Intravenous urography (IVU) by Dr. Bishnu Khatiwada

1. Dr Bishnu Khatiwada
1st year Resident
Radiodiagnosis, NAMS

2. Presentation Outline
 Introduction
 Indications
 Contraindications
 Patient preparation & Technique of IVU
 Non routine projections in IVU
 Modifications of IVU
 Complications
 After care
 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 together with the calyces,
renal pelvis, ureters and bladder

4. In recent years, there has been a
decline in the intravenous urogram
because of:
Development of newer imaging modalities like
CT Scan, USG, MRI
Adverse effects of contrast media.
Cost containment.

5. Indications
In Adults
 Suspected urinary tract pathology
 Investigation of persistent or frank hematuria
 Renal /ureteric calculi (prior to endourological
procedure)
 Complex urinary tract infection (including Renal TB)
 Ureteric fistulas and strictures
 Suspected transitional cell carcinoma

6. In Children:
Evaluation of VATER anomalies- 90% has Renal
anomalies.
Malformation of genitalia –hypospadiasis
Enuresis
Constant or intermittent dampness in girls to rule out
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 those cases radioisotope scan , USG, CT,
MRI provide alternative means of 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 these cases lower risk 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
 Sickle cell anemia

9.  Thyrotoxicosis
 Pregnancy
 A contrast material is excreted by a similar
mechanism to creatinine, a serum creatinine level
above 200micromol/l would indicate a patient who
would unlikely to excrete contrast satisfactorily.
 So, cautions in diabetics and patients with severe
disturbances of liver and 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 concentration of iodine in the renal cortex faster
compared to nonionic which is mainly excreted by
proximal tubules
 The timing for first radiograph to demonstrate
parenchymal phase best will thus differ.

11. HOCM or LOCM 370 are acceptable but the following
“high risk” group should receive LOCM.
 Infants/small children/elderly.
 Poorly hydrated patients
 Those with renal /cardiac failure
 Patients with diabetes, myelomatosis, sickle cell
disease
 Patients with previous contrast medium reactions/
strong allergic history

12.  Contrast agent: Ultravist ( Iopramide)
LOCM: 300-600mg Iodine meq/kg body weight
 Standard Dose:
Adult Dose : 50-100 ml
Pediatric dose: 1 ml/kg

13. Patient Preparation
 Bowel preparation is important as abdomen
should ideally be free of radio-opaque fecal matter
and gas
 NPO (No food for 4-6 hr prior to examination)
 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.

14. Is fluid deprivation indicated?
 Traditionally fluid was restricted prior to IVU in order
to improve opacification 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.

15.  Risk of irreversible renal damage to renal function in
previously healthy kidney due to contrast agent is very
low
 Also, with the advent of modern non-ionic contrast
agents which do not provoke an osmotic diuresis,
degree of opacification is unlikely to be significantly
altered by dehydration.
 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.

16. Radiation protection
 “Pregnancy rule” should be applied.
 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 bladder and lower ureters are not included
then female can also be given gonad protection.

17. Technique
 Informed consent
 Median ante-cubital vein-preferred injection site.
 19 G needle is advanced upto the vein and kept there
during entire procedure duration.
 IV cannula in place
–provides ER treatment if required
-for further injection of contrast if opacification is
inadequate

18.  Most adverse reactions are likely to occur within few
minutes after injection. So, Emergency drugs (eg.
Adrenaline), Oxygen and Resuscitation equipments
should also be readily available.
 Doctor (radiologist) should be available in the
department.

19. Classic series of plain films
 Preliminary post void full length film (control film).
 Immediate film (Nephrogram)
 5-min film
 15-min compression film
 15-min release film
 Post-micturition film

20. Preliminary/Control film
 Plain film is to demonstrate the urinary tract prior to
administration of contrast medium
 kVp= 70-80 (low kVp), mAs= 60-70
 Centering: the vertical central ray is directed to the
centre of the cassette
 Supine full length AP view of the abdomen 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.

22. Why to take preliminary/control film?
 To check exposure factors, centering
 State of bowel preparation
 Obvious pre-existing pathology, particularly urinary
tract calculi/calcification.

23. Calcification on the KUB
In the Urinary tract
 Renal: calculi, renal cell carcinoma, tuberculosis,
arterial (atheroma or aneurysm)
 Ureter: calculi, tuberculosis, schistosomiasis
 Bladder: calculi, tuberculosis, schistosomiasis,
transitional cell carcinoma

24. Outside the urinary tract
 Musculoskeletal: calcified tip of 12th rib
 Hepatobiliary: gallstones, hepatic granuloma
 Pancreas: chronic pancreatitis
 Adrenal: tuberculosis, Addison's disease
 Spleen: granuloma
 Aorta: atheroma, aneurysm
 Venous: phlebolith
 Uterine: fibroid
 Lymphatic: calcified lymph nodes (presumed
postinfective)

25. Immediate film (Nephrogram)
 AP film of renal areas.
 This film is exposed 10-14
seconds after contrast
injection (arm to kidney
time)
 Renal parenchyma is
opacified by contrast
medium in the renal tubules.
 Aim is to see Renal
outlines

26.  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
vertebra and height
of L1-L2
intervertebral disc.
Measurement of Kidney

27.  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

28.  Average thickness 3-
3.5cm in polar region
and 2-2.5cm in
interpolar region
 Decrease in
parenchymal thickness
seen in post
inflammatory or stone
related scarring.
 Increase in parenchymal
thickness is seen in
renal mass.
Measurement of Parenchymal thickness
Interpapillary line

29. 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.
 To see Pelvicalyceal
system

30.  Compression band is now applied around the
patients abdomen and balloon is positioned
midway between the anterior superior iliac spine
i.e precisely over the ureters as they crosses pelvic
brim.

31. Why compression technique?
 Compression inhibits ureteric drainage and
promote distension of pelvicalyceal system,
optimising their visualization

32. Before compression After compression

33. Contraindications of compression
 Recent abdominal surgery
 Abdominal Aortic Aneurysms
 Acute painful abdomen/ renal colic
 Large abdominal mass
 Urinary tract trauma
 Presence of Urinary diversion
 Presence of Renal transplant
 When 5-min film shows already distended calyces.

34. 15-min compression film
 AP view of renal areas
 There is usually adequate
distension of pelvicalyceal
system with opaque urine.
 Compression removed
when satisfactory
demonstration of
pelvicalyceal system has
been achieved.

36. 15-min Release film
 Supine AP film
 This film is taken to
show whole urinary
tract.

38. 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 bladder with
tube angled 15 degree caudad
and centered 5cm above the
symphysis pubis.
 Main aim of films is to
- Assess bladder emptying

39.  To demonstrate return of dilated upper tracts with
relief of bladder pressure.
 Aid diagnosis of VUJ calculi
 Diagnosis of bladder tumors
 Demonstrate urethral diverticulum.

40. Non-routine projections
Postero-anterior (prone)-abdomen
 Projection is to promote emptying of contrast from the
pelvicalyceal system into the ureter.
Right or left posterior oblique
 This is to show the relationship of the opacities to the
kidneys, ureters, and bladder.

41. Lateral Projection
 May be used as an alternative to oblique projection in
relative position of the opacities near to or in the
kidneys.
 Opacities in the kidneys will overshadow, or be very
near the vertebrae. Opacities outside the kidneys are
usually shown anterior to the vertebrae

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

43.  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.

44.  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 increases and enhancement of kidneys is
more diffuse

45.  At 1 minute: Contrast begins to appear in
calyces
 After 1 minute: Contrast in the normal calyces
will begin to drain immediately into the pelvis and
ureter and 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 to demonstrate entire length
of both (or even either ) ureters.

46. Modifications
 To increase sensitivity and to reduce radiation dose
to the patient
 3 circumstances:
1. When significant obstruction due to calculi,
there is delay in opacification of collecting system.
The delay may be considered upto 24 hr or 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

47.  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.

48. 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 exposure should be minimised. So,
single length preliminary film and a delayed full
length film around 30-45min may be well enough

49. IVU Modifications

50. Radiography Modification Purpose
Plain films
Nephrogram
Additional oblique
or tomograms
Thick slice CT
To assist localisation
of intrarenal
calcifications, also
USG
To improve
definition of renal
outlines

51. 5min film
15 min
compression
film
15 min
release film
2nd injection
of contrast
Series of 1cm
thick
tomograms
Additional
bladder views
To improve opacification
of PCS.
To diff betn overlying
shadows and filling
defects within collecting
systems
When bladder poorly filled
in release film
When irregular filling
defects/calculus in distal
ureter seen oblique films
to be taken.
USG can be done to
reduce radiation dose

52. Full length post
micturition film
Prone full
length film
Erect image
Bladder area
only
Additional film
Additional film
If upper tracts have
already been imaged
to reduce radiation
burden
When renal pelvis is
dilated Contrast pass
slowly ,this can be
accelereted
To image small
ureteric calculus by
oblique film

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

54.  Tailored Urogram.
 Hypertensive Urogram.
 Drip infusion urogram
 Limited urogram
 High dose urogram
Other Modifications

55.  Modifies the urogram to provide the information
needed to include or exclude the clinical problem.
 Study is terminated as soon as the desired information
is available.
Tailored Urogram

56.  Also called as minute sequence urogram.
 Films are taken 1,2,3,5 minutes after injection of
contrast media.
Hypertensive urogram

57.  Contrast is given in 500ml of normal saline.
 Advantages
- Nephrogram persists for longer time.
- PCS and ureters are visualized for longer time.
- No significant increase in contrast reactions.
- Administration is easy.
Drip infusion urography

58.  Overload the patient with 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

59.  Useful for follow up for earlier pathology
 Limited films are taken - KUB , 15 mins and post void.
@{limited phases are taken}
Limited Urography

60.  Indications:
 Renal impairment
 Poor bowel preparation
 Emergency urography
 Vesical fistula
But should be very cautious in Diabetes, Dehydration
and in elderly patient.
High dose urography

61. Due to contrast
 Minor reactions- Nausea, vomiting, mild rash,
headache, mild dyspnea
 Intermediate reactions- Extensive urticaria, facial
edema, bronchospasm, laryngeal edema, hypotension.
 Severe reactions- Circulatory collapse, pulmonary
edema, MI, cardiac and respiratory arrest
Complications

62. Due to Technique
 Upper arm or shoulder pain.
 Extravasation of contrast at injection site.

63.  Observation for 6 hrs
 Watch for late contrast reactions
 Prevention of dehydration
 In high risk patients – RFT should be done to watch
deterioration.
After care

64. CT Protocol

65. 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

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

67. Corticomedullary phase
 Renal cortex can be differentiated from renal medulla
at this stage because (1) the vascularity of the cortex is
greater than that of the medulla, and (2) contrast
material has not yet reached the distal aspect of the
renal tubules
 Useful for diagnosis of aneurysm or an arterio-
venous malformation or fistula

68. Nephrographic Phase
 Offers the best opportunity for discrimination
between the normal renal medulla and a renal
mass.
 Most valuable for detecting renal masses and
characterizing indeterminate lesions

69. Excretory phase
 Helpful to better delineate the relationship of a
centrally located mass with the collecting system.
 Also useful for evaluating urothelial masses.

70. CT-IVU
 Progressively replacing conventional intravenous
urography (IVU).
 Hybrid CT urography is a combination of CT and
IVU that uses projection radiographs along with
acquisition of CT images after intravenous contrast
injection
 IVU abdominal compression is applied after the
intravenous contrast medium injection for better
opacification and distention of the intrarenal
collecting system and the ureter

71.  Ten-minute decompressed film images help to
visualize almost the entire ureters. Twenty-minute and
postvoiding films are useful for bladder evaluation.
 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

72. IVU Images

73. Dromedary Hump
 Prominence of
superolateral
border of left
kidney

74. Horseshoe Kidney: Flower Vase Appearence
 In utero contact
between the
metanephric tissue of
the developing kidneys
results in a midline
connection (isthmus)
 Often visible on the
plain film but is better
seen on the nephrogram
phase of an IVU
between the lower poles.

75. Ectopic Ureter: Drooping lily appearence
 The lower pole moiety
is displaced
inferolaterally by an
upper pole
hydronephrosis.
 This usually occurs due to
obstruction of the upper
pole moiety ureter at its
orifice associated with
ectopic insertion or a
ureterocele.

76. Ureterocele: Cobra/Adder Head appearence
 On IVU, the ureterocele
can be seen as a non-
opacified structure
surrounded by opacified
urine in the bladder. This
has been described as a
cobra's head appearance.

77.  Later, full length film
shows opacification of
the distended upper
moiety ureter running
down to the opacified
ureterocele

78. Medullary Sponge Kidney: Paint brush appearence
 Ectasia (fusiform or
cystic) of the collecting
ducts within the renal
pyramids, seen in up to 1 in
200 IVUs.
 Benign incidental finding
but there is a weak
association with some
tumours (Wilms' disease &
phaeochromocytomas),
horseshoe kidney, and
distal renal tubular acidosis

79. Hydronephrosis
 During the acute episode, there are features on IVU of
severe acute obstruction, which include a delayed,
increasingly dense nephrogram and delayed
appearance (sometimes up to 24 h or more) of contrast
within the collecting system.
 When opacification occurs, it demonstrates clubbed
calyces and a dilated pelvis.
 Prior to opacification of the pelvicalyceal system, there
may be a negative pyelogram, i.e. dilated calyces
appearing as radiolucent areas surrounded by the
denser areas of the nephrogram

80. Crescent/Rim sign
 Contrast may be seen with a
curvilinear configuration just
peripheral to the calyces.
 This appearance has been
termed `crescents' and is
thought to represent contrast
stasis in collecting ducts
displaced around distended
calyces

81. Primary Megaureter
 Congenitally abnormal
musculature of the
distal ureter, leading to
focal failure of
peristalsis.
 The ureter above the
abnormal segment
becomes dilated,
sometimes massively.
 Bilateral in 25% cases.

82. Reflux Nephropathy
 Small Kidney
 Widespread cortical loss
(esp. at upper pole)
 Clubbing of calyces

83.  Small and Smooth
kidney
 Delayed persistent
nephrogram
 Delayed and dense
pyelogram.
 Ureteral notching
Renal Artery Stenosis

84. Bladder diverticulum
 Focal herniations of urothelium
and submucosa through the weak
sites in the bladder wall
 In the early stages, multiple
(sometimes numerous) small
protrusions of the bladder lumen
appear between the trabeculae
(sacculations).
 As they enlarge above 2 cm, they
become defined as diverticula

85. Polycystic Kidney Disease: Spider leg appearence
 The calyces have a
classical stretched
appearance due to
the presence of
multiple cysts

86. Take Home messages
 Indications of IVU
 Contraindications of IVU
 Patient preparation for
IVU
 Classic series of films.
 Non routine projections in
IVU
 Modifications of IVU
 Role of compression ?
 Contraindications of
compression films ?
 Advantage of IVU over
CT-IVU
 Advantages of CT-IVU over
IVU
 Ureteric calculus Vs
Phlebolith (4)
 Ureteric calculus Vs Blood
clot (2)
 Flower vase appearance,
Cobra head appearance,
Drooping lily sign,
Paint brush appearance,
Rim/Crescent sign,

87. References
 Textbook of Radiology, David Sutton, 7th edition
 Fundamentals of Radiology, Brynts and Helms
 CT and MRI of Whole Body, John R. Haaga, 5th edition
 Clark’s positioning, Stewart Whitley, 12th edition

88. Thank You