Imaging Studies of the Genitourinary Tract

Osama Elashry, M.D.Osama Elashry, M.D.Urology DepartmentUrology Department

Tanta UniversityTanta University

Osama Elashry, M.D.Osama Elashry, M.D.Urology DepartmentUrology Department

Tanta UniversityTanta University

IMAGING STUDIES OF IMAGING STUDIES OF THE GENITOURINARY THE GENITOURINARY

TRACTTRACT

Types of Imaging studiesTypes of Imaging studies

• X-Ray ExaminationX-Ray Examination Simple RadiographySimple Radiography Screening and Image IntensifierScreening and Image Intensifier

Digital angiographyDigital angiography Computerized Tomography (CT scan)Computerized Tomography (CT scan)

• Ultrasonography ExaminationUltrasonography Examination• Radio-isotope ExaminationRadio-isotope Examination

• Nuclear Magnetic Resonance Nuclear Magnetic Resonance Imaging (MRI)Imaging (MRI)

• X-Ray ExaminationX-Ray Examination Simple RadiographySimple Radiography Screening and Image IntensifierScreening and Image Intensifier

Digital angiographyDigital angiography Computerized Tomography (CT scan)Computerized Tomography (CT scan)

• Ultrasonography ExaminationUltrasonography Examination• Radio-isotope ExaminationRadio-isotope Examination

• Nuclear Magnetic Resonance Nuclear Magnetic Resonance Imaging (MRI)Imaging (MRI)

Plain X-ray film (KUB)(PUT) (GUT)Plain X-ray film (KUB)(PUT) (GUT)

Indications:Indications: Step to diagnose GU disease (e.g. Stones, Step to diagnose GU disease (e.g. Stones,

calcification, secondaries, ectopia vesica)calcification, secondaries, ectopia vesica) In all cases of urinary complains whether upper In all cases of urinary complains whether upper

(masses, colic, anuria) or lower (ch. dysuria, (masses, colic, anuria) or lower (ch. dysuria, hematuria, pyuria, retention, incontinence).hematuria, pyuria, retention, incontinence).

Before IVP.Before IVP. D.D of urologic from gastrointestinal diseases D.D of urologic from gastrointestinal diseases

(appendicitis, gall bladder disease).(appendicitis, gall bladder disease).

Contraindication: Contraindication: PregnancyPregnancy

Patient Preparation:Patient Preparation:

Fasting (12 hrs), Ambulation, enema (warm Fasting (12 hrs), Ambulation, enema (warm water), purgatives (caster oil), adsorbents. water), purgatives (caster oil), adsorbents.

Indications:Indications: Step to diagnose GU disease (e.g. Stones, Step to diagnose GU disease (e.g. Stones,

calcification, secondaries, ectopia vesica)calcification, secondaries, ectopia vesica) In all cases of urinary complains whether upper In all cases of urinary complains whether upper

(masses, colic, anuria) or lower (ch. dysuria, (masses, colic, anuria) or lower (ch. dysuria, hematuria, pyuria, retention, incontinence).hematuria, pyuria, retention, incontinence).

Before IVP.Before IVP. D.D of urologic from gastrointestinal diseases D.D of urologic from gastrointestinal diseases

(appendicitis, gall bladder disease).(appendicitis, gall bladder disease).

Contraindication: Contraindication: PregnancyPregnancy

Patient Preparation:Patient Preparation:

Fasting (12 hrs), Ambulation, enema (warm Fasting (12 hrs), Ambulation, enema (warm water), purgatives (caster oil), adsorbents. water), purgatives (caster oil), adsorbents.


THE GOOD PLAIN FILM SHOULD THE GOOD PLAIN FILM SHOULD INCLUDE:INCLUDE:

• The Last 2 RibsThe Last 2 Ribs

• All Lumber And Sacral VertebraeAll Lumber And Sacral Vertebrae

• Psoas MusclesPsoas Muscles

• Symphysis Pubis Symphysis Pubis

• Good Quality Good Quality

• Patient PreparationPatient Preparation

THE GOOD PLAIN FILM SHOULD THE GOOD PLAIN FILM SHOULD INCLUDE:INCLUDE:

• The Last 2 RibsThe Last 2 Ribs

• All Lumber And Sacral VertebraeAll Lumber And Sacral Vertebrae

• Psoas MusclesPsoas Muscles

• Symphysis Pubis Symphysis Pubis

• Good Quality Good Quality

• Patient PreparationPatient Preparation


You should report of the following: You should report of the following:

• Renal shadow (size, position, shape)Renal shadow (size, position, shape)

• Calcification or radiopaque shadow Calcification or radiopaque shadow (outside/inside the UT)(outside/inside the UT)

• Psoas shadowPsoas shadow

• Bone (vertebrae, ribs, hip, upper femur)Bone (vertebrae, ribs, hip, upper femur)

• Gastrointestinal tract shadowGastrointestinal tract shadow

You should report of the following: You should report of the following:

• Renal shadow (size, position, shape)Renal shadow (size, position, shape)

• Calcification or radiopaque shadow Calcification or radiopaque shadow (outside/inside the UT)(outside/inside the UT)

• Psoas shadowPsoas shadow

• Bone (vertebrae, ribs, hip, upper femur)Bone (vertebrae, ribs, hip, upper femur)

• Gastrointestinal tract shadowGastrointestinal tract shadow


1) RENAL SHADOW1) RENAL SHADOW

SizeSize

• from the upper border of the 1st lumber from the upper border of the 1st lumber to bottom of the 3rd or 4th lumber to bottom of the 3rd or 4th lumber vertebrae. vertebrae.

• Lt kidney is 0.5 cm longer than the Rt.Lt kidney is 0.5 cm longer than the Rt.

1) RENAL SHADOW1) RENAL SHADOW

SizeSize

• from the upper border of the 1st lumber from the upper border of the 1st lumber to bottom of the 3rd or 4th lumber to bottom of the 3rd or 4th lumber vertebrae. vertebrae.

• Lt kidney is 0.5 cm longer than the Rt.Lt kidney is 0.5 cm longer than the Rt.


Abnormalities of the renal shadow: Abnormalities of the renal shadow: • Absent:Absent: (unprepared patient, bad quality film, lack of (unprepared patient, bad quality film, lack of

perinephric fat, perinephric hematoma or abscess, perinephric fat, perinephric hematoma or abscess, congenitally absent, surgically removed, ectopic congenitally absent, surgically removed, ectopic kidney)kidney)

• Bilateral Enlargement:Bilateral Enlargement: (bil. hydronephrosis, polycystic (bil. hydronephrosis, polycystic kidney, lymphoma, amyloidosis).kidney, lymphoma, amyloidosis).

• Unilateral Enlargement:Unilateral Enlargement: (tumors, cyst, (tumors, cyst, hydronephrosis)hydronephrosis)

• Bilateral small kidneys:Bilateral small kidneys: (GN, PN, ischemia)(GN, PN, ischemia)

• Unilateral small kidney:Unilateral small kidney: (congenital hypoplasia, (congenital hypoplasia, atrophic kidney, ischemic kidney).atrophic kidney, ischemic kidney).

Abnormalities of the renal shadow: Abnormalities of the renal shadow: • Absent:Absent: (unprepared patient, bad quality film, lack of (unprepared patient, bad quality film, lack of

perinephric fat, perinephric hematoma or abscess, perinephric fat, perinephric hematoma or abscess, congenitally absent, surgically removed, ectopic congenitally absent, surgically removed, ectopic kidney)kidney)

• Bilateral Enlargement:Bilateral Enlargement: (bil. hydronephrosis, polycystic (bil. hydronephrosis, polycystic kidney, lymphoma, amyloidosis).kidney, lymphoma, amyloidosis).

• Unilateral Enlargement:Unilateral Enlargement: (tumors, cyst, (tumors, cyst, hydronephrosis)hydronephrosis)

• Bilateral small kidneys:Bilateral small kidneys: (GN, PN, ischemia)(GN, PN, ischemia)

• Unilateral small kidney:Unilateral small kidney: (congenital hypoplasia, (congenital hypoplasia, atrophic kidney, ischemic kidney).atrophic kidney, ischemic kidney).


Kidney Position: Kidney Position:

• The right kidney is lower than the left (Liver).The right kidney is lower than the left (Liver).

• The axis of the kidney:The axis of the kidney: the longitudinal axis of the kidney is directed the longitudinal axis of the kidney is directed

downward and laterally. So, the upper pole is downward and laterally. So, the upper pole is close the vertebral column than the lower pole.close the vertebral column than the lower pole.

• Abnormalities in position: Abnormalities in position: Misplaced kidney: Ectopic or PtosedMisplaced kidney: Ectopic or Ptosed

Abnormal axis in Horseshoe kidneyAbnormal axis in Horseshoe kidney

Kidney Position: Kidney Position:

• The right kidney is lower than the left (Liver).The right kidney is lower than the left (Liver).

• The axis of the kidney:The axis of the kidney: the longitudinal axis of the kidney is directed the longitudinal axis of the kidney is directed

downward and laterally. So, the upper pole is downward and laterally. So, the upper pole is close the vertebral column than the lower pole.close the vertebral column than the lower pole.

• Abnormalities in position: Abnormalities in position: Misplaced kidney: Ectopic or PtosedMisplaced kidney: Ectopic or Ptosed

Abnormal axis in Horseshoe kidneyAbnormal axis in Horseshoe kidney


Shape of the kidney: Shape of the kidney:

• The kidney has a bean shape.The kidney has a bean shape.

Abnormalities in the shape: Abnormalities in the shape:

• Expansion of one pole (Tumor, cyst, Expansion of one pole (Tumor, cyst, Carbuncle)Carbuncle)

• Lobulated kidney (Polycystic kidney)Lobulated kidney (Polycystic kidney)

Shape of the kidney: Shape of the kidney:

• The kidney has a bean shape.The kidney has a bean shape.

Abnormalities in the shape: Abnormalities in the shape:

• Expansion of one pole (Tumor, cyst, Expansion of one pole (Tumor, cyst, Carbuncle)Carbuncle)

• Lobulated kidney (Polycystic kidney)Lobulated kidney (Polycystic kidney)


•Gall bladder stoneGall bladder stone

•Aneurysm of the abd. AortaAneurysm of the abd. Aorta

•Aneurysm of the renal Aneurysm of the renal arteryartery

•Separated transverse Separated transverse process process

•Calcified cartilage of the Calcified cartilage of the ribsribs

•F.B. in the colonF.B. in the colon

•Calcified renal tumor or cyst Calcified renal tumor or cyst

•Nevus Nevus

2) CALCIFICATIONS OR RADIOPAQUE 2) CALCIFICATIONS OR RADIOPAQUE SHADOWS IN THE URINARY TRACT.SHADOWS IN THE URINARY TRACT.

• It is impossible to diagnose stone with a plain film It is impossible to diagnose stone with a plain film only.only.

Radiopaque shadow in the region of the kidney: Radiopaque shadow in the region of the kidney:

2) CALCIFICATIONS OR RADIOPAQUE 2) CALCIFICATIONS OR RADIOPAQUE SHADOWS IN THE URINARY TRACT.SHADOWS IN THE URINARY TRACT.

• It is impossible to diagnose stone with a plain film It is impossible to diagnose stone with a plain film only.only.

Radiopaque shadow in the region of the kidney: Radiopaque shadow in the region of the kidney:


CALCIFICATIONS OR RADIOPAQUE SHADOWS CALCIFICATIONS OR RADIOPAQUE SHADOWS IN THE URINARY TRACTIN THE URINARY TRACT

• Stag horn stone: Stag horn stone: Single cast occupying the Single cast occupying the pelvicalyceal system with mushroom endspelvicalyceal system with mushroom ends

• Staging stone: Staging stone: Not occupying the Not occupying the pelvicalyceal system with no mushroom ends.pelvicalyceal system with no mushroom ends.

CALCIFICATIONS OR RADIOPAQUE SHADOWS CALCIFICATIONS OR RADIOPAQUE SHADOWS IN THE URINARY TRACTIN THE URINARY TRACT

• Stag horn stone: Stag horn stone: Single cast occupying the Single cast occupying the pelvicalyceal system with mushroom endspelvicalyceal system with mushroom ends

• Staging stone: Staging stone: Not occupying the Not occupying the pelvicalyceal system with no mushroom ends.pelvicalyceal system with no mushroom ends.


Radiopaque shadow in the radiological Radiopaque shadow in the radiological line of the ureter: line of the ureter:

• Upper third: Upper third: over the transverse process of over the transverse process of the lumber vertebraethe lumber vertebrae

• Middle third: Middle third: over the ala of the sacrum and over the ala of the sacrum and sacroiliac joinsacroiliac join

• Lower third: Lower third: below the sacroiliac join to the below the sacroiliac join to the urinary bladder.urinary bladder.

Radiopaque shadow in the radiological Radiopaque shadow in the radiological line of the ureter: line of the ureter:

• Upper third: Upper third: over the transverse process of over the transverse process of the lumber vertebraethe lumber vertebrae

• Middle third: Middle third: over the ala of the sacrum and over the ala of the sacrum and sacroiliac joinsacroiliac join

• Lower third: Lower third: below the sacroiliac join to the below the sacroiliac join to the urinary bladder.urinary bladder.


Radiopaque shadow in the region of the Radiopaque shadow in the region of the pelvis:pelvis:Radiopaque shadow in the region of the Radiopaque shadow in the region of the pelvis:pelvis:

•Urinary bladder stoneUrinary bladder stone

•Urinary bladder FBUrinary bladder FB

•Lower third ureteral stoneLower third ureteral stone

•Calcified thrombusCalcified thrombus

•Calcified ovary Calcified ovary

•Calcified uterine tumorCalcified uterine tumor

•IUDIUD

•Prostatic calculiProstatic calculi

•Calcified seminal vesicleCalcified seminal vesicle

•Phelebolith Phelebolith


D.D. between stone in the Urinary bladder and lower third D.D. between stone in the Urinary bladder and lower third ureter: ureter:

• ShapeShape

• MovementMovement

• Click testClick test

• IVPIVP

• CystoscopyCystoscopy

Causes of fixed Radiopaque shadow in the urinary Causes of fixed Radiopaque shadow in the urinary bladder:bladder:

• Stone in the intramural ureterStone in the intramural ureter

• Stone in the bladder neckStone in the bladder neck

• Stone in diverticulumStone in diverticulum

• Calcified polypCalcified polyp

• Calcified tumorCalcified tumor

D.D. between stone in the Urinary bladder and lower third D.D. between stone in the Urinary bladder and lower third ureter: ureter:

• ShapeShape

• MovementMovement

• Click testClick test

• IVPIVP

• CystoscopyCystoscopy

Causes of fixed Radiopaque shadow in the urinary Causes of fixed Radiopaque shadow in the urinary bladder:bladder:

• Stone in the intramural ureterStone in the intramural ureter

• Stone in the bladder neckStone in the bladder neck

• Stone in diverticulumStone in diverticulum

• Calcified polypCalcified polyp

• Calcified tumorCalcified tumor


Stone OpacityStone OpacityStone OpacityStone Opacity

Radiopaque stonesRadiopaque stones

Calcium OxalateCalcium Oxalate

Calcium PhosphateCalcium Phosphate

Triple Phosphate Triple Phosphate (Struvite stones)(Struvite stones)

Cystine stoneCystine stone

Radiolucent stonesRadiolucent stones

Uric acid stonesUric acid stones

Urate stonesUrate stones

Xanthin stonesXanthin stones

Indigo stonesIndigo stones


When you see a radiopaque shadow, When you see a radiopaque shadow, you have to comment on the you have to comment on the following: following:

• SiteSite

• Size Size ونص مرة بتكبر ونص األشعة مرة بتكبر األشعة

• NumberNumber

• ShapeShape

,When you see a radiopaque shadow ,When you see a radiopaque shadow you have to comment on the you have to comment on the :following :following

• SiteSite

• Size Size ونص مرة بتكبر ونص األشعة مرة بتكبر األشعة

• NumberNumber

• ShapeShape


3) REPORT ON THE PSOAS 3) REPORT ON THE PSOAS SHADOW: SHADOW:

• May be obliterated by pathological May be obliterated by pathological condition of the kidneys e.g. condition of the kidneys e.g. Hydronephrosis or perinephric space Hydronephrosis or perinephric space collectioncollection

3) REPORT ON THE PSOAS 3) REPORT ON THE PSOAS SHADOW: SHADOW:

• May be obliterated by pathological May be obliterated by pathological condition of the kidneys e.g. condition of the kidneys e.g. Hydronephrosis or perinephric space Hydronephrosis or perinephric space collectioncollection


4) REPORT ON THE BONE SHADOW4) REPORT ON THE BONE SHADOW

• ArthritisArthritis

• RadiculitisRadiculitis

• Spina BifidaSpina Bifida

• Ectopia VesicaEctopia Vesica

• MetastasisMetastasis

• Fractures (ribs, spine)Fractures (ribs, spine)

4) REPORT ON THE BONE SHADOW4) REPORT ON THE BONE SHADOW

• ArthritisArthritis

• RadiculitisRadiculitis

• Spina BifidaSpina Bifida

• Ectopia VesicaEctopia Vesica

• MetastasisMetastasis

• Fractures (ribs, spine)Fractures (ribs, spine)


TO REPORT ON X-RAY FILM: TO REPORT ON X-RAY FILM:

Preliminary data: Preliminary data:

• Plain film or not (written, no dye????)Plain film or not (written, no dye????)

• Complete or not (last 2 ribs, 2 cm below the Complete or not (last 2 ribs, 2 cm below the symphysis pubis, both flanks)symphysis pubis, both flanks)

• Patient is centralized or notPatient is centralized or not

• Good film (quality)Good film (quality)

• Male or female (written, IUD)Male or female (written, IUD)

• Adult or notAdult or not

• SHOWING: ??? SHOWING: ??? Main Report:Main Report:

TO REPORT ON X-RAY FILM: TO REPORT ON X-RAY FILM:

Preliminary data: Preliminary data:

• Plain film or not (written, no dye????)Plain film or not (written, no dye????)

• Complete or not (last 2 ribs, 2 cm below the Complete or not (last 2 ribs, 2 cm below the symphysis pubis, both flanks)symphysis pubis, both flanks)

• Patient is centralized or notPatient is centralized or not

• Good film (quality)Good film (quality)

• Male or female (written, IUD)Male or female (written, IUD)

• Adult or notAdult or not

• SHOWING: ??? SHOWING: ??? Main Report:Main Report:

INTRAVENOUS UROGRAPHY (IVP or IVU)INTRAVENOUS UROGRAPHY (IVP or IVU)

Contrast AgentsContrast Agents

1- high osmolar contrast media (most common):1- high osmolar contrast media (most common):

Sodium or methylglucamine salts of diatrizoate Sodium or methylglucamine salts of diatrizoate (Uorografin 76%, Renografin 60%, Hypaque 45%, (Uorografin 76%, Renografin 60%, Hypaque 45%, Urovideo 75%) and iothalamate (Conray 250, 325, 420). Urovideo 75%) and iothalamate (Conray 250, 325, 420).

2- Newer nonionic agents 2- Newer nonionic agents “low osmolar contrast media”“low osmolar contrast media”: :

• Iohexol (Omnipaque) - Iopromide (Ultravist) - Ioversol Iohexol (Omnipaque) - Iopromide (Ultravist) - Ioversol (Optiray) (Optiray)

In cases with Sensitivity to the older contrast media: In cases with Sensitivity to the older contrast media: cardiac decompensation, advanced age or debility, cardiac decompensation, advanced age or debility,

electrolyte imbalance, patients with renal functional electrolyte imbalance, patients with renal functional impairment, and patients with a significant allergic impairment, and patients with a significant allergic history, including reactions to previously history, including reactions to previously administered contrast media. administered contrast media.

Contrast AgentsContrast Agents

1- high osmolar contrast media (most common):1- high osmolar contrast media (most common):

Sodium or methylglucamine salts of diatrizoate Sodium or methylglucamine salts of diatrizoate (Uorografin 76%, Renografin 60%, Hypaque 45%, (Uorografin 76%, Renografin 60%, Hypaque 45%, Urovideo 75%) and iothalamate (Conray 250, 325, 420). Urovideo 75%) and iothalamate (Conray 250, 325, 420).

2- Newer nonionic agents 2- Newer nonionic agents “low osmolar contrast media”“low osmolar contrast media”: :

• Iohexol (Omnipaque) - Iopromide (Ultravist) - Ioversol Iohexol (Omnipaque) - Iopromide (Ultravist) - Ioversol (Optiray) (Optiray)

In cases with Sensitivity to the older contrast media: In cases with Sensitivity to the older contrast media: cardiac decompensation, advanced age or debility, cardiac decompensation, advanced age or debility,

electrolyte imbalance, patients with renal functional electrolyte imbalance, patients with renal functional impairment, and patients with a significant allergic impairment, and patients with a significant allergic history, including reactions to previously history, including reactions to previously administered contrast media. administered contrast media.


Physiology of Contrast AgentsPhysiology of Contrast Agents

• The contrast molecules unbound in the The contrast molecules unbound in the plasma, therefore excreted entirely by plasma, therefore excreted entirely by glumerular filtration. glumerular filtration.

• Contrast media are neither secreted nor Contrast media are neither secreted nor reabsorbed by the proximal tubule. Thus, the reabsorbed by the proximal tubule. Thus, the final concentration may be 50 to 100 times final concentration may be 50 to 100 times greater than in the fluid first filtered. greater than in the fluid first filtered.

Physiology of Contrast AgentsPhysiology of Contrast Agents

• The contrast molecules unbound in the The contrast molecules unbound in the plasma, therefore excreted entirely by plasma, therefore excreted entirely by glumerular filtration. glumerular filtration.

• Contrast media are neither secreted nor Contrast media are neither secreted nor reabsorbed by the proximal tubule. Thus, the reabsorbed by the proximal tubule. Thus, the final concentration may be 50 to 100 times final concentration may be 50 to 100 times greater than in the fluid first filtered. greater than in the fluid first filtered.


Technique Technique First measure the blood urea and serum creatinine First measure the blood urea and serum creatinine

(urea > 80 mg% and creatinine >2 mg/dl do infusion)(urea > 80 mg% and creatinine >2 mg/dl do infusion)

Preparation of the bowel. Preparation of the bowel.

Plain film of the abdomen Plain film of the abdomen

Contrast administration: intravenously, as a rapid Contrast administration: intravenously, as a rapid bolus injection, slow injection, or drip infusion. bolus injection, slow injection, or drip infusion.

In the average-size adult, 1-2 ml/kg with max. In the average-size adult, 1-2 ml/kg with max.

100 ml of contrast are usually administered (with the 100 ml of contrast are usually administered (with the bolus injection) or 200 to 300 ml with the infusion bolus injection) or 200 to 300 ml with the infusion injection. (Or 5 ampoules urographin with 250 ml injection. (Or 5 ampoules urographin with 250 ml glucose 5%)glucose 5%)

Technique Technique First measure the blood urea and serum creatinine First measure the blood urea and serum creatinine

(urea > 80 mg% and creatinine >2 mg/dl do infusion)(urea > 80 mg% and creatinine >2 mg/dl do infusion)

Preparation of the bowel. Preparation of the bowel.

Plain film of the abdomen Plain film of the abdomen

Contrast administration: intravenously, as a rapid Contrast administration: intravenously, as a rapid bolus injection, slow injection, or drip infusion. bolus injection, slow injection, or drip infusion.

In the average-size adult, 1-2 ml/kg with max. In the average-size adult, 1-2 ml/kg with max.

100 ml of contrast are usually administered (with the 100 ml of contrast are usually administered (with the bolus injection) or 200 to 300 ml with the infusion bolus injection) or 200 to 300 ml with the infusion injection. (Or 5 ampoules urographin with 250 ml injection. (Or 5 ampoules urographin with 250 ml glucose 5%)glucose 5%)


TechniqueTechnique

Filming ( if bolus, do 3-5 min filming, if infusion do Filming ( if bolus, do 3-5 min filming, if infusion do filming after the half of the infusion is taken). Then filming after the half of the infusion is taken). Then 5,10,15,30 minutes filming then every hour for 24 5,10,15,30 minutes filming then every hour for 24 hours.hours.

Immediate and 3-5 min film---tomograms are made to Immediate and 3-5 min film---tomograms are made to visualize the renal parenchymavisualize the renal parenchyma

Within 10 min ---see the kidney, calyces, renal pelvis Within 10 min ---see the kidney, calyces, renal pelvis (pyelographic phase). (pyelographic phase).

30 min. Films – see the rest of the ureters and 30 min. Films – see the rest of the ureters and bladder.bladder.

Postvoiding film conclude the examination. Postvoiding film conclude the examination.

Positions for filming (lateral, prone, erect (in ptosis, Positions for filming (lateral, prone, erect (in ptosis, urinary obstruction, bladder herniation, cystocele, urinary obstruction, bladder herniation, cystocele, air-fluid levels), and delayed films) air-fluid levels), and delayed films)

TechniqueTechnique

Filming ( if bolus, do 3-5 min filming, if infusion do Filming ( if bolus, do 3-5 min filming, if infusion do filming after the half of the infusion is taken). Then filming after the half of the infusion is taken). Then 5,10,15,30 minutes filming then every hour for 24 5,10,15,30 minutes filming then every hour for 24 hours.hours.

Immediate and 3-5 min film---tomograms are made to Immediate and 3-5 min film---tomograms are made to visualize the renal parenchymavisualize the renal parenchyma

Within 10 min ---see the kidney, calyces, renal pelvis Within 10 min ---see the kidney, calyces, renal pelvis (pyelographic phase). (pyelographic phase).

30 min. Films – see the rest of the ureters and 30 min. Films – see the rest of the ureters and bladder.bladder.

Postvoiding film conclude the examination. Postvoiding film conclude the examination.

Positions for filming (lateral, prone, erect (in ptosis, Positions for filming (lateral, prone, erect (in ptosis, urinary obstruction, bladder herniation, cystocele, urinary obstruction, bladder herniation, cystocele, air-fluid levels), and delayed films) air-fluid levels), and delayed films)


Complications of UrographyComplications of Urography

l . Immediate l . Immediate

• Minor: Minor: Nausea, vomiting, arm pain, and headach Nausea, vomiting, arm pain, and headach

• Sever allergic:Sever allergic: Erythema, urticaria, facial or glottic Erythema, urticaria, facial or glottic edema. edema.

Treatment: Treatment: antihistamines, steroids and/or epinephrineantihistamines, steroids and/or epinephrine..

• Chemotoxic or idiosyncratic reactionsChemotoxic or idiosyncratic reactions: (most serious): (most serious)

Include: convulsions, pulmonary edema, cardiovascular Include: convulsions, pulmonary edema, cardiovascular collapse, thrombosis, cardiac arrest. 1 of every 7,500 collapse, thrombosis, cardiac arrest. 1 of every 7,500

• The mortality rate for contrast administration, 1:100,000The mortality rate for contrast administration, 1:100,000

2. Delayed2. Delayed

Nephrotoxicity: Patients with diabetic nephropathy, Nephrotoxicity: Patients with diabetic nephropathy, creatinine levels are >3 mg/dl. This nephrotoxicity is creatinine levels are >3 mg/dl. This nephrotoxicity is usually reversible. usually reversible.

Complications of UrographyComplications of Urography

l . Immediate l . Immediate

• Minor: Minor: Nausea, vomiting, arm pain, and headach Nausea, vomiting, arm pain, and headach

• Sever allergic:Sever allergic: Erythema, urticaria, facial or glottic Erythema, urticaria, facial or glottic edema. edema.

Treatment: Treatment: antihistamines, steroids and/or epinephrineantihistamines, steroids and/or epinephrine..

• Chemotoxic or idiosyncratic reactionsChemotoxic or idiosyncratic reactions: (most serious): (most serious)

Include: convulsions, pulmonary edema, cardiovascular Include: convulsions, pulmonary edema, cardiovascular collapse, thrombosis, cardiac arrest. 1 of every 7,500 collapse, thrombosis, cardiac arrest. 1 of every 7,500

• The mortality rate for contrast administration, 1:100,000The mortality rate for contrast administration, 1:100,000

2. Delayed2. Delayed

Nephrotoxicity: Patients with diabetic nephropathy, Nephrotoxicity: Patients with diabetic nephropathy, creatinine levels are >3 mg/dl. This nephrotoxicity is creatinine levels are >3 mg/dl. This nephrotoxicity is usually reversible. usually reversible.


IndicationsIndications

• Flank pain/colic (persistent or recurrent)Flank pain/colic (persistent or recurrent)

• HematuriaHematuria

• LithiasisLithiasis

• Abdominal masses (?? renal masses)Abdominal masses (?? renal masses)

• Abdominal trauma to exclude trauma to urinary tractAbdominal trauma to exclude trauma to urinary tract

• Diagnosis of congenital anomaliesDiagnosis of congenital anomalies

• Diagnosis of pathological conditions in the ureter or Diagnosis of pathological conditions in the ureter or bladder (obstruction, tumors)bladder (obstruction, tumors)

• Pyrexia of unknown etiology, dyspepsia.Pyrexia of unknown etiology, dyspepsia.

The vast majority of patients requiring urologic imaging The vast majority of patients requiring urologic imaging will be best served by having IVPwill be best served by having IVP

IndicationsIndications

• Flank pain/colic (persistent or recurrent)Flank pain/colic (persistent or recurrent)

• HematuriaHematuria

• LithiasisLithiasis

• Abdominal masses (?? renal masses)Abdominal masses (?? renal masses)

• Abdominal trauma to exclude trauma to urinary tractAbdominal trauma to exclude trauma to urinary tract

• Diagnosis of congenital anomaliesDiagnosis of congenital anomalies

• Diagnosis of pathological conditions in the ureter or Diagnosis of pathological conditions in the ureter or bladder (obstruction, tumors)bladder (obstruction, tumors)

• Pyrexia of unknown etiology, dyspepsia.Pyrexia of unknown etiology, dyspepsia.

The vast majority of patients requiring urologic imaging The vast majority of patients requiring urologic imaging will be best served by having IVPwill be best served by having IVP


ContraindicationsContraindications

Absolute: Absolute: pregnancy.pregnancy.

RelativeRelative hypersensitivityhypersensitivity Multiple myeloma: oliguria after contrast Multiple myeloma: oliguria after contrast

administration, due to the precipitation of protein-administration, due to the precipitation of protein-contrast aggregates (Bence-Jones Protein) contrast aggregates (Bence-Jones Protein)

Renal insufficiency: Patients with creatinine >4 Renal insufficiency: Patients with creatinine >4 mgldL or a blood urea >100 mgldLmgldL or a blood urea >100 mgldL

Fluid and electrolyte imbalance: Severely dehydrated Fluid and electrolyte imbalance: Severely dehydrated or marked electrolyte imbalance or marked electrolyte imbalance

Multiple consecutive contrast studiesMultiple consecutive contrast studies Thyrotoxicosis: due to iodine sensitivity.Thyrotoxicosis: due to iodine sensitivity.

ContraindicationsContraindications

Absolute: Absolute: pregnancy.pregnancy.

RelativeRelative hypersensitivityhypersensitivity Multiple myeloma: oliguria after contrast Multiple myeloma: oliguria after contrast

administration, due to the precipitation of protein-administration, due to the precipitation of protein-contrast aggregates (Bence-Jones Protein) contrast aggregates (Bence-Jones Protein)

Renal insufficiency: Patients with creatinine >4 Renal insufficiency: Patients with creatinine >4 mgldL or a blood urea >100 mgldLmgldL or a blood urea >100 mgldL

Fluid and electrolyte imbalance: Severely dehydrated Fluid and electrolyte imbalance: Severely dehydrated or marked electrolyte imbalance or marked electrolyte imbalance

Multiple consecutive contrast studiesMultiple consecutive contrast studies Thyrotoxicosis: due to iodine sensitivity.Thyrotoxicosis: due to iodine sensitivity.


HOW TO COMMENT ON THE IVPHOW TO COMMENT ON THE IVP• Preliminary data Preliminary data (This is an IVP of adult (This is an IVP of adult

patient “male or female”, complete film patient “male or female”, complete film with good quality, taken after? minuteswith good quality, taken after? minutes))

• Function:Function: good or bad (based on timing of good or bad (based on timing of appearance of the dye, density, appearance of the dye, density, homogeneity, concentration)homogeneity, concentration)

• Radiological anatomyRadiological anatomy of the kidney and of the kidney and pelvicalyceal systempelvicalyceal system

HOW TO COMMENT ON THE IVPHOW TO COMMENT ON THE IVP• Preliminary data Preliminary data (This is an IVP of adult (This is an IVP of adult

patient “male or female”, complete film patient “male or female”, complete film with good quality, taken after? minuteswith good quality, taken after? minutes))

• Function:Function: good or bad (based on timing of good or bad (based on timing of appearance of the dye, density, appearance of the dye, density, homogeneity, concentration)homogeneity, concentration)

• Radiological anatomyRadiological anatomy of the kidney and of the kidney and pelvicalyceal systempelvicalyceal system


Radiological anatomy of the kidney and Radiological anatomy of the kidney and pelvicalyceal system:pelvicalyceal system:

Nephrogram (see the upper and lower poles of the Nephrogram (see the upper and lower poles of the kidney, size, position.kidney, size, position.

Calyces: (see the major and minor calyces): Calyces: (see the major and minor calyces): Number, shape, crescent appearance of the minor Number, shape, crescent appearance of the minor calyx, directed laterally.calyx, directed laterally.

Pathology: Pathology: Hydrocalycosis, hydronephrosis ( ?Hydrocalycosis, hydronephrosis ( ?reason), Spider leg appearance (tumor, cyst), reason), Spider leg appearance (tumor, cyst), Filling defectFilling defect

Renal pelvis (Intrarenal or extrarenal, shape, Renal pelvis (Intrarenal or extrarenal, shape, filling defects)filling defects)

Radiological anatomy of the kidney and Radiological anatomy of the kidney and pelvicalyceal system:pelvicalyceal system:

Nephrogram (see the upper and lower poles of the Nephrogram (see the upper and lower poles of the kidney, size, position.kidney, size, position.

Calyces: (see the major and minor calyces): Calyces: (see the major and minor calyces): Number, shape, crescent appearance of the minor Number, shape, crescent appearance of the minor calyx, directed laterally.calyx, directed laterally.

Pathology: Pathology: Hydrocalycosis, hydronephrosis ( ?Hydrocalycosis, hydronephrosis ( ?reason), Spider leg appearance (tumor, cyst), reason), Spider leg appearance (tumor, cyst), Filling defectFilling defect

Renal pelvis (Intrarenal or extrarenal, shape, Renal pelvis (Intrarenal or extrarenal, shape, filling defects)filling defects)


Causes of absent kidney on IVP: Causes of absent kidney on IVP: Congenitally absentCongenitally absent Surgically removedSurgically removed Destroyed by a diseaseDestroyed by a disease Reflex inhibition (renal colic)Reflex inhibition (renal colic) Ectopic Ectopic

DD.: DD.: HistoryHistory UltrasonographyUltrasonography Infusion UrographyInfusion Urography Ascending pyelographyAscending pyelography Radio-isotope renal scanning Radio-isotope renal scanning

Causes of absent kidney on IVP: Causes of absent kidney on IVP: Congenitally absentCongenitally absent Surgically removedSurgically removed Destroyed by a diseaseDestroyed by a disease Reflex inhibition (renal colic)Reflex inhibition (renal colic) Ectopic Ectopic

DD.: DD.: HistoryHistory UltrasonographyUltrasonography Infusion UrographyInfusion Urography Ascending pyelographyAscending pyelography Radio-isotope renal scanning Radio-isotope renal scanning


Comment on the ureter: Comment on the ureter:

(normally the ureter is not completely (normally the ureter is not completely filled due to peristalsis) if completely filled due to peristalsis) if completely filled it is ureteroectasis or hydroureter.filled it is ureteroectasis or hydroureter.

•HydroureterHydroureter

•RefluxReflux

•StrictureStricture

•Filling defectFilling defect

Comment on the ureter: Comment on the ureter:

(normally the ureter is not completely (normally the ureter is not completely filled due to peristalsis) if completely filled due to peristalsis) if completely filled it is ureteroectasis or hydroureter.filled it is ureteroectasis or hydroureter.

•HydroureterHydroureter

•RefluxReflux

•StrictureStricture

•Filling defectFilling defect


CystogramCystogram: :

• (descending cystogram) 30 minutes film. If (descending cystogram) 30 minutes film. If before the 30 minutes, say the bladder is not before the 30 minutes, say the bladder is not completely filled.completely filled.

• The bladder appears as an oval or rounded in The bladder appears as an oval or rounded in shape, resting on the symphysis pubis with shape, resting on the symphysis pubis with smooth outlinessmooth outlines

• Abnormalities: shape ???, bladder is Abnormalities: shape ???, bladder is elevated ???, abnormal outlines ???? elevated ???, abnormal outlines ???? Filling defects (smooth or irregular)Filling defects (smooth or irregular)

CystogramCystogram: :

• (descending cystogram) 30 minutes film. If (descending cystogram) 30 minutes film. If before the 30 minutes, say the bladder is not before the 30 minutes, say the bladder is not completely filled.completely filled.

• The bladder appears as an oval or rounded in The bladder appears as an oval or rounded in shape, resting on the symphysis pubis with shape, resting on the symphysis pubis with smooth outlinessmooth outlines

• Abnormalities: shape ???, bladder is Abnormalities: shape ???, bladder is elevated ???, abnormal outlines ???? elevated ???, abnormal outlines ???? Filling defects (smooth or irregular)Filling defects (smooth or irregular)


Causes of filling defect in Urinary bladder: Causes of filling defect in Urinary bladder: • Radiolucent stoneRadiolucent stone

• Bladder polyp (bilharzial)Bladder polyp (bilharzial)

• Blood clotBlood clot

• Bladder tumorBladder tumor

• Balloon of Foley’s catheterBalloon of Foley’s catheter

• Foreign bodyForeign body

• ureterocelesureteroceles

Causes of filling defect in Urinary bladder: Causes of filling defect in Urinary bladder: • Radiolucent stoneRadiolucent stone

• Bladder polyp (bilharzial)Bladder polyp (bilharzial)

• Blood clotBlood clot

• Bladder tumorBladder tumor

• Balloon of Foley’s catheterBalloon of Foley’s catheter

• Foreign bodyForeign body

• ureterocelesureteroceles

Imaging Studies of the Genitourinary Tract

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