INTRAVENOUS UROGRAPHY 1

INTRAVENOUS UROGRAPHY 1

1. INTRAVENOUS UROGRAPHY
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
urograpywas 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 integrity of 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 delayed films (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
▪Shape
Bean shaped
Convex laterally & linear
medially
Contour –smooth &
regular
▪Size
12-15cm in length
Right kidney appears
smalllerthan left
Length –31/2 verterbral
bodies
Children –4 vertebral
bodies
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 quadratuslumborum
muscle.
▪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 osmolality
is 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 gauze
cannulais used
▪Upper arm or shoulder pain may
be due to stasis of contrast in
vein which may be relieved by
abduction of 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 –Pyelographicphase
➢“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 Ureteral
Compression
▪Evidence of obstruction on the 5-minute
image
▪Abdominal aortic aneurysm or 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 nonvisualised
upper 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 anterior
bladder 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 (Urographic
Nephrogram)
▪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 Visualise
Nephrogram
▪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-minute image, the nephrogram
should be receding as the collecting system
becomes opacified.
▪On the 10-minute image, the pyelogramis
the dominant urographicelement.
▪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 ipsilateralposterior 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 clubbing of 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(nonobstructive
dilatation).
▪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 ureteral
dilatation.
▪More chronic forms of obstruction and other chronic
ureteralconditions are typically associated with
greater degrees of ureteraldilatation
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 postvoid
image 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
pelvicalycealsystems
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
vaselikecurve
▪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’ appearence
68Dept of Urology, GRH and KMC, Chennai.

69. RetrocavalUreter
▪The uretermay have a
sickle, S or reverse J
appearance before
crossing behind and
medial to the IVC.
▪The ureterdescends
medial 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
opacifiedcalyx
•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 (pelvicalyceal
pattern 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 ureter
from a dilated renal
pelvis and is a typical
finding of ureteropelvic
junction 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 parenchymal
defects “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. Dromedary hump
▪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 splenic
impression 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 caliceal
fornices
▪“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;
Calycinespreading; 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. ▪Standing column of
contrast from Rt.PUJ
to VUJ
▪Stone impacted at VUJ
▪Edema in the right side
of interuretericridge
(arrow)
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
Bladder Tumor
95Dept of Urology, GRH and KMC, Chennai.

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

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

98. 98Dept of Urology, GRH and KMC, Chennai.

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

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

101. 101Dept of Urology, GRH and KMC, Chennai.

102. Hemorrhagic Cystitis
Bladder shows contrast material with a
lobulatedand irregular contour withingthe
lumen of the bladder
102Dept of Urology, GRH and KMC, Chennai.

103. 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
103Dept of Urology, GRH and KMC, Chennai.

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

105. 105Dept of Urology, GRH and KMC, Chennai.

106. ▪Extensive calcification
which was non-
functional
▪“Putty Kidney”
▪Consistent with
autonephrectomy
106Dept of Urology, GRH and KMC, Chennai.

107. GU Tb-IVU
▪The most common findings being
hydrocalycosis,hydronephrosis, or
hydroureterdue to stricture formation .
▪Early signs include the moth-eaten
appearanceof calycealerosion and papillary
irregularity-best seen on early excretory
films.
107Dept of Urology, GRH and KMC, Chennai.

108. 108Dept of Urology, GRH and KMC, Chennai.

109. ▪Cavitarylesions communicating with the
collecting system are characteristic of TB.
▪These lesions eventually enlarge as parenchymal
destruction 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
109Dept of Urology, GRH and KMC, Chennai.

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

111. 111Dept of Urology, GRH and KMC, Chennai.

112. 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 appearance due to multiple
strictures
▪Ureterovesicaljunction obstruction is caused by tuberculous
cystitis or strictures of the distal third of the ureter.
▪The cystogramfilms may show a small contracted bladder due to
excessive fibrosis
112Dept of Urology, GRH and KMC, Chennai.

113. Kerr’s Kink
▪Scarring & angulation
of ureteropelvic
junction
▪Hiked up pelvis
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.

118. 118Dept of Urology, GRH and KMC, Chennai.