Intravenous urography (IVU)- Avinesh Shrestha

Ivu is a radiological investigation for visualization and assessment of the urinary tract.This presentation covers brief anatomy of urinary tract, indication and contraindication,contrast media dose and administration, routine and modified ivu procedure,its complication,ctivu and some abnormalities in the urinary tract.

1. Intravenous Urography(IVU)

2. UROGRAPHY Radiologic Investigations of the renal drainage, or collecting system are performed by various procedures classified under the general term U rography. There are three technique for urography which are: Intravenous Urography Antegrade Urography Retrograde Urography

3. INTRODUCTION An intravenous Urography ( IVU) is an x-ray examination of the kidneys, ureters and urinary bladder(KUB) that uses iodinated contrast material for its visualization. The contrast material is administered intravenously, which is excreted by kidneys, making the urine opaque to x-rays and allowing visualization of the renal parenchyma together with calyces, renal pelvis, ureters and bladders. It is also known as Excretion Urography . Previously the study was known as Intravenous Pyelogram (IVP) suggesting the study of renal parenchyma(i.e. renal pelvis and calyces),however this study is not limited to these structures only, so, IVP is a misnomer . Now, the term “ P yelogram ” is reserved for studies visualizing only the collecting system.

4. Anatomy Organs of the Urinary System: Kidneys 2 Ureters 2 Urinary Bladder 1 Urethra 1

5. Anatomy

6. Anatomy : Kidney

7. Anatomy : Kidney

8. Anatomy : Kidney

9. Anatomy : Ureter Ureters

10. Ureteric constrictions: Normally , three constricted points exist along the course of each ureter. If a kidney stone attempts to pass from kidney to bladder, it may have trouble passing through these three regions. 1 st : the ureteropelvic (UP) junction, where the renal pelvis funnels down into the small ureter. 2 nd : is near the brim of the pelvis, where the iliac blood vessels cross over the ureters. 3 rd :is where the ureter joins the bladder, termed the ureterovesical junction, or UV junction. Most kidney stones that pass down the ureter tend to hang up at the third site, the UV junction, and once the stone passes this point and moves into the bladder, it generally has little trouble passing from the bladder and through the urethra to the exterior. 6/22/2016 Anatomy : Ureter

11. Anatomy : Urinary Bladder & Urethra MALE FEMALE

12. Anatomy : Urinary Bladder & Urethra MALES VS. FEMALES The urethra is five times longer in males than in females. In females the urethra is only 3–4 cm (1.5 inches) long .In males the urethra is approximately 20 cm (8 inches) long and has three regions. The prostatic urethra, about 2.5 cm (1 inch) long, runs within the prostate. The membranous urethra, which runs through the urogenital diaphragm, extends about 2 cm from the prostate to the beginning of the penis. The spongy urethra, about 15 cm long, passes through the penis and opens at its tip via the external urethral orifice. The urethra is a common duct for the urinary and reproductive systems in males. These two systems are entirely separate in females.

13. Path Of Urine

14. Anatomy 12th rib Upper pole of right kidney Pelvis of right kidney Lower pole of right kidney Right ureter Renal papillae Fornix of minor calyx Minor calices Major calices Pelvis of left kidney Psoas major Left ureter Urinary bladder

15. Urinary bladder, male, a-p, tilted X-ray, IVU 20 min after intravenous contrast Abdominal part of ureter Pelvic part of ureter Apex of urinary bladder Intramural part of ureter Impression of prostate Fundus of urinary bladder Transverse process of L V Sacro -iliac joint Linea arcuata Ischial spine Pubic symphysis Anatomy

16. PRACTICE PARAMETER FOR THE PERFORMANCE OF EXCRETORY UROGRAPHY -ACR–SAR Revised 2014 The indications for an EU examination include, but are not limited to, the following: Assessment of the integrity of the urinary tract following trauma or therapeutic interventions, especially when cross-sectional imaging is inappropriate or unavailable. One example of such an indication is an examination performed in the operating room when a trauma patient is too unstable to undergo cross-sectional imaging prior to surgery. Assessment of the urinary tract for suspected congenital anomaly, when thought to be more appropriate than cross-sectional imaging Evaluation of patients with suspected or known ureteral obstruction Assessment of the upper urinary tract (renal collecting systems and ureters) for urothelial lesions that may explain hematuria and for identification of urinary tract abnormalities that may predispose to infection, especially when cross-sectional examinations using US, CT, or MRI are either unavailable or felt to be inappropriate for the clinical circumstance Follow-up of patients with recurrent renal/ureteral calculi, with a limited number of images obtained pre and post-contrast administration. Such limited studies may reduce the patient’s radiation burden compared with repetitive CT studies. INDICATIONS

17. Suspected urinary tract pathology Ureteric fistulas and strictures Complex UTI (including tuberculosis). persistent or frank hematuria Suspected transitional cell carcinoma Potential renal donors Differentiation of function of both kidneys Renal/ ureteric calculi(Nephrolithiasis) Obstructive uropathy Hydronephrosis INDICATIONS(IN ADULTS)

18. VATER anomalies Malformation of urinary tract Neurological disorders affecting urinary tract Malformation of genitalia. Enuresis(involuntary urination) and H/o recurrent UTI Anorectal anomalies INDICATIONS(IN CHILDREN)

19. Renal insufficiency Cardiac failure/cardiovascular disease Dehydration Diabetes with Azotemia Previous allergic history/previous contrast medium reaction H/o Pheochromocytoma (a rare tumor of adrenal gland tissue) asthma sickle cell disease multiple myeloma Treatment with ß-blockers(may impair the response to treatment of bronchospasm induced by contrast medium) Pregnancy Patient IN RELATIVE RISKS/ Relative contraindications

20. No food for 4-6 hour prior to examination. Bowel prep is considered as not necessary because it has been found that it does not improve the diagnostic quality of the examination, instead it is unpleasant for the patient, however patient can be advised to have Low- residue diet with plenty of oral fluid, the day prior to the IVU and be ambulant(walking/standing) for 2hrs prior to the examination to reduce bowl gas. All radiopaque material should be taken out from the region of study and patient should be dressed in appropriate gown. Blood creatinine levels should be in its normal limit (M=0.6 to 1.5,F=0.5-1.2 mg/dl) and Blood urea level should range between 9 to 42 mg/dl Proper history of patient must be taken, like allergic reactions, asthma, diabetes, etc. and precautions should be taken accordingly. PATIENT PREPARATION

21. Traditionally, dehydration prior to IVU was done in order to improve opacification of collecting system. But due to the development of quality and content of contrast media , (non-ionic contrast medium )dehydration is not necessary for the opacification instead, It increases risk of nephrotoxicity which may be permanent in patients with DM M. myeloma Hyperuricemia SCD( scikle cell disease) Pre-existing renal disease, Therefore dehydration is not suggested nowadays. So, Adequate patient hydration is important to minimize the risk of nephrotoxicity i.e. clear liquids are allowed up until the exam . If the patient cannot take adequate oral fluids, consider adequate intravenous hydration . However,Risk of irreversible damage to renal function in previously healthy kidney due to contrast agent is very low. Contd …

22. The safest method is to Consider an alternative imaging method if possible, if not then: Should Use a non-ionic low or iso-osmolar contrast agent. For patient with H/O previous CM rxn , use different non-ionic ,low or iso-osmolar CM to that used previously, also administering methyl prednisolone 32mg orally 12 and 2 h prior to CM injection should be considered. Maintaining close supervision and leaving the cannula in place and observing for 30 min. Be ready to treat promptly any adverse reaction and ensure that emergency drugs, equipment and doctors are ready If patient is under the treatment of Metformin(Diabetic patient),In consultation with the referring clinician, the treatment should be stopped 48 h before the procedure and should be withheld for a further 48 h after the procedure and renal function should be re-assessed before restarting metformin treatment. If the patient is asthmatic, premedication in the form of steroids is administered 2 days prior. Contd … Precautions for Adverse reaction

23. Venipuncture is an invasive procedure that carries risks for complications, especially when contrast media is injected. Before beginning the procedure, the technologist must ensure that the patient and the patient party is fully aware of these potential risks and has signed an informed consent form. If a child is undergoing the examination, the procedure should be explained to both the child and the guardian, and the guardian should sign the informed consent form. SIGNING INFORMED CONSENT FORM

24. “Pregnancy” rule should be followed. If whole of renal tract is to be visualized, no gonad shielding is possible for the females, but for males the testis can be protected by placing a lead rubber sheet over upper thighs below lower edge of symphysis pubis. When bladder and lower ureters are not included then female can also be given gonad protection . We should complete the examination with as minimum exposure/no. of films as possible. RADIATON PROTECTION

25. Any standard radiographic unit is suitable to perform the procedure. Compression band is sometimes applied over distal ends of ureters to retard flow of opacified urine into bladder and to ensure adequate filling of renal pelvis and calyces, so it is required for the procedure. IV cannula or Butterfly needle(20-24G),Fixing tape, D/S Syringe-50ml,10ml, Medical Gloves, tourniquet, cotton swap, dry cotton, etc. Equipment

26. CONTRAST MEDIA Non-ionic, Iodinated,Water soluble, LOCM or IOCM CM Dose: For adult: 1ml/kg body weight for concentration of 300mgI/ml The concentration can be increased upto 600mgI/ml if the patient is well hydrated. For Children(2-12 years) 1.5ml/kg body weight for concentration of 300mgI/ml For Infants(1month-2 years) 3ml/kg body weight for concentration of 300mgI/ml For Newborn(<1month) 4ml/kg body weight for concentration of 300mgI/ml

27. The exact protocol for IVU will vary according to the department, however the standard protocol for IVU is summarized as: Preliminary film CM administration Nephrographic film 5 min renal film Abdominal compression 10 min Renal and upper urinary tract film 15 min release film of ureter and bladder Bladder image Modifications can be used in any steps if the image is not satisfactory. PROCEDURE

28. Contd … P reliminary/Scout Films Supine, full length AP of abdomen is taken. To demonstrate bowel preparation, check exposure factor, and location of radiopaque stones or any radiopaque artifacts. If necessary the position of overlying opacities may be further demonstrated by: Supine AP of renal areas, in expiration. The x-ray beam is centred in the mid-line at the level of lower costal margin o r 35° posterior oblique views, or, Tomography of the kidneys at the level of a third of the AP diameter of the patient (app.8-11 cm). The optimal angle of swing is 25-40°. The examination should not proceed until these films are reviewed by radiologist and claimed satisfactory. Filming Sequence:

29. Venipuncture Venous access via the median cubital vein is the preferred injection site because flow is retarded in the cephalic vein as it pierces the clavipectoral fascia also, it is most stable , close to surface and overlying skin is less sensitive, however this is not the absolute rule and different puncture site can be chosen as required. The gauge of the cannula/needle should allow the injection to be given rapidly as bolus to maximize the density of nephrogram. The puncture site then should be stabilized to ensure easy access and is in exact position with the help of fixing tape. I.V . bolus injection within 30-60 sec Upper arm or shoulder pain may be due to stasis of contrast in vein which may be relieved by abduction of the arm. Median cubital Cephalic Basilic Contd …

30. Immediate film/Nephrogram AP of the renal areas is taken. This film is exposed 10-14 s after the injection is completed (app. Arm to kidney time ). It Aims to show the nephrogram, i.e. renal parenchyma opacified by contrast medium in renal tubules. Contd … Filming Sequence:

31. 5-min film AP of renal areas. To determine if excretion is symmetrical and is invaluable for assessing the need to modify the technique, e.g. a further injection of CM if there has been poor initial opacification . It Shows nephrogram, renal pelvis, upper part of ureter. Contd … Filming Sequence:

32. Compression band is now applied around the patients abdomen positioned midway between the ASIS i.e. precisely over the ureters as they cross the pelvic brim. The aim is to produce better pelvicalyceal distension. Compression is contraindicated in following cases: After recent abdominal surgery After renal trauma If there is a large abdominal mass or aortic aneurysm. When the 5-min film shows already distended calyces. Contd … Filming Sequence:

33. 10 min compression film : AP of renal areas. There is usually adequate distension of the pelvicalyceal systems with opaque urine by this time. Compression is released when satisfactory demonstration of the pelvicalyceal system has been achieved. Contd … Filming Sequence:

34. 15 min film/ Release film : Supine AP KUB. This film is taken to show the whole urinary tract. Contd … Filming Sequence:

35. Full bladder: Coned view of bladder area is taken Significance To demonstrate shape and size of bladder To diagnosis the change in mucosal pattern To demonstrate the leakage of urine To identify the mass within bladder or extra vesical mass Contd … Filming Sequence:

36. After micturition film: Either a full length abdominal film or a coned view of the bladder with the tube angled 15° caudate and centered 5 cm above the symphysis pubis is taken, based on earlier findings. Significance: Assess bladder emptying/To see the Residual vol of urine To demonstrate VUR Aid diagnosis of VUJ calculi Dx of bladder tumors Demonstrate urethral diverticulum. Contd … Filming Sequence:

37. Oblique films Posterior oblique of kidneys, ureters or bladder: Position : Pt. is rotated 30-35° in rt or lt side depending on pathology side. To determine whether the radiopaque shadow is in the ureter or outside. ADDITIONAL FILMS

38. Prone film: Position : Pt. lies prone after doing 15 min full film and after 4-5 min. of lying prone (so that lower ureter is dependent part) full film is taken. To investigate pelviureteric and ureteric obstruction as the heavy contrast loaded urine will more readily gravitate to the site of the obstruction. To displace the overlying bowel gas towards periphery . Tomography - when there are confusing overlying gas shadows in renal areas. ADDITIONAL FILMS

39. AP with caudal angulation: Position : AP position, film of kidney area with 25° caudal tube angulation. To separate the over shadows by stomach on left kidney. Erect film: To determine whether or not there is small ureteric calculus, also erect oblique film of area of ureter can be taken to demonstrate layering of calculi in cysts and abscesses. ADDITIONAL FILMS

40. Delayed films: This can be Considerable upto 24 hours. It is done in c/o significant acute obstruction when early nephrogram is seen but collecting system is not seen. In c/o long standing hydronephrosis In c/o congenital lesions like non-visualized upper calyceal system with ectopic or obstructed ureter. As many films are taken, it is necessary to perform minimum no. of additional films. Time interval is generally doubled (and taken as 0.5, 1, 2, 4, 16, 24 hours) If there is no opacification of an acutely obstructed kidney at 30 min it is usually unhelpful to perform the next film before around 4 h after contrast injection. A further manoeuvre to minimise radiation dose in patients with a strong clinical suspicion of ureteric colic is to omit all films after contrast until a full length 15 min film is performed. ADDITIONAL FILMS

41. In case of Pregnancy: Rarely necessary to perform, however if necessary, The collecting system in pregnancy is capacious and the ureter exhibit poor peristalsis therefore, a single full length preliminary film and a delayed full length around 30-45 min may be well enough in this case. MODIFICATIONS

42. In case of children: Films at 2 min (supine) and 7 min (prone) is taken after contrast administration. Or a 2 min (renal area) , 5 min (renal area),and 15 min full length abdominal film. Abdominal compression not used. To improve visualization of left kidney child can be given a carbonated beverage. The right kidney can be well seen through the liver in a 15-20 degree caudal tilted view. MODIFICATIONS

43. In neonates Excretion of contrast medium is delayed and prolonged. The concentration of contrast medium is relatively poor. Optimum visualization of upper UT may not occur until 1-3 hour. If initial 2 min and 5 min film show little opacification, further film at 1, 2 and 3 hour may provide more information than multiple films in 1st hour. MODIFICATIONS

44. In case of suspicious shadows in renal areas : lateral film of renal area is taken. I nspiratory and expiratory film of renal area is taken to demonstrate the relationship of opacities and filling defects of renal tract. Diuretic urogram Useful when intermittent obstruction is suspected but cannot be confirmed by standard urogram . I.V. frusemide is used to induce diuresis. The dose of Lasix/ Frusemide is 0.3-1mg/kg in adults and 0.5mg/kg in child. The film is taken 5-10 mins after adminstering the diuretic. MODIFICATIONS

45. Limited urography : Used for follow up of earlier pathology. Films taken: KUB, 15 min and post void. Emergency urography: Done in cases of urinary colic. Films taken: Preliminary KUB and 15 min film after CM injection. MODIFICATIONS

46. In case of VUJ obstruction : Oblique film of bladder area of obstruction side can be taken. Ectopic kidney : full film KUB region from immediate to last film. Renal agenesis : full film KUB from immediate to last film can be taken with Delayed films upto 24 hours. Bladder diverticulum : Which is an Abnormal pouch formed within bladder. Lateral film of bladder area can be taken. Vesicovaginal fistula : lateral film of bladder area can be taken. In case of Hypertension : Minute sequence urogram is performed where, Films taken at 1,2,3,5 mins after injection of contrast media IN CASE OF PATHOLOGY/ABNORMALITIES

47. Control(Full length KUB) CM injection Immediate(renal area) 5 min(renal area) 15 min(Full film) Modifications if required Full bladder(Bladder area) Post void(Bladder area) Modifications in any steps can be done if required. Department Protocol:

48. General psychological reassurance. Needle wound site dressed and checked for extravasation. Patients should be encouraged to drink lots of fluids for several hours after receiving contrast material. Ensure that the patient understands how to receive the results. Escort to changing rooms and bid good-bye. AFTERCARE

49. Due to CM: Reactions due to CM: mild, moderate and severe. Due to technique: Incorrectly applied abdominal compression may produce intolerable discomfort or hypotension. Swelling ,pain and infection during injection Extravasation of CM COMPLICATIONS

50. The strengths of urography are: rapid overview of the entire urinary tract, detailed anatomy of the collecting system, demonstration of calcifications, it is sensitive for obstruction, and low cost, ADVANTAGES

51. The weaknesses are that: it depends on kidney function, it provides little assessment of parenchymal structure ( eg . cystic vs. solid), the perinephric space is not demonstrated, may miss small stones , it provides no assessment of glomerular filtration rate. DISADVANTAGES

52. Renal agenesis Supernumerary kidney Ectopic kidney (pelvic, intrathoracic ) Crossed ectopia Horseshoe kidney Duplex kidney Ureterocele Congenital anomalies

53. Renal agenesis

54. Stag horn calculi

55. Crossed renal ectopia

56. Rt. Mild hydronephrosis

57. Duplicated collecting system

58. Bladder diverticula

59. ureterocele

60. ADDITIONAL MODALITIES Radio nuclide imaging for renal function evaluation. Ultrasound. C.T. for investigation of trauma and renal masses. Renal Angiography. Retrograde pyelography, Urethrography . Magnetic resonance imaging.

61. In 1995, Smith et al reported the value of unenhanced CT in evaluating patients with acute flank pain in comparison with that of IVU. Since that time, many imaging centers have replaced IVU with unenhanced CT for evaluation of patients with acute renal colic in the emergency setting. CT has also become the imaging method of choice in evaluating patients with renal inflammatory disease and traumatic injuries. As IVU is less sensitive in detecting renal masses and if, when a mass is detected with IVU , further characterization with cross-sectional imaging is necessary because IVU does not allow reliable differentiation of solid masses from cysts . However, IVU remains the standard of reference for noninvasive visualization of intraluminal filling defects in the collecting systems and urothelial abnormalities. And has continued to be the initial imaging modality of choice for assessing the upper tract urothelium.with major indication of hematuria Also it is an advantage when compared for radiation dose and cost CT-IVU AND GENERAL IVU

62. Despite the advances in radiologic techniques, no standard method exists for the noninvasive imaging evaluation of the urinary collecting system, with each modality having its own merits and demerits for optimal visualization of the entirety of the urinary system.  The ability to correlate urographic findings with those from other imaging modalities will remain an important skill until an ideal “global ” urinary tract imaging technique emerges. Nevertheless, urography is still important in the diagnosis of many urinary tract diseases. CONCLUSION

63. REFERENCES A guide to radiological procedure :Stephen Chapman, fifth edition, sixth edition Clark’s special procedure in radiography Intravenous Urography:Technique and Interpretation :Dyer et al CT Urography : Kawashima et al Radiological procedures a guideline : Dr. Bhushan N. Lakhkar . Merrill’s atlas of radiological procedures : Vol2 Principle of anatomy and physiology : Tortora and Derrickson