ASU & MCU --- RADIOLOGY IMAGING PROCEDURE

IT IS COMPLETE DESCRIPTION OF ASCENDING CYSTOURETHROGRAM AND MICTURATING CYSTOURETHROGRAM. YOU CAN FIND EVERY TINY DETAIL IN THIS.

1. Radiology Department MCH, Kolkata

2. ASU &MCU Sayantan Biswas Radiogrpher , kolkata

3. Introduction- Urethrography is two type- Asu Mcu Urethrography is a procedure to see the Blooder and urethra, which can not see using general x-ray methods.

4. Embryology of Bladder and Urethra 4th-7th week- the cloaca divides into urogenital sinus anteriorly and anal canal posteriorly. Urogenital sinus- can be divided into 3 parts Upper larger part forms Urinary Blooder Pelvic part- in male forms prostatic and membranous urethra. Phallic part-Bulbar and penile urethra, greatly differs between the two sexes.

5. Anatomy of Urinary Bladder > Hollow, distensible, muscular organ located within the pelvic cavity, posterior to the symphysis pubis and inferior to the parietal peritonium . The size of the bladder varies: when filled, the upper border of the bladder, should not rise above the level of the lumbosacral junction in the child and the second or third sacral segment in the adult. Normal bladder wall is thickness is 2-3mm in fully distended bladder. Apex of the bladder attached to anterior abdominal wall by median umbilical ligament . Base is continuous with the bladder neck.

6. Here we can see the prostate gland

7. Anatomy of Urethra-- In males: 20 cm in length It has four named regions Prostatic urethra: Is approximately 3 cm in length Passes through the prostate gland Membranous urethra: is approximately 1 cm in length. Passes through the urogenital diaphragm. Bulbar urethra: From inferior aspect of urogenital diaphragm to penoscrotal junction Spongy (penile) urethra: Passes through the length of the penis

8. Male urethra

9. In female- The urethra is about 1.9 to 2 inches long and exits the body between the clitoris and vagina, extending from the internal to the external urethral orifice.

10. X-ray images of male and female urethra

11. Asu Ascending Urethrography Or Retrograde Urethrography

12. Indication- Strictures of urethra Congenital abnormalities Fistulae or false passages Urethral trauma Urethral diverticula Periurethral or prostatic abscess Contraindication- Acute UTI Recent instrumentation

13. Contrast medium- Water soluble contrast media like conray 280 , Trivideo 400mg , Urograffine 60% is used which are diluted with normal saline in 1:3 ratio. Equipments- Tilting Radiographic tabel Fluoroscopy/spot film device Foley's catheter, syring, gloves,cotton and sterile water

14. Preparation- Patient is ask to micturate prior to the procedures. Procedure/Technique- The patient should positioning obliquely at 45° with the bottom leg flexed at 90° at the knee and the top leg kept straight Alternatively, the patient can be supine, if using fluoroscopic C-arm , the C-arm can be rotate in vertical plane 45° degrees.

15. Patient Positon C-Arm

16. The penile glans and urethral meatus should be cleaned with antiseptic. The Foley catheter is then placed just inside the urethral meatus so that the Foley catheter balloon rest in tha fossa navicularis. With the Foley in position, the catheter balloon is filled with 1-2 ml radiopaque contrast or saline solution. Overfilling must be avoided, or it will cause the rupture of distal urethra. Then the operator pulls tha penis laterally to straighten the urethra, grasping the penis as distal as possible, and distal to the inflated balloon.

17. The catheter-tipped syringe is filled with 50 ml radiopaque contrast, and 20-30 ml contrast is injected in a retrograde fashion. Taking a preinjection “ scout ” film of the urethra to compare the RGU images is important. Static images of urethra are taken during retrograde injection of radiopaque contrast.

18. Filming- Supine PA 30°RAO 30° LAO Complication- UTI Contrast reaction Urethral trauma or rupture Extravasation or intravasation due to excessive pressue in stricture.

19. X-ray Imaging

20. MCU Micturating cystourethrogram Or Voiding cystourethrogram

21. Indication- Children: UTI Voiding difficulties VUR Pelvic trauma Baseline study prior to lower UT surgery. Meningomyelocele, Sacral Agenesis, Rectal Anomalies. For post operative evaluation of ureteric abnormalities.

22. Adults- Trauma to urethra UTI Urethral stricture Urethral diverticulum Reflux nephropathy prior to renal transplant

23. Contrast medium- Water soluble contrast media like conray 280 , Trivideo 400mg , Urograffine 60% is used which are diluted with normal saline in 1:3 ratio. Equipments- Foley’s catheter 【10F】 and syringe. In infant feeding tube no 5F-7F. Fluoroscopy with spot film device and tilting table.

24. Procedure- Using sterile technique, a catheter is introduce into bladder. A 5f feeding tube with side holes are used for children and in older children or adults 8f or 10 f catheters are used. In girls after initial inspection of perineum to identify any local genitilia abnormalities (cystoceles or labial fusion) the catheter is introduced.. When it enters the bladder a varying amount of urine will flow through it if no flow a catheter is introduced till urine is obtained.

25. Suprapubic pressure is sometimes helpful. In males foreskin is retracted and catheter is introduced. The catheter should be lubricated with anaesthetic jelly and inserted slowly and gently into the urthera holding the penis is vertical position. The normal bladder capacity in children is estimated to be 1 ounce ie 29 cc . For newborns 30 to 35 cc can be instilled For upto 3 yrs 200 to 250 cc . Adequate capacity is reached when the child becomes uncomfortable and begins voiding around the catheter. Bladder capacity is variable but can often be predicted with the previous mentioned formula.

26. Filming- In children- In children upto 2 yrs of age bladder is filled by hand injection. For older children contrast medium is instilled from a bottle elevated one metre above the examination table. During filming, fluroscopic screening is performed at short intervals to see any vu reflux,diverticuli. The child is turned oblique on both sides to ensure that minimal reflux is not overlooked.

27. In infant- voiding starts the moment catheter is removed. At the end of voiding ,frontal film is taken which includes entire abdomen including the kidney region to prevent overlooking the vu reflux which is apparent only on termination of voiding and may reach upper collecting system

28. In adult male- Bladder is filled in the usual way as in older child and voiding filming is done in both oblique projection views. The voiding study in male adults can be modified by getting the patient to void against resistance .

29. In adult female - The procedure is essentially the same as in girls, In addition to the standard exposed film double taken at rest and during straining demonstrates the degree of bladder descent if any.

30. ALTERNATE TECHNIQUES 1) SUPRAPUBIC BLADDER PUNCTURE Sometimes in pelvic trauma not possible to catheterize 2) URETHIROCYSTOGRAPHY Contrast medium introduced into the bladder during RGU. 4) EXCRETION MCU ( MCU followed by IVU ) Advantage- avoid catheterization and related risk of infection. Disadvantage- VUR can not be visualized properly. takes longer time

31. X-ray imaging

32. X-ray Image

33. After care-- Patient should be warned of rare dysuria and retention of urine. In case of reflux-antibiotics are to be prescribed. COMPLICATIONS-- Contrast reaction Contrast induced cystitis UTI Catheter trauma Bladder perforation due to overfilling of contrast Retention of Foley's catheter

34. Vesico Ureteric Reflux

35. Congenital (Hutch) diverticulum Sac formed by herniation of bladder mucosa and submucosa through muscular wall. Weakness in detrusor muscle posterolateral to ureteral orifice . Congenital diverticula usually are narrow necked.

36. Urechal sinus CT Image X-ray Image

37. Urechal cyst MR Image

38. Bladder extrophy b> X-ray Image MR Images

39. Bladder duplication CT Image X-ray Image USG

40. Bladder herination X-ray Image

41. Bladder stone X-ray Image

42. Vesicovaginal Fistulae X-ray Image

43. Urethral diverticulum X-ray Image

44. Tuberculous Urethritis X-ray Image

45. Male Female X-ray Image

46. Role of urethrography Accurately delineates the anatomy of urethra. Location, number and extent of the strictures are very well displayed. Delineation of the bladder neck and urethra is best achieved on the MCU in the oblique projection. Secondary changes in the bladder. To demonstrate the VUR. Visualisation of any associated fistulas.

47. Thank You