• Another method –drip infusion
technique,infusion kit with 40-50g iodine
delivered in 250-400ml fluid.

28. PREPARATION OF THE PATIENT
• Complete urine and blood examination to assess the renal
function.
The patient is given mild laxatives(1-2 oz castor oil) about
twelve to twenty four hours before the proposed x-ray
examination. (A night before the urographic
examination) .Eliminates fecal material and reduces
amount of gas in bowel.
The patient is kept nil by mouth over night and is
dehydrated by stopping the fluid intake.
Most uroradiologist believe that with modern contrast
media over hydration should be avoided but dehydration
is unnecessary.
In practice adviced omit fluids after 11pm,omit breakfast
which decreases chance of vomiting and produce slight
dehydration.
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29. • The dehydration helps in better
concentration of the contrast and clearer x-
ray pictures.
• The patient should not be dehydrated if
suffering from renal failure as it may lead to
severe fluid and electrolyte imbalance.
• Sensitivity to the dye (Hypaque or
Urographin)checked.

31. • Equipments:
• Medium powered X-Ray generator set-up, typical 40-60
kW.
• Basic tomography equipment.
• Abdominal compression equipment.
• Medium / Regular film screen combination in a variety
of sizes.

32. • Pads and immobilisation aids.
• Intravenous administration equipment:
• 50 ml syringe, filling needle, skin prep, sticky tape,
• Selection of needles, straight/'Butterfly' 16, 19,
21,23 gauge.
• Tourniquet or blood pressure cuff.
• Emergency drugs and equipment.

34. Technique
• Venous access via the median antecubital vein is the
preferred injection site
• The gauge of the cannula/needle should allow the
injection to be given rapidly as bolus to maximize the
density of nephrogram.
• Upper arm or shoulder pain may be due to stasis of
contrast in vein which may be relieved by abduction
of the arm.

35. Films
• Preliminary film:
➢ Supine, full length AP of
abdomen in inspiration.
➢ The lower border of cassette
is at the level of symphysis
pubis and the x-ray beam is
centred in the midline at the
level of iliac crests.
➢ To demonstrate
preparation, check
bowel
exposure
location of
factor, and
radiopaque stones or any
radiopaque artifacts
05/02/19

36. • If necessary the position of overlying
opacities may be further demonstrated by:.
• Supine AP of renal areas, in expiration. The
x-ray beam is centred in the mid-line at the
level of lower costal margin
• The examination should not proceed until
these films are reviewed by radiologist and
claimed satisfactory.

37. Contrast media:
• Low osmolar contrast
media (LOCM)- 300-
600mgI/ml
• Adult dose : 50-100ml
• Paediatric dose : 1ml/kg
05/02/19

38. FILM SEQUENCE
➢1-3 minutes Antero-posterior- film coned to the renal area
➢5 minutes Antero-posterior-film coned to the renal area
➢Apply ureteral compression
➢10 minutes Antero-posterior
➢Release compression
➢“Flush”, “X” or “Release view”- - full length view at 20 minutes
➢Upright post void Antero-posterior

40. Scout film
• Calculus
• Skeletal abnormality
• Intestinal gaspattern
• Calcifications
• Abdominal masses
• Foreign bodies

46. WHAT TO LOOK FOR IN IVU
➢Size, shape, position and axis of kidneys
➢External cortex and inner medulla
➢Calyceal system
➢Renal pelvis and ureteropelvic junction
➢Ureter
➢Uretero-vesical junction
➢Urinary bladder
➢Relation of ureter to spine and psoas
muscle

51. • The size of the kidneys should be assesed during
nephrographic phase
• The normal kidney may range from 9 to13 cm in
cephalo caudal length, with the left kidney inherently
larger than the right by 0.5 cm and the kidneys
slightly larger in men than in women
• Significant discrepancies (right kidney 1.5 cm larger
than the left kidney,left kidney 2 cm larger than the
right kidney) require explanation.

52. • On the 5-minute image, the nephrogram
should be receding as the collecting system
becomes opacified.
• On the 10-minute image, the pyelogram is the
dominant urographic element.
• Alterations in this temporal sequence require
explanation.

53. •
• Visualization of the collecting system and renal pelvis can be
augmented with the use of abdominal compression,
Trendelenburg position, and other gravity maneuvers such as
placing the patient with the side of interest in the ipsilateral
posterior oblique position
The appearance of the calices and renal pelvis should be
examined closely
• Early and mild obstruction is indicated by subtle rounding of the
forniceal margins
• More severe and prolonged obstruction evidenced by
progressive loss of the papillary impression and eventual
clubbing of calices.

54. ➢Ureters
➢Ureters begin to transport opacified urine about 3 mins post injection
➢Maximum ureteral filling occurs between 5-10 minutes.

55. • At the release of compression, the bolus of contrast
material–laden urine entering the ureters provides
optimal visualization throughout their length
Persistence of a standing column of contrast material
on several images may indicate obstruction or ureteral
ileus (nonobstructive dilatation).
Medial deviation of the ureter should be considered
when the ureter overlies the ipsilateral lumbar
pedicle.
lateral deviation should be considered when the
ureter lies more than 1.5 cm beyond the tip of the
transverseprocess, but comparison with the position
of the contralateral ureter should always be made.
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56. • Urographic image
shows multiple filling
defects in the left renal
pelvis and ureter.
• Multifocal transitional
cell carcinoma was
confirmed in this case.

57. An absolute ureteral diameter exceeding 8 mm
is considered a criterion for dilatation
Asymmetry of ureteral caliber is a more significant
finding.
Early in its course, high-grade ureteral obstruction may
be associated with only minimal ureteral dilatation.
More chronic forms of obstruction and other chronic
ureteral conditions are typically associated with greater
degrees of ureteral dilatation

58. ➢Bladde
r

59. •
• By 15–30 minutes after the injection of contrast
material, the bladder is often sufficiently filled,
• the 15-minute KUB radiograph may be adequate for
evaluation of bladder.
As the bladder distends with contrast the
intraluminal contrast material should be spherical
and smoothly marginated and the wall progressively
less evident.

61. Bladder transitional cell carcinoma.
• Bladder image shows a filling
defect with a papillary
configuration along the right
bladder wall
• Note the irregular distribution of
contrast material
• associated with the filling defect
(“stipple sign”)

63. • The postvoid image may also be helpful in
evaluating patients with upper urinary tract
dilatation.
• Persistence of the dilatation on the postvoid
image suggests fixed obstruction,
• The postvoid image is most helpful in
assessing residual volume.

65. Rare complications
• ARRYTHMIAS AND CARDIAC DISORDERS
• PULMONARY EDEMA
• RESPIRATORY AND CARDIAC ARREST
• History of previous reaction to the
admistration of contrast media is the greatest
single predictor of contrast reaction

66. Extravasation of contrast medium
• Local pain, erythema, swelling
• Usually resolve with local therapy
Rarely, significant tissue necrosis and skin-
sloughing occur (even with small amounts)
• severe, may lead to compartment
syndrome
• Severe edema, loss of pulses, necrosis
More common with injection in hand or foot

67. • Initial recommended treatment of
extravasation
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- Elevation of affected extremity above heart
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- Ice packs (15-60min/3 times per day)
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- Close observation for 2-4 hrs

68. Immediate plastic surgery consultation
for the following indications
•Extravasated volume exceeds 100 cc of nonionic contrast
•Skin blistering
•Altered tissue perfusion
•Decreased capillary refill over or distal to injection site
•Increasing pain after 2-4 hours
•Change in sensation distal to site extravasation

69. ANOMALIES AND VARIATIONS

71. • Renal agenesis
U/L-Absent renal outline &
pelvicalyceal system, 99mTc
DMSA most sensitive test.
B/L-Uncommon & incompatible
with life

72. Renal Ectopia
• Failure of complete ascent
of the kidney to its normal
position
• IVU- abnormally placed
kidneys

74. Crossed fused renal ectopia
• Two complete pelvicalyceal
systems on one side usually one
above the other
• Ureter from the lower renal
pelvis crosses the midline and
enters bladder normally

76. Horseshoe kidney
• Kidneys placed lower than
normal
Malrotation of pelvis
Lower pole calyces of both
sides deviated towards
midline
Ureters have characteristic
vaselike curve
Pelvicalyectasis
Renal calculi
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77. • Intravenous urogram
(IVU) shows an altered
renal axis with medially
directed lower renal
poles, which suggests
horseshoe kidney.
• Also the dilated
collecting system of the
left kidney, resulting
from a uretero pelvic
junction obstruction;
this is a frequently
associated finding

79. Duplex collecting system
• Minor form – bifid renal pelvis
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Ureteral duplication
Incomplete – ureters fuse in
their course
Complete – 2 ureters open
seperately in bladder, lower
moiety inserted orthoptically
& upper moiety ectopically
“Drooping lily” sign-
obstructed upper moiety
ureter, in a completely
duplicated system, may
produce downward and lateral
displacement of the functional
lower moiety collecting
system,
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82. Horse shoe kidney
Duplex bilateral

83. Ureterocele
• Contrast filled structure
with a thin smooth
radiolucent wall
surrounded by contrast
containing urine in the
bladder- “Cobra’s head’
appearence

85. Retrocaval ureter
• The ureter may have a
sickle, S or reverse J
appearance before crossing
behind and medial to the
IVC.
The ureter descends medial
to right lumbar pedicle.
Proximal ureter is dilated.
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87. Congenital Hydronephrosis
➢Due to functional obstruction at the pelvi-ureteral junction
➢Aetiology- cong. Bands, adhesions, neuro muscular
inco- ordination, abberent vessels
➢Advanced cases
• large soft tissue mass replacing the renal parenchyma. No
opacification of collecting system
➢Lesser degrees of obstruction
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Nephrogram- thin rim of renal substance outlining kidney
Later films – crescent shaped opacities produced by dilated
stretched tubules surrounding the enlarged non opacified calyx
• Delayed films – slow filling of calyces & renal pelvis

89. • The balloon on a string sign
This sign refers to the
appearance of a high and
somewhat eccentric exit
point of the ureter from a
dilated renal pelvis and is a
typical finding of
ureteropelvic junction
obstruction

91. PUJO

92. Polycystic kidneys
• Autosomal dominant
➢ Plain films- cyst calcification
➢ IVU- enlarged kidneys with
compression and displacement
of calyces by intrarenal cyst
• Autosomal recessive
B/L symmetrical enlargement of
kidneys
Streaky nephrogram
Calyces maybe distorted

96. • Dromedary hump.
• Tomogram from excretory
urography demonstrates a
prominent cortical hump in
the interpolar region of the
left kidney.
• It represents normal
functioning tissue.

101. • Bladder calculi
05/02/19

105. Medullary sponge kidney
• Brush like linear striations
in renal papillae
Enlargement of kidney
Renal calculi
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106. Renal masses
• Small SOL
➢Localised bulge with increased
thickness of the renal substance
➢Deforms or displaces or
distends a calyx

107. • Medium sized lesions
Localized or generalized enlargement of the
kidneys
Displacement or distortion of renal pelvis, ureter
or adjacent structures
Malrotation
Very large lesions
Non functioning kidneys
Calycine spreading
Visceral displacement
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108. Features of malignancy
• Pathognomic sign
Invasion of collecting system producing
amputation of calyx or intra luminal filling
defet
•Suggestive sign vascular mass
calcification

114. GU Tb-plain KUB
• Disparity in renal size on plain films may indicate early
increase in size of the affected kidney due to caseous lesions
or a shrunken fibrotic kidney of autonephrectomy.
Calcifications are seen in 30% to 50%
A characteristic diffuse, uniform,extensive parenchymal,
putty-like calcification, forming a lobar cast of the kidney is
seen with autonephrectomy
Calculi may also be seen in the collecting system or ureter
secondary to stricture formation.
Ureteral calcifications are rare and are characteristically
intraluminal as opposed to the mural calcifications of
schistosomiasis
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115. • . Bladder wall calcifications seen in late cases of
bladder contraction.
• Calcifications of the prostate and seminal vesicles
are seen in 10% of cases .
• Plain film findings suggestive of tuberculosis may be
seen in surrounding tissues such as erosions of the
vertebral bodies or calcifications in a cold abscess of
the psoas muscle.

117. GU Tb-IVU
• The most common findings being
hydrocalycosis,hydronephrosis,
• or hydroureter due to stricture formation .
• Early signs include the moth-eaten appearance of
calyceal erosion and papillary irregularity- signs are
best seen on early excretory films.

118. • Cavitary lesions communicating with the collecting system are
characteristic of TB.
These lesions eventually enlarge as parenchymal destruction
ensues.
Fibrotic distortion of the collecting system and ureter is also
seen.
Calyceal obliteration and amputation, hydrocalycosis,
segmental or total hydronephrosis, and a shriveled reduced
capacity renal pelvis may all be signs of renal tuberculosis
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119. • Scarring and angulation of the ureteropelvic junction (UPJ)
may also occur, the so-called “Kerr’s kink” .
Tuberculosis of the ureter is commonly seen as a rigid,
straightened “pipe-stem” ureter also beaded, corkscrew
appearance.
Ureterovesical junction obstruction is caused by tuberculous
cystitis or strictures of the distal third of the ureter.
secondary stone formation on top of this stricture .
The cystogram films may show a small contracted bladder
due to excessive fibrosis
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120. Thank you