Intravenoupyelonephrogramcomphrensive.pptx

Intravenous Urogram comphrensive

1. Intravenous Urogram Dr. Anil kumar s Dr. Umamageshwari

2. An Intravenous Urogram is a special x-ray examination of the kidneys, bladder, and ureters. An Intravenous Urogram can show the size, shape, and position of the urinary tract, and it can evaluate the collecting system inside the kidneys. Intravenous Urogram can be done as a emergency Procedure without any preparation.

3. Obstructive uropathy -IVU is the gold standard. Screening of entire urinary tract in cases of haematuria or pyuria. Diseases of renal collecting system and renal pelvis. Differentiation of function of both kidneys. Abnormalities of the ureter. TB of the urinary tract. Calculus disease. Suspected renal injury. Renal colic or flank pain . Tumors Indications of IVU- Adult

4. Indications of IVU- Children Unilateral renal agenesis or hypoplasia Ectopic kidney (pelvic or cross-fused) Horseshoe kidney Hydronephrosis due to PUJ ( pelviureteric junction) obstruction Duplicated collecting systems Ectopic ureter (especially in girls with constant dribbling) Ureterocele Dilated ureter ( megaureter )

5. Advantages of IVU Detailed anatomy of the collecting systems Demonstration of major calcification Sensitive for acute obstruction Low cost

6. 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.

7. Contraindications Contrast allergy Hepato -renal syndrome Thyrotoxicosis Pregnancy Raised serum creatinine

8. Preparation Required for the Procedure ? Fasting : Patient should fast for at least 5 hours before the exam. Laxatives are not recommended – they do not improve image quality . Renal Function: Check eGFR to assess kidney function, especially in at-risk patients. Contrast Medium Precautions: Screen for allergies and any prior contrast reactions . Obtain written informed consent per hospital protocol. Emergency Preparedness: Ensure availability of emergency medications and resuscitation equipment in case of contrast reactions.

9. H ow is it performed ? During Intravenous Pyelogram, a dye called contrast material is injected into a vein into the patients arm. A series of X-ray pictures is then taken at timed intervals. The test should be done in a X Ray Department where a doctor is available as on occasions the contrast can cause severe reactions which may lead to medical emergencies.

10. IVU Technique & Contrast Parameters Radiographic Exposure Settings kV: 65–75 → optimized contrast mA: 600–1000 Exposure time: < 0.1 second IV Access & Contrast IV access: 18G or 19G for bolus injection Contrast medium: Water-soluble, nonionic preferred (safer profile) Dose: Up to 1.5 ml/kg body weight

11. Contrast LOCM 370 (LOCM = Low osmolar contrast material) Adult dose = 50 – 100 ml Pediatric dose = 1ml for each kg

12. The full length film In inspiration A 35 x 43 cm cassette Positioned with the lower border at the symphysis pubis to ensure the urethra (particularly the prostatic urethra) The cross-kidney film In expiration A 24 x 30 cm cassette With the lower border 2.5 cm below the iliac crests The study typically includes that portion of the anatomy from the level of the diaphragm to the inferior pubic symphysis

13. (A) Full length and (B) cross kidney films

14. Calcification on IVU-Urinary tract Renal: calculi, renal cell carcinoma, tuberculosis Ureter: calculi, tuberculosis, schistosomiasis Bladder: calculi, schistosomiasis, transitional cell carcinoma

15. Post contrast IVU films (A) Immediate( Nephrogram phase) (B) 5 min (Secretory phase) (C) 15 min film with compression producing calyceal distension; (D)30 min film (Ureterogram phase) (E) 45 min film ( Cystogram phase) (F) Post voiding film

16. Preliminary film (control film)

17. Immediate film ( Nephrogram phase) A.P. view 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.

18. Immediate film (Nephrogram phase)

19. 5-15 minutes film (Secretory phase) A 5-minute anteroposterior (AP) radiograph of the kidneys is taken, followed by the application of a lower abdominal compression band to distend the upper urinary tracts. To Both Kidney contour Contrast is filling both the Renal pelvis or not, or is there any delayed filling?

20. Compression is contraindicated in the following conditions: Renal trauma – risk of exacerbating bleeding or injury Large abdominal mass – potential for rupture or discomfort Recent abdominal surgery (post-operative) – may disrupt healing or sutures Abdominal aortic aneurysm – risk of aneurysmal rupture due to pressure

21. 5-15 minutes film (Secretory phase )

22. 30 minutes film ( Ureterogram phase) : Is there any collecting systems and ureters dilatation or filling defect?

23. 30 minutes film- Ureterogram phase

24. 45 minutes film ( Cystogram phase) : 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?

25. Post voiding film : Residual urine Contrast left on upper tract? (normally there is no contrast left on upper urinary tract on post voiding film)

26. Post voiding film

27. Pathologies

28. Congenital

29. Renal Anomalies: Unilateral renal agenesis or hypoplasia Ectopic kidney (pelvic or cross-fused) Horseshoe kidney Hydronephrosis due to PUJ ( pelviureteric junction) obstruction Duplicated collecting systems Ureteral Anomalies: Ectopic ureter (especially in girls with constant dribbling) Ureterocele Dilated ureter ( megaureter ) Bladder Abnormalities: Fistulous connection between rectum and urinary tract may alter IVU findings (e.g., gas in urinary tract)

30. Unilateral renal agenesis No visualization of one kidney; delayed or absent nephrogram and contrast excretion on one side.

31. Renal Ectopia Kidney visualized in abnormal position (e.g., pelvic); malrotated; short ureter.

32. Crossed Renal Ectopia Kidney visualized in abnormal position (e.g., pelvic); malrotated; short ureter.

33. Flower vase appearance Horseshoe kidney Lower poles of both kidneys fused; midline isthmus seen; medial deviation of calyces; ureters may cross isthmus anteriorly.

34. Polycystic kidneys . Spider leg appearance

35. Two separate pelvicalyceal systems ± double ureters ; may show ureterocele or reflux in one moiety. Duplex ureters

36. Ectopic ureter Ureter drains abnormally (e.g., into vagina or urethra); may show elongated or ectopic ureter; poor or absent bladder filling from that kidney.

37. Recto urethral fistula V isualize the urinary tract and reveal a fistula tract connecting the urethra or bladder to the rectum. 

38. Obstructive Anomalies These lead to impaired urinary drainage and may cause hydronephrosis or other complications. Pelvi-ureteric junction (PUJ) obstruction – causes hydronephrosis Ureterocele Ureteric calculus Bladder outlet obstruction Vesicoureteral reflux

39. Pyelo -ureteric Junction Obstruction Shows as Dilation of Right Renal Pelvis and Calyces- Hydronephrosis.

40. Ureterocele Filling defect in the bladder (Cobra head sign) which may be distended, collapsed or even everted An everted ureterocele will appear like a Bladder diverticulum.

41. Ureteric Calculus Radiopaque shadow along ureter (if visible) HUN proximal to the stone Cut-off sign at site of obstruction Absent or faint distal ureteral contrast

42. Bladder outlet obstruction Bladder Findings : Thickened, trabeculated bladder wall Post-void residual urine Irregular bladder contour Upper Tract IVU Findings (Secondary Changes): HUN Cut-off sign: Sudden stop in contrast column at urethra Poor distal ureteral visualization: From obstructed or refluxing bladder

43. Vesicoureteral reflux

44. Benign prostatic hyperplasia White = bladder. Dark = benign enlargement of prostate, pushing down on inferior bladder

45. Infections

46. Renal Tuberculosis Subset of Genitourinary Tuberculosis Accounts for 15–20% of extrapulmonary TB Involves: Renal parenchyma Calyces Renal pelvis May also affect ureter, bladder, and urethra.

47. Parenchymal scars – seen in ~50% of cases Hydronephrosis – due to infundibular or ureteric strictures Irregular caliectasis – non-uniform dilatation of calyces Moth-eaten calyces – early sign; ragged, irregular calyceal outlines Phantom calyx – non-functioning calyx due to infundibular stenosis Moth-eaten calyces

48. Phantom calyx – non-functioning calyx due to infundibular stenosis

49. End stage Progressive hydronephrosis parenchymal thinning Dystrophic calcification Autonephrectomy

50. Lower Urinary Tract Tuberculosis Ureteral Involvement Kerr kink – sharp angulation at ureterovesical junction (UVJ) Sawtooth ureter – irregular ureteral margins from ulceration and fibrosis Pipe-stem ureter – smooth, rigid, narrow ureter (chronic fibrosis) Beaded or corkscrew ureter – alternating narrow and dilated segments

51. Bladder Involvement Thimble bladder – small, fibrotic, contracted bladder with little capacity Dense calcifications – especially of the prostate in men (visible on plain film or IVU)

52. Pyelonephritis Acute Pyelonephritis Often normal IVU in early stages Poor calyceal opacification Renal swelling → lateral bulging of renal contour Chronic Pyelonephritis Irregular, blunted calyces – especially upper and lower poles Parenchymal scarring and asymmetric kidney size Focal cortical thinning Contracted kidney with distorted collecting system ± Nephrolithiasis or obstruction (complications)

53. Trauma Renal collecting system and ureters Stab wound of right ureter shows extravasation (at arrow) on intravenous pyelogram .

54. Tumours Renal Cell Carcinoma Transitional Cell Carcinoma

55. Renal Cell Carcinoma Filling defect in the renal pelvis or calyces Distorted calyces – stretching or splaying due to mass effect Non-opacification of part of the collecting system Enlarged kidney with mass effect May mimic pseudotumor (e.g., TB or abscess)

56. Intravenous pyelography (IVP) shows a filling defect in the middle calyx of the left kidney

57. Transitional Cell Carcinoma Persistent filling defect in renal pelvis, ureter, or bladder "Golf ball" or "moth-eaten" appearance in calyces Ureteral narrowing or obstruction Hydronephrosis Irregular bladder wall filling defect Multiple filling defects within the right collecting system and ureter.

58. Thank you