IVP, RGU & MCU

IVP, RGU, MCU

1. IVP, RGU & MCU DR. NISHIT VIRADIA

2. IVP It is a radiographic examination of urinary tract including renal parenchyma, calyces and pelvis after iv injection of contrast. Intravenous pyelogram is a misnomer as it implies visualization of pelvis and calyces without parenchyma. The term pyelogram is reserved for retrograde studies visualizing only collecting system

3. What is an Intravenous Pyelogram? An Intravenous Pyelogram (IVP) is a radiological study of pathology in urinary tract (kidney , ureter , baldder , urethra ) by giving a contrast media intravenously. An IVP outlines the kidneys, showing their size and internal structure. This procedure can also show how the kidney is working as well the urinary tract is working.

4. B e n ef it s Imaging of the urinary tract with IVP is a minimally invasive procedure. IVP images provide valuable, detailed information to assist physicians in diagnosing and treating urinary tract conditions from kidney stones to cancer. An IVP can often provide enough information about kidney stones and urinary tract obstructions to direct treatment with medication and avoid more invasive surgical procedures .

5. Indications Haematuria Calculus in urinary tract Tumour of kidney,Ureter,Bladder Infection in urinary tract e.g . Tuberculosis, Nephritis, Cystitis 5. Congenital anamolies of Urinary tract e.g.Unilateral kidney , Bifid ureter , Ectopic kidney, polycystic kidney Suspected urinary tract pathology To study kidney function Post urinary tract surgery

6. Contra-Indications: History Of allergy to iodinated contrast media. Pregnancy Cardiac and Renal failure. Multiple Myeloma Hepatorenal syndrome Raised serum creatinin level Thyrotoxicosis Metformin

7. The procedure

8. Equipments

9. C o ntrast LOCM (LOCM = Low osmolar contrast material) Adult dose = 50 – 100 ml , Pediatric dose = 1ml for each kg

10. Compound Name type Osmolality Ionic Diatrizoate Monomer 1550 High Ionic Metrizoate Monomer 2100 High Ionic Iothalamate 600-2100 High Ionic Ioxaglate Dimer 580 Low Non-ionic Iopamidol Monomer 796 Low Non-ionic Iohexol   Monomer 884 Low Non-ionic Ioxilan Monomer 695 Low Non-ionic Iopromide Monomer 774 Low Non-ionic Ioversol Monomer 350 Low Non-ionic Iodixanol Dimer 290 Low

11. Adverse effects of contrast Chemotoxic Nephrotoxicity Nonoliguric Creatinine peaks in 3-5 days Risk 1 in 1000-5000 if no risk factors Risk factors: renal insufficiency, DM, CHF, hyperuricemia, proteinuria, multiple doses of contrast Metformin (Glucophage) overdose causes lactic acidosis  withhold for 48 hours after contrast Anaphylactoid / Idiosyncratic

12. Adverse effects of contrast Anaphylactoid / Idiosyncratic Mild : metallic taste, warmth, sneezing, coughing, mild hives  no treatment Moderate : vomiting, severe hives, HA, palpitations, facial edema Severe : hypotension, bronchospasm, laryngeal edema, pulmonary edema, LOC Idiosyncratic rxns for ionic contrast = as high as 12%, most mild. Tx with Antihistamine = mild, Epi or beta agonist = severe. Non-ionic = 3%

13. Preparation Ask patient for history . Bowel Preparation Do not dehydrate the patient.

14. Preliminary film

15. Mode of injection Contrast media usually given iv bolus injection within 30-60 seconds The density of nephrogram is directly proportional to the plasma concentration.

16. Immediate film (Nephrogram phase) It shows nephrogram . This radiograph often omitted as the renal outline are usually adequately visualized in 5 min film.

17. 5 minute film ( Nephrogram ) It shows nephrogram , renal pelvis, upper part of ureter .

18. Compression Band Compression band is now applied. It is to produce better pelvicalyceal distention Contraindication Renal trauma Large abdominal mass After abdominal Sx If in 5 min film pelvis & calyces not adequately opacified

19. 15 minutes film Visualization of ureter is better in prone position This position reverse the curve of the inferior course of ureter making it anti-dependent to gravity.

20. 3 5 minutes film (Cystogram phase) inspect : 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?

21. Postvoiding film look for: Residual urine Bladder mucosal lesion Diverticulitis Bladder tumor Outlet obstruction VUR

22. Pyelo- ureteric Junction O b s truction Shows as Dilation of Right Renal Pelvis and Calyces.

23. Dilation of Left Renal Pelvis and Calyces Above the Obstructing Calculus

24. Renal collecting syst e m and u r eters Crossed Renal Ectopia on the Left Kidney and Right Kidney is not in Right Renal Fossa .

25. Renal collecting system and ureters Stab wound of right ureter shows extravasati on (at arrow) on intravenous pyelogram.

26. IVP demonstratig a horseshoe kidney. " Flower vase A ppearance "

27. IVP demonstrating the characteristic stretching of calyces by cysts in polycystic kidneys . Spider leg appearance

28. a Non-opacified partly obstructing ureterocele surrounded by opacified urine in the bladder full length film shows opacification of the distended upper moiety ureter running down to the opacified ureterocele

29. Duplex ureters on IVP: complete bilateral

30. Left megaureter on IVP showing dilatation of the entire length of the ureter with secondary pelvi calyectasis

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

32. Intravenous pyelogram showed no obstructive uropathy, but symmetric diverticula could be seen near both ureteral orifices (arrows). These lesions, known as Hutch diverticula, are usually congenital rather than occurring as a result of a neurogenic bladder or an infection or obstruction

33. Nodular squamous cell carcinoma of the urinary bladder. Dilated left lower ureter probably secondary to obstruction by tumor. Nonvisualization of the right ureter caused by complete occlusion

34. rgu

35. ANATOMY OF URETHRA • MALE URETHRA IS 18-20 CMS LONG • EXTENDS FROM BLADDER NECK TILL THE MEATAL OPENING AT PENIS It has four named regions: Prostatic urethra: Is approximately 3 cm in length. Passes through the prostate gland. Membranous urethra: Is approximately 1 cm in length. Passes through the urogenital diaphragm. Bulbar urethra From inferior aspect of urogenital diaphragm to penoscrotal junction. Spongy (penile) urethra: Passes through the length of the penis.

36. PARTS OF URETHRA ANTERIOR URETHRA -PENILE URETHRA -BULBAR URETHRA POSTERIOR URETHRA MEMBRANOUS URETHRA PROSTATIC URETHRA

37. PROSTATIC URETHRA BEGINS AT INTERNAL URETHRAL ORIFICE & RUNS VERTICALLY DOWNWARDS WIDEST & MOST DILATABLE PART, NARROWEST WHERE IT JOINS MEMBRANOUS URETHRA VERU MONTANUM IS A MEDIAN LONGITUDINAL RIDGE OF MUCOUS MEMBRANE

38. MEMBRANOUS URETHRA SHORTEST , NARROWEST & LEAST DISTENSIBLE PART OF THE URETHRA 2-2.5 CMS SURROUNDED BY EXTERNAL URETHRAL SPHINCTER THE BULBOURETHRAL GLANDS OF COWPER ARE PLACED ONE ON EACH SIDE OF MEMBRANOUS URETHRA URETHRAL GLANDS ALSO OPEN HERE

39. PENILE (SPONGY) URETHRA LENGTH 14-15 CMS & 6MM DIAMETER IT IS DILATED WITHIN THE GLANS PENIS TO FORM FOSSA NAVICULARIS URETHRAL GLANDS OF LITTRE OPEN HERE

40. Female urethra Widest at bladder neck. 4-5cms in length Narrowest & least distensible at meatus. This forms the Spinning top configuration of urethra on normal MCU.

41. Definition A retrograde urethrogram is a routine radiologic procedure (most typically in males) used to image the integrity of the urethra by using iodinated contrast media.

42. Indications Strictures Pelvic trauma/ Urethral tears Urethral obstruction Urethral foreign body. Urethral diverticulum . Periurethral / prostatic abscess. Fistula / false passages. Urethral mucosal tumours Post operative evaluation

43. Contraindications Acute urinary tract infection

44. T echnique Patient lies supine on the x-ray table Retract the fore skin and clean the tip of penis with betadine or antiseptic solution. Inject a small amount of local anesthetic into the urethra with a 8- F Foley catheter or syringe and balloon is inflated with 1-3 ml of water. Local anesthesia helps to relax the sphincter as the patient may contract it during the procedure thus leading to a diagnosis of a stricture Contrast medium is injected under fluoroscopy control and films are taken The male urethra is best seen in the oblique position . Female urethra is best seen in lateral or anteroposterior position .

45. Image interpretation Normal retrograde urethrogram (RGU): If the radiopaque contrast is injected properly, the entire anterior and posterior urethra should be filled with contrast and seen to jet into the bladder neck. The verumontanum is seen as an ovoid filling defect in the posterior urethra The distal end of the verumontanum marks the proximal boundary of the membranous urethra and constitutes the urethra that passes through the urogenital diaphragm.

46. Affect of patient positioning on the appearance of the urethra during retrograde urethrography. (a) Retrograde urethrogram obtained with the patient supine shows the bulbous urethra as a diverticulum-like outpouching. (b) On a retrograde urethrogram obtained after the patient was placed in a steep oblique position with the penis stretched, the penoscrotal junction and bulbous urethra have a normal appearance.

47. COMPLICATIONS Contrast reaction ( due to absorption through bladder mucosa ) UTI Urethral trauma or rupture. Extravasation of contrast – due to use of excessive pressure in stricture.

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

49. Penile urethra stricture

50. a)Urethral stricture, b)periurethral abscess

51. Urethral calculi Mostly expelled from bladder into the urethra during voiding- migrant calculi. Primary calculi may be seen in association with urethral stricture or urethral diverticulum. Symptoms include weak stream, dysuria, and hematuria. RGU usually depicts a rounded filling defect in the urethra.

52. Tuberculous urethritis Descending infection and renal tuberculosis is evident. In the acute phase, there is urethral discharge with associated involvement of the epididymis, prostate, and other parts of the urinary system. In chronic phase patients present with obstructive symptoms secondary to urethral strictures. May lead to periurethral abscesses, which, unless treated, produce numerous perineal and scrotal fistulas- Watering can perineum. Retrograde urethrography typically demonstrates an anterior urethral stricture associated with multiple prostatocutaneous and urethrocutaneous fistulas.

53. Gonococcal urethral stricture. Retrograde urethrogram reveals a segment of irregular, beaded narrowing in the distal bulbous urethra with opacification of the left Cowper duct.

54. Blunt Urethral Trauma Classified Anatomically as - Anterior - Posterior Anterior urethral injury MC iatrogenic (due to instrumentation) May occur if pt falls on a blunt object or direct injury to perineum Straddle Injury - compression of urethra against anterior pelvic ring Posterior urethral injury results from A crushing force to the pelvis Is associated with pelvic fractures.

55. Goldman & Sander classification (Based on findings at retrograde urethrography) Type I injury Rupture of the puboprostatic ligaments which stretches the prostatic urethra Continuity of the urethra is maintained

56. Type II injury ( 15 %) The membranous urethra is torn above an intact urogenital diaphragm , which prevents contrast material extravasation from extending into the perineum

57. Type III injury (MC) The membranous urethra is ruptured but the injury extends into the proximal bulbous urethra because of laceration of the urogenital diaphragm Extravasation not only into the pelvic extraperitoneal space but also into the perineum.

58. Type IV Bladder neck injury with extension to the urethra.

59. Type V injury Injury to the Anterior urethra - partial or complete. Extravasation seen to penile soft tissue.

60. MCU

61. MICTURATING CYSTOURETHROGRAM Voiding cystourethrogram demonstrates the lower urinary tract & helps to detect VUR , bladder pathology , congenital or aquired anamolies of bladder It is performed by passing a catheter through the urethra into the bladder, filling the bladder with contrast material and then taking radiographs while the patient voids.

62. ANTEROGRADE URETHROGRAPHY/ MICTURATING CYSTOURETHROGRAPHY INDICATIONS CHILDREN - UTI Voiding difficulties. Vesico ureteric reflux. Baseline study prior to urinary tract surgery. Post operative evaluation of ureteric abnormalities. Trauma. Suspected anatomic abnormalities of bladder neck & urethra. ( posterior urethral valve ) ADULTS - Functional disorders of bladder & urethra. Suspected vesicovaginal / vesicocolic fistula. Suspected bladder / urethral trauma. Urethral diverticula

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

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

65. Filming In children : upto 2 yrs of age bladder is filled by hand injection. For older children contrast medium is instilled from a bottle elevated one metre above the examination table. During filming , fluroscopic screening is performed at short intervals to see any vu reflux ,diverticuli . The child is turned oblique on both sides to ensure that minimal reflux is not overlooked. In infants : voiding starts the moment catheter is removed. At the end of voiding ,frontal film is taken which includes entire abdomen including the kidney region to prevent overlooking the vu reflux which is apparent only on termination of voiding and may reach upper collecting system.

66. In adult male : bladder is filled in the usual way as in older child and voiding filming is done in both oblique projection views. The voiding study in male adults can be modified by getting the patient to void against resistance i.e. by compression of distal part of penis thus enhancing the visualization of urethra by artificial distention .

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

68. Posterior urethral valve in newborn and in a 7 yr. Old boy

69. Posterior urethral valve -image shows a dilated posterior urethra with an abrupt transition to a normal-calibre anterior urethra with bladder neck hypertrophy, the irregular trabeculated bladder wall, and the left-sided grade III vesicoureteric reflux.

70. Grading of VUR Grade 1 : reflux limited to ureter Grade 2 : reflux into renal pelvis Grade 3 : mild dilatation of ureter and pelvicalyceal system. Grade 4 : tortuous ureter with moderate dilatation, blunting of fornicies but preserved papillary impressions. Grade 5 : tortuous ureter with severe dilatation of ureter and pelvicalyceal system, loss of fornicies and papillary impressions

71. Congenital megalourethra This is a rare congenital anomaly resulting from the faulty development of the corpora cavernosa and corpus spongiosum.

72. megalourethra in an infant. Lateral mcu image reveals an extensively dilated anterior and posterior urethra

73. Urachal diverticulum. Posteroanterior mcu image shows a gross urachal diverticulum bladder.

74. MCU image shows a diverticulum resulting from spontaneous opacification of a prostatic utricle

75. (a) Early anteroposterior voiding cystourethrogram demonstrates a ureterocele

76. Tuberculous urethritis Descending infection and renal tuberculosis is evident. In the acute phase, there is urethral discharge with associated involvement of the epididymis , prostate, and other parts of the urinary system. In chronic phase patients present with obstructive symptoms secondary to urethral strictures. May lead to periurethral abscesses, which, unless treated, produce numerous perineal and scrotal fistulas- Watering can perineum. Retrograde urethrography typically demonstrates an anterior urethral stricture associated with multiple prostatocutaneous and urethrocutaneous fistulas.