Excretory urography

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  • Aka Excretory urographyUse decreased significantly in recent years CT, US, MR

    Remains primary modality for visualization of pelvi-calyceal system

  • HaematuriaRenal colicRecurrent urinary tract infectionTraumaRenal tumorRenal hypertensionCalculi (kidney , ureter, bladder)Bladder pathology ( diverticula ,fistula )

  • UrogramVisualization of kidney parenchyma,calyces and pelvis resulting from IV injection of contrast

    PyelogramDescribes retrograde studies visualizing only the collecting system So, IVP is misnomer, should be IVU

  • Cystography Describes visualization of the bladderUrethrography Visualization of urethra Cystourethrography Combined study to visualize bladder and urethra

  • NBM for 5 hrsAmbulent for 2 hrs to reduce bowel gases

  • Inject nonionic contrast Or LOCM as bolus, 30-60 secAdult 50-100 mlPediatric 1ml/kg

  • True contrast reactions are uncommonMost commonly seen are minor side effectsFlushing Metallic taste in mouthTachycardiaUsually resolve within a few minutes

  • Scout viewAdditional views

  • Supine , full-length AP abdomen, full inspirationLower border of cassette at the level of symphysis pubis, beam centered in midline at the level of iliac crests

    Often difficult to fit this large area on a single radiograph, may need.14 x 17 of abdomen10 x 12 of lower pelvis

  • Look for CalcificationsAbnormal soft tissueAir within urinary tractBony abnormalitiesDetermine if a contraindication to abdominal compression exists

  • Oblique Views (35 degree posterior oblique) - Good for questionable ureteral lesions - For differentiating extrinsic and intrinsic renal and ureteral masses -Visualization of posterolateral aspect of bladderSupine AP of renal areas in expirationTomography of kidneys

  • Immediate FilmAP of renal areas.10-14 sec after injectionShows nephrogram

    5-min FilmAP of renal areasDetermine if excretion symmetricalAssess the need to modify technique Application of compression band baloon at level of anterior superior iliac spines

  • Compression contraindicated inRecent abdominal surgeryRenal traumaLarge abdominal mass or aortic aneurysmAlready dilated calyces on 5-min film

  • 10-min FilmAP of renal areasCompression released if pelvicalyceal system adequately visualizedRelease filmSupine AP abdomenWhole urinary tractEmpty bladder

  • Post voiding Film Full length OR Coned view of bladder(tube 15 degree caudal, centered 5 cm above symphysis pubis) Must be obtained immediately after voidingTo determine residual urine in bladder >especially in older male patientsTo look for bladder neoplasmsVUJ calculiUrethral diverticulum in females

  • TCC

  • Delayed Views1 hour to 48 hours- in cases of obstruction Better to CT patient for immediate diagnosis

  • Prone filmHelps fill ureteral areas not seen in supine position since upper ureters more anterior than kidney

  • Erect filmPromotes emptying of collecting system Optimal for showing bladder herniasShows layering of calculi in cystsDemarcates areas of ureteral obstruction better than prone views

  • Dynamic test used to define The anatomy the function of the lower urinary tract.

    Performed by..placing a catheter through the urethra into the bladderfilling the bladder with contrast materialtaking x-rays while the patient voids.

  • Vesico-ureteric refluxBladder abnormalitiesStress incontinenceUrethral trauma leading to obstructionPosterior urethral valves

  • Acute UTI

  • HOCM or LOCMFluoroscopy unit with spot film device and tilting tableVideo recorderJaques or folleys catheter. In small infants 5-7 size feeding tube is adequate

  • Patient preparationMicturate prior to examination

    Preliminary FilmConed view of bladder , using the under-couch tube

  • To demonstrate vesico-ureteric refluxExclusively in childrenSupine on x-ray tableInsert catheter asepticallyDrain residual urineContrast medium dripped into bladder and observed under fluoroscopyRecord refluxPatient asked to micturateSpot films taken during micturition

  • Oblique/lateral position for males to observe entire urethraFull length abdominal view to look for..Unnoticed contrast reflux into kidneysPost-micturition residue

  • To demonstrate vesico-vaginal / recto-vesical fistulaFilms taken in lateral position

    To demonstrate stress incontinenceCatheter left in situ until patient is in erect position

  • Include sacrum and symphysis pubisLateral bladderLateral bladder, straining - catheter removedLateral bladder during micturition

  • KUBevaluate the bones of the spine and pelvis (injury or congenital anomaly such as spina bifida) and the soft tissues (calcifications, foreign bodies, etc.)

  • posterior processes are absent below L-4. This patient has lower lumbar spina bifida.

  • This child has significant constipation, the variegated pattern of stool and gas in the colon.

  • Images are obtained while the bladder is being filled with liquid contrast.The bladder should appear smooth and regular and there should be no filling defects except the balloon of the urethral catheter.The edges of the bladder image should be smooth.

  • This patient has an obstruction in the urethra. She has spina bifida (see that shunt tubing?). Nerve damage from the spina bifida results in a physiologic obstruction to urine drainage through the urethra. Her bladder responded to the obstruction by detrusor muscle hypertrophy. This thickened muscle caused the irregular border of the bladder.Christmas tree bladder

  • To demonstrate the urethra (strictures or obstruction) and the bladderThe presence or absence of vesicoureteral reflux.

  • This film shows a normal male urethra; there is no obstruction. The variation seen in the diameter of the urethra is normal.Indentation at the urethral sphincter (normal)

  • May demonstrate RefluxExtravasation of urine from the bladder or urethraResidual urine in bladderNo reflux and no residual bladder urine is seen in normal post-void film.Normal post-void film

  • No special care neededRarely dysuria leading to urinary retention - analgesicAntibiotics prescription to patients with reflux

  • Due to contrast mediumContrast induced cystitisContrast reaction due to absorption by bladder mucosa

    Due to techniqueAcute UTICatheter trauma - dysuria , frequency, hematuria , retentionPerforation from over distentionCatheterization of vagina or an ectopic ureteral orificeRetention of Foley's catheter

  • I:Ureter onlyII: Into sharp, delicate calycesIII.Blunted calyces

  • IV:severe bluntingV:Dilated, tortuous ureter

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