INTRAVENOUS UROGRAPHY

INTRAVENOUS UROGRAPHY

1. INTRAVENOUS
UROGRAPHY (IVU)
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. DEFINITION
RADIOGRAPHIC STUDY OF THE RENAL PARENCHYMA, PELVIS,
URETERS AND URINARY BLADDER AFTER INTRAVENOUS INJECTION
OF CONTRAST MEDIA
3Dept of Urology, GRH and KMC, Chennai.

4. TERMINOLOGY
•Urogram
Visualization of kidney parenchyma,
calyces and pelvis resulting from IV
injection of contrast.
•Pyelogram
Describesretrograde studies visualizing
only the collecting system.
•IVP ismisnomer
4Dept of Urology, GRH and KMC, Chennai.

5. Moses Swick
HISTORY
•Introduction of excretory
urography was done in 1929, by
American urologist Moses Swick.
•He injected an organically-bound
iodide compound—later named
Uroselectan—into a vein, taking
X-rays as the material cleared
the body through the urinary
tract.
5Dept of Urology, GRH and KMC, Chennai.

6. INDICATIONS
American College of Radiology (ACR) guidelines
•To evaluate the presence or continuing presence of
suspected or known ureteralobstruction.
•To assess the integrityof the urinary tract status
post trauma.
•To assess the urinary tract for suspected congenital
anomalies.
•To assess the urinary tract for lesions that may
explain hematuriaor infection
•Investigation of HTN in young adults not controlled
6Dept of Urology, GRH and KMC, Chennai.

7. Contraindications
Absolute contraindication –Contrast Allergy
Relative contraindications-
•Renal failure (raised serum creatininelevel >1.5
mg/dL)
•Hepatorenalsyndrome
•Generalized allergic conditions
•Multiple myeloma
•Pregnancy
•Infancy
•Thyrotoxicosis
•Diabetes
7Dept of Urology, GRH and KMC, Chennai.

8. Advantages
•Clearly outlines of the entire urinary system so can see even
mild hydronephrosis.
•Easier to pick out obstructing stone when there are multiple
pelvic calcifications.
•Can show non-opaque stones as filling defects.
•Demonstrate renal function and allow for verification that the
opposite kidney is functioning normally.
8Dept of Urology, GRH and KMC, Chennai.

9. Disadvantages
•Need for IV contrast material
•Contrast agent may provoke anaphylactoidreactions,
nephropathy.
•Multiple delayedfilms (Can take hours as contrast passes quite
slowly into the blocked renal unit and ureter.)
•May not have sufficient opacificationto define the anatomy and
point of obstruction.
•Requires a significant amount of radiation exposure and may
not be ideal for young children or pregnant women
9Dept of Urology, GRH and KMC, Chennai.

10. Anatomy
•The parenchyma of the kidney is
divided into two major
structures: superficial is the renal
cortexand deep is the renal
medulla.
•Grossly, these structures take the
shape of 8 to 18 cone-shaped
renal lobes, each containing renal
cortex surrounding a portion of
medulla called a renal pyramid
(of Malpighi).
•Between the renal pyramids are
projections of cortex called renal
columns(of Bertin).
10Dept of Urology, GRH and KMC, Chennai.

11. •Nephrons, the urine-producing
functional structures of the
kidney, span the cortex and
medulla.
•The tip, or papilla, of each
pyramid empties urine into a
minor calyx(8-12)
•Minor calyces empty into major
calyces(2-4), and major calyces
empty into the renal pelvis,
which becomes the ureter.
11Dept of Urology, GRH and KMC, Chennai.

12. Shape & Size
12Dept of Urology, GRH and KMC, Chennai.

13. Position
•Lumbar fossa
•Left kidney slightly higher than
right
•Upper pole of left kidney –T11-
12
•Upper pole of Right kidney –
T12-L1
•Lower limit –well above iliac
crest at the level of L3 or L3-4 IV
disc
•Medial border –parallel to
psoasmargin
13Dept of Urology, GRH and KMC, Chennai.

14. Renal Axes
•Long axis of the kidney is
parallel to the lateral border of
thepsoasmuscleand lies on the
quadratuslumborummuscle.
•In addition, the kidneys lie at an
oblique angle, that is the
superior renal pole is more
medial and anterior than the
inferior pole.
•Their transverse axes form an
approximately 45°angle with
the sagittalplane
14Dept of Urology, GRH and KMC, Chennai.

15. Intravascular Radiological Contrast Media
(IRCM)
▪Iodine is the main element which imparts Radio opacity
▪All currently used IRCM are chemical modifications
of a 2,4,6-tri-iodinated benzene ring.
▪They are classified on the basis of their physical
and chemical characteristics, including their
chemical structure, osmolality, iodine content, and
ionization in solution.
▪In clinical practice, categorization based on
osmolalityis widely used.
15Dept of Urology, GRH and KMC, Chennai.

16. HIGH
•IONIC
MONOMERS
•Contain sodium
or meglumine
salts
•2 ORGANIC
SIDECHAINS &
CARBOXYL
GROUP
•1500-1900
MOSM/KG H2O
•EG:
DIATRIAZOATE –
Urograffin,
angiograffin, &
Urovision.
•IOTHALAMATE
ISO OSMOLAR
•NON IONIC
DIMERS
•EG: IOTROL
•IODIXANOL
LOW
•NON IONIC MONOMERS:
•ORGANIC SIDE
CHAIN+HYDROXYL
GROUP
•EG:IOHEXOL IOPAMIDOL
IOVERSOL IOPROMIDE
•AGENTS OF CHOICE
•LOW TOXICITY since do
not dissociate in the
body
•IONIC DIMERS:
•2 IONIC MONOMERS-
CARBOXYL GROUP
•EG: IOXAGLATE
•ADR:3%
•Expensive than HOCM
16Dept of Urology, GRH and KMC, Chennai.

17. 17Dept of Urology, GRH and KMC, Chennai.

18. 18Dept of Urology, GRH and KMC, Chennai.

19. Patient Preparation
•Complete urine and blood examination to assess the renal function.
•The patient is given mild laxatives about twelve to twenty four hours prior.
The patient is kept nil by mouth over night
•In active healthy patients, food or liquid restriction or administration of
laxative has little value.
•With modern contrast media overhydrationshould be avoided but
dehydration is unnecessary.
•Pretesting does not provide reliable information regarding sensitivity to
contrast media and is therefore not performed before the injection
•Take informed consent
19Dept of Urology, GRH and KMC, Chennai.

20. •Dose of contrast :patient size ,radiologist preference
•200mg of I per pound body weight: 20-30 g ,50-100ml
•Pediatric –1ml/kg
•Bolus injection given through IV access
•Rapid : < 60 sec-better nephrogram
•Slow: 2-3 min ,less side effects
•Density of nephrogram= plasma level of contrast
•Drip infusion: 40-45g of I in 250-400 ml of fluid; not practised nowadays
20Dept of Urology, GRH and KMC, Chennai.

21. •Bolus injection gives immediate peak plasma level followed by rapid
decline due to
•Vascular mixing
•Extravasculardiffusion
•Renal excretion
•Diagnostic quality depends on
•Amount of iodine excreted
•Volume of urine formed to distend PCS
21Dept of Urology, GRH and KMC, Chennai.

22. Technique
•Venous access via the median
antecubitalvein is the preferred
injection site because flow is
retarded in the cephalic vein as it
pierces the clavipectoralfascia.
•The gauge of the cannula/needle
should allow the injection to be given
rapidly as bolus to maximize the
density of nephrogram. Usually 18
gauzecannulais used
•Upper arm or shoulder pain may be
due to stasis of contrast in vein which
may be relieved by abductionof the
arm.
22Dept of Urology, GRH and KMC, Chennai.

23. Scout Film ( plain film of abdomen)
•State of bowel preparation
•Calcified density in the renal tract
•To check exposure factors & positioning
•Skeletal abnomality–spinal deformities in
congenital disorders, skeletal metastases,
metabolic bone changes as in rickets
•Abdominal masses
•Foreign bodies
23Dept of Urology, GRH and KMC, Chennai.

24. Preliminary Film
➢Supine,fulllengthAPof
abdomenininspiration.
➢Thelowerborderofcassette
isatthelevelofsymphysis
pubisandthex-raybeamis
centredinthemidlineatthe
levelofiliaccrests.
➢Todemonstratebowel
preparation,checkexposure
factor,andlocationof
radiopaquestonesorany
radiopaqueartifacts.
24Dept of Urology, GRH and KMC, Chennai.

25. Film Sequence
➢1-3 minutes Antero-posterior-film coned to the renal area
➢5 minutes Antero-posterior-film coned to the renal area (to see if excretion
is symmetrical; if poor opacification, further injection of contrast)
➢Apply ureteralcompression
➢10 minutes Antero-posterior (5mins after compression; 10mins from
contrast administration –Pyelographic phase)
➢“Flush”, “X” or “Release view”--full length view at 20 minutes (ureter&
bladder images after release of compression)
➢Upright post void Antero-posterior
25Dept of Urology, GRH and KMC, Chennai.

26. 26Dept of Urology, GRH and KMC, Chennai.

27. 27Dept of Urology, GRH and KMC, Chennai.

28. 28Dept of Urology, GRH and KMC, Chennai.

29. 29Dept of Urology, GRH and KMC, Chennai.

30. Contraindications to UreteralCompression
•Evidence of obstructionon the 5-minute
image
•Abdominal aortic aneurysmor other
abdominal mass
•Severe abdominal pain
•Recent abdominal surgery
•Suspected urinary tract trauma
•Presence of a urinary diversion
•Presence of a renal transplant
30Dept of Urology, GRH and KMC, Chennai.

31. Additional Views & Modifications
•Plain films –Additional oblique views to assist the location of
potentially intra renal opacities
•5min film –Second injection of contrast to improve opacificationof
PCS if inadequate
•15 minsrelease film
•When the bladder is poorly filled additional delayed films
•Small suspected calculus in distal ureterconfirmed with oblique films
31Dept of Urology, GRH and KMC, Chennai.

32. •Delayed films –3, 6, 12, 24 hrs for delayed opacification
•Early nephrogrambut collecting system not visualised
•Long standing HUN –Rim sign
•In certain congenital lesions such as nonvisualisedupper calycealsystem
with ectopic or obstructed ureter
•Unrewarding in total absence of an early nephrogram
•Immediate after micturitionfilm –VU reflux
•Rapid sequence urography
•Renal artery stenosis
•2, 4, 6 min
•To compare rate of excretion of each kidney
32Dept of Urology, GRH and KMC, Chennai.

33. •Prone film
•For viewing filling of ureteralareas that are not seen in supine position
•Useful in renal ptosis, lesions on the anteriorbladder wall, bladder
herniation
•Erect film
•For demonstrating renal ptosis, bladder hernias, cystocoeles
•Demonstrates layering of calculi in cysts or abscesses
33Dept of Urology, GRH and KMC, Chennai.

34. •Hypertensive urogram
•Discontinued
•Work up for renal hypertension in pts younger than 50 years
•Findings –small kidney (smaller than the opposite kidney by more than
1.5cm), delayed nephrogram, hyperconcentrationin late film
•Hydration urogram/ FrusemideIVU
•20 mg of FrusemideIV after 15 min film
•Suspected PUJO not evident of standard IVU
•Provoke HUN & pain
34Dept of Urology, GRH and KMC, Chennai.

35. WHAT TO LOOK FOR IN IVU
➢Size, shape, position and axis of kidneys
➢External cortex and inner medulla
➢Calycealsystem
➢Renal pelvis and ureteropelvicjunction
➢Ureter
➢Uretero-vesicaljunction
➢Urinary bladder
➢Relation of ureterto spine and psoasmuscle
RADIATION DOSE FROM IVU
➢1,465 mR/projection for males
➢1,047 mRfor females
35Dept of Urology, GRH and KMC, Chennai.

36. Phases of Nephrogram
•Spontaneous nephrogram
•Non opacifiedkidney outlined by retroperitoneal fat visible on plain film
•Vascular nephrogram
•Contrast reaches renal artery in 15 secs(arm to kidney time)
•Coexists with diffusion of contrast
•Lasts for few secsto 1 min
•Total body opacificationphase
•Contrast freely filtered by glomeruli
•Due to opacificationof pre & retro renal softtissue
•Lasts for 1 min
•Tubular Phase
•Contrast in proximal and distal tubules
•Density fades
•Pyelographicphase
•Contrast in the collecting system
36Dept of Urology, GRH and KMC, Chennai.

37. Vasular(Angiographic Nephrogram)
•Occurs during passage of contrast material through the cortical
microvasculature.
•Short lasting seen within 30 sec of rapid IV bolus
•Approx. 80% of renal blood flows to the cortex →renal cortex looks
much more radiodenseas compared to medulla (CM differentiation)
•If CM differentiation is not seen, the vascular nephrogramis
inadequate & must be interpreted with great caution
•Requires intact vascular system –indicator of disturbance in blood
flow to the kidney
37Dept of Urology, GRH and KMC, Chennai.

38. Tubular (UrographicNephrogram)
•Appear after the contrast medium has been concentrated in PCT
•Density is greater approx 1 min of injection of IV bolus at which time peak
plasma level is reached
•Radiodensityof medulla equals to that of cortex →homogenous with no CM
differentiation
•Permits accurate evaluation of fundamentals of renal radiology –size,
position, axis & contour
•Normal tubular nephrogramrequires
•Normal blood flow
•Structural & functional integrity of nephrons
•Unobstructed flow of filtrate through the tubules
38Dept of Urology, GRH and KMC, Chennai.

39. Failure to VisualiseNephrogram
•Insufficient dose of contrast
•Acute or chronic renal failure
•End stage renal disease
•Absent kidney
•Renal artery occlusion / avulsion
39Dept of Urology, GRH and KMC, Chennai.

40. Abnormal Density Patterns
•Immediate, faint & persistent nephrogram
•Increasingly dense nephrogram
•Immediate, dense & persistent nephrogram
40Dept of Urology, GRH and KMC, Chennai.

41. Immediate, faint, persistent nephrogram
•Peak density is seen on the first film exposed at the completion of injection
of contrast
•Density is disproportionate with amount of contrast material injected.
Though faint, persists for several hours
•Cause
•Reduction in number of functioning nephrons→immediate faint nephrogram
•Severely impaired glomerularfiltration & low plasmclearance rate of contrast →
persistent nephrogram
•Conditions
•Chronic glomerulardisease
•Sudden loss of glomerularfunction –atheroembolicrenal disease
41Dept of Urology, GRH and KMC, Chennai.

42. Increasingly dense nephrogram
•Faint to begin with and
increasingly dense over a period
of hours to days
•Seen in
•Acute extrarenalobstruction
•Diminished perfusion pressure of
kidney –SHT, RAS
•Intratubularobstruction–
calculus, casts, acute papillary
necrosis
•Acute renal vein thrombosis
•Acute glomerulardisease
•Acute tubular necrosis
42Dept of Urology, GRH and KMC, Chennai.

43. Immediate, dense, persistent nephrogram
•As dense as normally expected to be at 1 min
•Level of density persists
•Pathogenesis
•Unimpaired glomerularfiltration →immediate dense nephrogram
•Diffusion of filtrate into interstitiumdue to damaged tubules return of
filtered material to the circulation →persistent nephrogram
•Seen in
•Acute tubular necrosis
•Acute bacterial nephritis
43Dept of Urology, GRH and KMC, Chennai.

44. 44Dept of Urology, GRH and KMC, Chennai.

45. 45Dept of Urology, GRH and KMC, Chennai.

46. Inhomogenousnephrograms
•Striated nephrogram/ Sunburst nephrogram
•Fine linear strands of alternating lucency& density uniformly oriented in
direction similar to that of tubules & collecting ducts
•Seen in –Acute extrarenalobstruction, Acute bacterial nephritis, acute
pyelonephritis, AR-Infantile polycystic kidney disease, Medullarycystic
disease, Medullarysponge kidney
•Patchy nephrogram
•Patchy densities in nephrogram
•Seen in –Polyartertitisnodosa, scleroderma, Necrotisingangitis
•Cortical rim nephrogram
•Only thin rim of peripheral cortex is opacifiedthat is perfusedby capsular
collateral arteries
•Reliable indicator of underperfusionof kidney
•Seen in –Infarction of kidney, segmental RA occlusion, Renal vein
thrombosis (some cases)
46Dept of Urology, GRH and KMC, Chennai.

47. SUNBURST NEPHROGRAM
CORTICAL RIM NEPHROGRAM
PATCHY NEPHROGRAM
47Dept of Urology, GRH and KMC, Chennai.

48. •The size of the kidneys should be assesedduring
neprographicphase
•The normal kidney may range from 9 to13 cm in
cephalocaudallength, with the left kidney
inherently larger than the right by 0.5 cm and
the kidneys slightly larger in men than in women
•Significant discrepancies (right kidney 1.5 cm
larger than the left kidney,leftkidney 2 cm
larger than the right kidney) require explanation.
48Dept of Urology, GRH and KMC, Chennai.

49. 5 & 10 MINUTE FILM
•At this stage the calyces, renal pelvis and part of the ureterswill be
visible.
•Nephrogramwill be reduced but both kidneys should have the same
density
49Dept of Urology, GRH and KMC, Chennai.

50. •In normally functioning kidneys, contrast is first seen in the calyces at 2 mins
following bolus injection.
50Dept of Urology, GRH and KMC, Chennai.

51. •On the 5-minuteimage, the nephrogramshould be receding as the
collecting system becomes opacified.
•On the 10-minuteimage, the pyelogramis the dominant urographic
element.
•Alterations in this temporal sequence require explanation.
51Dept of Urology, GRH and KMC, Chennai.

52. •Visualization of the collecting system and renal pelvis can be
augmented with the use of abdominal compression, Trendelenburg
position, and other gravity maneuverssuch
as placing the patient with the side of interest in the ipsilateral
posterior oblique position
•The appearance of the calices and renal pelvis should be examined
closely
52Dept of Urology, GRH and KMC, Chennai.

53. •Early and mild obstruction is indicated by subtle rounding of the
fornicealmargins
•More severe and prolonged obstruction evidenced by progressive
loss of the papillary impression and eventual clubbingof calices.
53Dept of Urology, GRH and KMC, Chennai.

54. ➢Ureters
➢Uretersbegin to transport opacifiedurine about 3 minspost injection
➢Maximum ureteralfilling occurs between 5-10 minutes.
54Dept of Urology, GRH and KMC, Chennai.

55. •At the release of compression, the bolus of contrast material–laden
urine entering the uretersprovides optimal visualization throughout
their length
•Persistence of a standing column of contrast material on several images
may indicate obstruction or ureteralileus(nonobstructivedilatation).
•Medial deviation of the uretershould be considered when the ureter
overlies the ipsilaterallumbar pedicle.
•Lateral deviation should be considered when the ureterlies more than
1.5 cm beyond the tip of the transverseprocess, but comparison with the
position of the contralateraluretershould always be made
55Dept of Urology, GRH and KMC, Chennai.

56. •An absolute ureteraldiameter exceeding 8 mm is considered a
criterion for dilatation.
•Asymmetry of ureteralcaliberis a more significant finding.
•Early in its course, high-grade ureteralobstruction may be
associated with only minimal ureteraldilatation.
•More chronic forms of obstruction and other chronic ureteral
conditions are typically associated with greater degrees of ureteral
dilatation
56Dept of Urology, GRH and KMC, Chennai.

57. Bladder
•By 15–30 minutes after the
injection of contrast material, the
bladder is often sufficiently filled,
and the 15-minute KUB radiograph
may be adequate for evaluation.
•As the bladder distends with
contrast the intraluminalcontrast
material should be sphericand
smoothly marginatedand the wall
progressively less evident.
•Bladder wall thickening and
irregularity of the luminal contrast
material should be noted
57Dept of Urology, GRH and KMC, Chennai.

58. •The postvoidimage may also be helpful in evaluating patients with
upper urinary tract dilatation.
•Persistence of the dilatation on the postvoidimage suggests fixed
obstruction,
•The postvoidimage is most helpful in assessing residual volume.
58Dept of Urology, GRH and KMC, Chennai.

59. Congenital anomalies &
variations

60. Unilateral Agenesis
60Dept of Urology, GRH and KMC, Chennai.

61. Renal Ectopia
•Failure of complete ascent of
the kidney to its normal
position
•IVU-abnormally placed kidneys
61Dept of Urology, GRH and KMC, Chennai.

62. Crossed fused Renal ectopia
•Two complete pelvicalyceal
systems on one side usually
one above the other
•Ureterfrom the lower renal
pelvis crosses the midline and
enters bladder normally
62Dept of Urology, GRH and KMC, Chennai.

63. Crossed Fused Ectopic Kidney
63Dept of Urology, GRH and KMC, Chennai.

64. HorshoeKidney
•Kidneys placed lower than normal
•Malrotationof pelvis
•Lower pole calyces of both sides
deviated towards midline
•Uretershave characteristic vaselike
curve
•Pelvicalyectasis
•Renal calculi
•Intravenous urogram(IVU) shows
an altered renal axis with medially
directed lower renal poles, which
suggests horseshoe kidney. Also
note the dilated collecting system
of the left kidney, resulting from a
ureteropelvic junction obstruction;
this is a frequently associated
finding
64Dept of Urology, GRH and KMC, Chennai.

65. HorshoeKidney
65Dept of Urology, GRH and KMC, Chennai.

66. •Minor form –bifid renal
pelvis
•Ureteralduplication
•Incomplete –uretersfuse in
their course
•Complete –2 uretersopen
seperatelyin bladder, lower
moiety inserted
orthoptically& upper
moiety ectopically
•“Drooping lily” sign-
obstructed upper moiety
ureter, in a completely
duplicated system, may
produce downward and
lateral displacement of the
functional lower moiety
collecting system,
DUPLEX COLLECTING SYSTEM
66Dept of Urology, GRH and KMC, Chennai.

67. DROPPING LILY SIGN
67Dept of Urology, GRH and KMC, Chennai.

68. URETEROCOELE
Contrast filled structure with a thin
smooth radiolucent wall surrounded by
contrast containing urine in the
bladder-“Cobra’s head” appearance.
68Dept of Urology, GRH and KMC, Chennai.

69. RetrocavalUreter
•The uretermay have a sickle, S
or reverse J appearancebefore
crossing behind and medial to
the IVC.
•The ureterdescendsmedial to
right lumbar pedicle.
•Proximal ureteris dilated.
69Dept of Urology, GRH and KMC, Chennai.

70. Congenital Hydronephrosis
•Due to functional obstruction at the pelvi-ureteraljunction
•Aetiology-cong. Bands, adhesions, neuromuscular inco-
ordination, abberentvessels
•Advanced cases -large soft tissue mass replacing the renal
parenchyma; No opacificationof collecting system
•Lesser degrees of obstruction
•Thin rim of renal substance outlining kidney.
•Later films –crescent shaped opacities produced by dilated
stretched tubules surrounding the enlarged non opacified
calyx
•Delayed films –slow filling of calyces & renal pelvis
•Mildest form-minimal deviation from the normal appearance
70Dept of Urology, GRH and KMC, Chennai.

71. Grading of Hydronephrosis
•Grade 1(mild)
•dilatation of therenal pelviswithout dilatation of the calyces (can also occur
in the extrarenalpelvis)
•no parenchymalatrophy
•Grade 2(mild)
•dilatation of the renal pelvis (mild) and calyces (pelvicalycealpattern is
retained)
•no parenchymalatrophy
•Grade 3(moderate)
•moderate dilatation of the renal pelvis and calyces
•blunting of fornicesand flattening of papillae
•mild cortical thinning may be seen
•Grade 4(severe)
•gross dilatation of the renal pelvis and calyces, which appear ballooned
•loss of borders between the renal pelvis and calyces
•renal atrophy seen as cortical thinning
71Dept of Urology, GRH and KMC, Chennai.

72. 72Dept of Urology, GRH and KMC, Chennai.

73. Grade 3
73Dept of Urology, GRH and KMC, Chennai.

74. PUJO
•The balloon on a string
sign This sign refers to the
appearance of a high and
somewhat eccentric exit
point of the ureterfrom a
dilated renal pelvis and is a
typical finding of
ureteropelvicjunction
obstruction
74Dept of Urology, GRH and KMC, Chennai.

75. Polycystic kidney
•Autosomaldominant
➢Plain films-cyst calcification
➢IVU-enlarged kidneys with
compression and displacement
of calyces by intrarenalcyst
•Autosomalrecessive
•B/L symmetrical enlargement
of kidneys
•Streaky nephrogram
•Calyces maybe distorted
75Dept of Urology, GRH and KMC, Chennai.

76. Polycystic Kidney
•B/lenlarged kidneys
•Asymmetric (left> right)
•Multiple parenchymaldefects
“Swiss cheese” nephrogram
76Dept of Urology, GRH and KMC, Chennai.

77. Polycystic Kidney
77Dept of Urology, GRH and KMC, Chennai.

78. MalrotatedKidneys
78Dept of Urology, GRH and KMC, Chennai.

79. Persistence of Fetal Lobulations
79Dept of Urology, GRH and KMC, Chennai.

80. Dromedaryhump
•Prominent cortical hump in the interpolarregion of the left kidney.
•On a compression image obtained in a later phase of the sequence,
the hump is subtended by a normal collecting system.
•Normal variants of the renal contour, caused by the splenicimpression
onto the superolateralleft kidney.
•Dromedary humps are important because they may mimic a renal
mass, and as such is considered arenal pseudotumour.
80Dept of Urology, GRH and KMC, Chennai.

81. Atrophic Small Smooth Kidney
•Chronic glomerulonephritis
•Arteriosclerosis
•Papillary necrosis
•Embolic disease
•Hypotension
•Alportsyndrome
•Nephrosclerosis
•Amyloidosis(late)
81Dept of Urology, GRH and KMC, Chennai.

82. Papillary Necrosis
82Dept of Urology, GRH and KMC, Chennai.

83. Papillary Necrosis
Central Excavation with “Ball on Tee”
apperance
83Dept of Urology, GRH and KMC, Chennai.

84. Papillary Necrosis
•Excavation extending from the
calicealfornices
•“LOBSTER CLAW” deformity
84Dept of Urology, GRH and KMC, Chennai.

85. Renal masses
•Small lesions →Localisedbulge with increased thickness
of the renal substance; Deforms or displaces or distends a
calyx
•Medium sized lesions →Localized or generalized
enlargement of the kidneys; Displacement or distortion of
renal pelvis, ureteror adjacent structures
•Very large lesions →Non functioning kidneys; Calycine
spreading; Visceral displacement
85Dept of Urology, GRH and KMC, Chennai.

86. Renal Mass
•Loss of renal contour
•Displacement and splaying of calyces
86Dept of Urology, GRH and KMC, Chennai.

87. Features of Malignant Masses
•Pathognomonic–Invasion of
collecting system producing
amputation of calyx or
intraluminalfilling defect.
•Suggestive
•Vascular mass
•Calcification
•Tumor shell –wall is thick &
irregular
•Absent mobility with respiration
& change in position
87Dept of Urology, GRH and KMC, Chennai.

88. URETER
88Dept of Urology, GRH and KMC, Chennai.

89. 89Dept of Urology, GRH and KMC, Chennai.

90. 90Dept of Urology, GRH and KMC, Chennai.

91. Transitional Cell Carcinoma
•Multiple filling defects in Left
renal pelvis and ureter
•“Goblet” appearance below the
filling defect –typically seen in
lesions that grow slowly into the
lumen of the ureter
91Dept of Urology, GRH and KMC, Chennai.

92. •Ureteralfilling defects may be
single or multiple and can
usually be attributed to luminal,
mural, or extrinsic causes.
•Urographicimage shows
multiple filling defects in the left
renal pelvis and ureter.
•Multifocal transitional cell
carcinoma was confirmed in this
case.
92Dept of Urology, GRH and KMC, Chennai.

93. 93Dept of Urology, GRH and KMC, Chennai.

94. Bladder Pathologies
•Overlapping intestines
•Intravesicalgas
•Intravesicalsolid/fb
•Calculi
•Clots
•Diverticulum
•Intramural lesions
•Extrinsic compression
•Prostate enlargement
•Vaginal mass (“female prostate
defect”)
94Dept of Urology, GRH and KMC, Chennai.

95. Clot within Bladder
95Dept of Urology, GRH and KMC, Chennai.

96. 96Dept of Urology, GRH and KMC, Chennai.

97. 97Dept of Urology, GRH and KMC, Chennai.

98. Bladder transitional cell carcinoma
.
•Bladder image shows a filling
defect with a papillary
configuration along the right
bladder wall
•Note the irregular distribution of
contrast material associated
with the filling defect (“stipple
sign”)
98Dept of Urology, GRH and KMC, Chennai.

99. 99Dept of Urology, GRH and KMC, Chennai.

100. 100Dept of Urology, GRH and KMC, Chennai.

101. Hemorrhagic Cystitis
Bladder shows contrast material with a
lobulated and irregular contour within the
lumen of the bladder
101Dept of Urology, GRH and KMC, Chennai.

102. GU TB -plain KUB
•Disparity in renal size on plain films may indicate early increase in
size of the affected kidney due to caseouslesions or a shrunken
fibrotic kidney of autonephrectomy.
•Calcifications are seen in 30% to 50%
•A characteristic diffuse, uniform,extensiveparenchymal, putty-like
calcification, forming a lobar cast of the kidney is seen with
autonephrectomy
•Calculi may also be seen in the collecting system or ureter
secondary to stricture formation.
•Ureteralcalcifications are rare and are characteristically
intraluminalas opposed to the mural calcifications of
schistosomiasis
102Dept of Urology, GRH and KMC, Chennai.

103. •. Bladder wall calcifications seen in late cases of bladder contraction.
•Calcifications of the prostate and seminal vesicles are seen in 10% of
cases .
•Plain film findings suggestive of tuberculosis may be seen in
surrounding tissues such as erosions of the vertebral bodies or
calcifications in a cold abscess of the psoas muscle.
103Dept of Urology, GRH and KMC, Chennai.

104. 104Dept of Urology, GRH and KMC, Chennai.

105. •Extensive calcification which
was non-functional
•“Putty Kidney”
•Consistent with
autonephrectomy
105Dept of Urology, GRH and KMC, Chennai.

106. GU TB -IVU
•The most common findings being hydrocalycosis,hydronephrosis, or
hydroureterdue to stricture formation .
•Early signs include the moth-eaten appearance of calycealerosion
and papillary irregularity-best seen on early excretory films.
106Dept of Urology, GRH and KMC, Chennai.

107. 107Dept of Urology, GRH and KMC, Chennai.

108. •Cavitarylesions communicating with the collecting system are
characteristic of TB.
•These lesions eventually enlarge as parenchymaldestruction
ensues.
•Fibrotic distortion of the collecting system and ureteris also seen.
•Calycealobliteration and amputation, hydrocalycosis, segmental or
total hydronephrosis, and a shriveled reduced capacity renal pelvis
may all be signs of renal tuberculosis
108Dept of Urology, GRH and KMC, Chennai.

109. 109Dept of Urology, GRH and KMC, Chennai.

110. 110Dept of Urology, GRH and KMC, Chennai.

111. GUTB –Ureter& Bladder
•Scarring and angulationof the ureteropelvicjunction (UPJ) may also
occur, the so-called “Kerr’s kink” .
•Tuberculosis of the ureteris commonly seen as a rigid, straightened
“pipe-stem”
•Ureteralso beaded, corkscrew appearancedue to multiple strictures
•Ureterovesicaljunction obstruction is caused by tuberculouscystitis
or strictures of the distal third of the ureter.
•The cystogramfilms may show a small contracted bladder due to
excessive fibrosis
111Dept of Urology, GRH and KMC, Chennai.

112. Kerr’s Kink
•Scarring & angulationof
ureteropelvicjunction
•Hiked up pelvis
112Dept of Urology, GRH and KMC, Chennai.

113. 113Dept of Urology, GRH and KMC, Chennai.

114. 114Dept of Urology, GRH and KMC, Chennai.

115. 115Dept of Urology, GRH and KMC, Chennai.

116. 116Dept of Urology, GRH and KMC, Chennai.

117. 117Dept of Urology, GRH and KMC, Chennai.