Intravenous Urography (IVU)

Dr.Abdalla Mutwakil Gamal

Radiology Department

Sebha Medical Center

Contents

Introduction

The procedure

Examples for abnormal findings

IVU vs KUB & USG vs NCCT

Introduction

Definition

- X-Ray + Contrast

- Other names

Indications

1 – Hematuria

2 – Renal Colic

3 – Recurrent urinary tract infection

4 – Suspected urinary tract pathology

Contraindications

They are the general contraindications to water

soluble agents :

- Contrast allergy

- Hepatorenal syndrome

- Thyrotoxicosis

- Pregnancy

- Raised serum creatinine

Advantages of IVU

- Detailed anatomy of the collecting systems

- Demonstration of major calcification

- Sensitive for acute obstruction

- Low cost

Limitations of IVU

- It depends on kidney function

- Do not differentiate solid or cystic lesion

- Requires contrast medium and radiation.

- Missing small stones.

- Quality of study may be limited by

inadequate bowel preparation, bowel ileus,

swallowed air and technician variability.

- Inconvenience of a long filming sequence.

The procedure

Equipments

Contrast

LOCM 370 (LOCM = Low osmolar contrast material)

Adult dose = 50 – 100 ml , Pediatric dose = 1ml for each kg

Patient preparation

- Eating and drinking

- Moving around

- Bowel preparation

- Metformin

Preliminary film (control film)

Technique

- Dye injection

- Precautions during dye injection

- Taking x-rays

Films

Immediate

film 5-15 min film

(Nephrogram

phase)

30-min film

(Ureterogram

phase)

45-min film

(Cystogram

phase)

Postvoiding

film

Immediate film (Nephrogram phase)

A.P. of the renal areas to show the

nephrogram, i.e. the renal parenchyma

opacified by the contrast medium in the

renal tubules.

(taking it after injection equals about 10 to

14 seconds which is the approximate arm-

to-kidney time).

5-15 minutes film (Secretory phase)

inspect :

- Both Kidney contour

- Contrast is filling both the Pyelum or not,

- is there any delayed filling?

30 minutes film (Ureterogram phase)

inspect:

Is there any collecting systems and ureters

dilatation or filling defect? (normal ureter

filling is rarely demonstrate the whole ureter

from proximal to distal as there is a

peristaltic wave )

45 minutes film (Cystogram phase)

inspect :

- Bladder size and shape

- Contrast is filling the bladder or not

- Bladder surface is smooth or rough

- Is there any diverticlula, filling defect or

prostate indentation?

Postvoiding film

look for:

- Residual urine

- Contrast left on upper tract? (normally there

is no contrast left on upper urinary tract on

postvoiding film)

Patient Aftercare

- Needle wound site dressed and checked

for extravasation.

- Check patient understands how to receive

the results.

- Ensure patient understands any

preparation instructions are finished

- Escort to changing rooms and bid good-

bye.

Sample Report

- Clinical Information:

- Description:

- Impression:

Description

- A supine view of the abdomen demonstrates a normal bowel gas pattern, with no evidence

of free intraperitoneal air, pathologic calcification, or soft tissue mass. The bony structures

are unremarkable.

- Following the administration of intravenous contrast, prompt and symmetric bilateral

nephrograms are identified.

- The kidneys are normal in size, contour, axis, and position.

- Prompt excretion is noted bilaterally into normal renal collecting systems and ureters, with

no evidence of intraluminal filling defect or mucosal irregularity.

- The bladder is smooth-walled, with no evidence of intraluminal filling defect or mucosal

abnormality.

- There is no significant post void residual.

Examples for abnormal findings

Example for Findings – Before dye injection

Stone in the left ureter

Example for Findings – Before dye injection

classic lobar pattern of calcification,

which is pathognomonic of end-stage

renal tuberculosis. Ureteral

calcification is also noted, which is

fainter in upper parts (arrowheads)

Example for Findings – Kidneys

Horseshoe Kidney - Tissue Bridge Across

Midline Causes Abnormal Orientation of Renal

Axis

Example for Findings – Kidneys

Extravasation of Contrast from Left Kidney

Secondary to High Grade Obstruction

Example for Findings – renal collecting system and ureters

Pyelo-ureteric Junction Obstruction Shows as

Dilation of Right Renal Pelvis and Calyces.

Example for Findings – renal collecting system and ureters

Dilation of Left Renal Pelvis and Calyces

Above the Obstructing Calculus

Example for Findings – renal collecting system and ureters

Stab wound of right ureter shows

extravasation (at arrow) on intravenous

urogram.

Example for Findings – renal collecting system and ureters

Crossed Renal Ectopia on the Left Kidney and

Absent Right Kidney.

Example for Findings – Urinary Bladder

Round shadow on right side of bladder later

shown to be a bladder cancer.

Example for Findings – Urinary Bladder

Nodular squamous cell carcinoma of the

bladder. Dilated left lower ureter probably

secondary to obstruction by tumor.

Nonvisualization of the right ureter caused

by complete occlusion

Example for Findings – Urinary Bladder

Intravenous urography showed no

obstructive uropathy, but symmetric

diverticula could be seen near both ureteral

orifices (arrows). These lesions, known as

Hutch diverticula, are usually congenital

rather than occurring as a result of a

neurogenic bladder or an infection or

obstruction.

Benign prostatic hyperplasia. White = bladder.

Dark = benign enlargement of prostate,

pushing down on inferior bladder

IVU vs KUB & USG vs NCCT

USG & KUB vs IVU

S J Andrews, P T Brooks, D C Hanbury, et al. Ultrasonography and abdominal radiography versus

intravenous urography in investigation of urinary tract infection in men: prospective incident

cohort study. BMJ 2002;324:454. http://www.bmj.com/content/324/7335/454. Accessed April 5,

2014.

Participants: Consecutive series of men (n=114) referred to the department of urology for investigation of

proved urinary tract infection.

Results: Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being a

poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder and

ultrasonography detected more abnormalities than intravenous urography alone. No important

abnormality was missed by this combination (sensitivity 100% and specificity 93%).

Conclusions: Ultrasonography with abdominal radiography is as accurate as intravenous urography in

detecting important urological abnormalities in men presenting with urinary tract infection. This

combination is safer than intravenous urography and should be the initial investigation for such patients.

Additional determination of urinary flow rate is useful for the assessment of an incompletely emptying

bladder.

USG & KUB vs IVU

Zafar Amin, Abdul Salam. ROLE OF ULTRASOUND AND INTRAVENOUS UROGRAPHY IN PATIENTS

WITH RENAL COLIC. Pakistan Armed Forces Medical Journal. 2011; 7(4). http://www.pafmj.org/showdetails.php?id=529&t=o . Accessed April 5, 2014.

Materials and Methods: One hundred and eleven consecutive patients with clinically suspected urinary tract

calculi were selected for study. At first they underwent sonography along with x-ray KUB and then IVU.

We evaluated the sensitivity, specificity, negative /positive predictive values and accuracy of US X-ray

KUB combination and IVU for detecting renal / ureteric calculi while final diagnosis (gold standard)

obtained from the results of clinical course/urological procedures.

Results: Out of 111 consecutive patients 46 (41 %) were normal and 65 (59 %) patients had KUB calculi.

US along with x-ray KUB detected 59 patients and missed 6 patients and likewise IVU detected 61

patients out of 65 patients. Sensitivity, specificity, and accuracy of both these modalities are almost

similar with IVU having slightly upper edge.

Conclusion: IVU remains an important investigation in the assessment of calculus and other causes of

urinary tract obstruction. Ultrasound in combination with x-ray KUB is an excellent modality having almost

similar diagnostic capability as IVU in detecting KUB calculi along with many more significant advantages,

as it has less radiation dose, relatively inexpensive, universally available, easily applicable and high

diagnostic efficacy.

NCCT vs IVU

N Khan, Z Anwar, AM Zafar, F Ahmed, et al. A comparison of non-contrast CT and intravenous

urography in the diagnosis of urolithiasis and obstruction. African Journal of Urology . 2012; 18(3). http://www.ajol.info/index.php/aju/article/view/84103 . Accessed April 5, 2014.

Subjects and methods: This is a retrospective review of radiological and clinical data of patients with

suspected urolithiasis or ureteric obstruction who had both NCCT and IVU performed within 30 days of

each other. The data were analyzed using the statistical packages Epidata™ and SPSS™. The number

of calculi, presence of hydronephrosis and hydroureter, cysts and ureteric wall thickening were evaluated

in both NCCT and IVU. Additionally, perinephric stranding in NCCT and delayed excretion in IVU were

also evaluated.

Results: Of the 139 patients (87 male and 52 female), 102 patients (73.4%) had positive findings on

NCCT and 71 (51.1%) on IVU. On NCCT 133 stones were detected in 80 patients (57.6%), 67 (48.2%) in

the kidney, 63 (45.2%) in the ureter and 3 (2.2%) in the bladder. The findings on NCCT were

hydronephrosis in 43 (31%), hydroureter in 34 (24.5%), perinephric stranding in 7 (5%), ureteric wall

thickening in 4 (2.8%), renal mass and renal cyst in 1 (0.7%) each. On IVU 86 stones were detected in 46

patients (33.1%), 53 (38.1%) in the kidney, 31 (22.3%) in the ureter and 1 (1.4%) in the bladder. The

findings on IVU were hydronephrosis in 31 (22.3%), hydroureter in 18 (13%), delayed excretion in 5

(3.6%), renal cyst and ureteric wall thickening in 1 (0.7%) each. Incidental findings were more common on

NCCT (23/139, 16.6%) than IVU (2/139, 1.4%).

Conclusions: NCCT compared with IVU had a higher detection rate for ureterolithiasis, especially for

stones in the distal ureter. An added benefit of NCCT was the detection of significant additional findings.