This ppt aims to deliver a quick info about the common radiological procedure of intravenous urography.

1. EXCRETION
UROGRAPHY
By: Sudil Paudyal
B.Sc.MIT 2nd
year
IOM,MMC
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2. Introduction
• Also known as intravenous urography (IVU).
• Most frequently employed radiologic investigation of
renal drainage.
• The contrast material is administered intravenously.
• Best method for adults unless use of other methods is
specified and is used in examinations of upper urinary
tracts of infants and children.
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3. • Urogram: Visualization of kidney parenchyma, calyces
and pelvis resulting from IV injection of CM.
• Pyelogram: Describes retrograde studies visualizing only
the collecting system.
• So, IVP is misnomer, should be IVU
• Excretion urography used nowadays.
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4. Anatomy
Kidneys:
• A pair of bean-shaped organs approximately 12 cm long.
They extend from vertebral level T12 to L3 when the
body is in the erect position. The right kidney is
positioned slightly lower than the left because of the
mass of the liver.
Internal structure
• Within the dense, connective tissue of the renal
capsule, the kidney substance is divided into an outer
cortex and an inner medulla.
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5. • Cortex-contains glomeruli, Bowman's capsules, and proximal
and distal convoluted tubules. It forms renal columns, which
extend between medullary pyramids.
• Medulla-consists of 10 to 18 striated pyramids and contains
collecting ducts and loops of Henle. The apex of each pyramid
ends as a papilla where collecting ducts open.
• Calyces-the minor calyces receive one or more papillae and
unite to form major calyces,of which there are two to three
per kidney.
• Renal pelvis-the dilated upper portion of the ureter that
receives the major calyces.
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7. • Relations:
• Anteriorly, a portion of the liver, duodenum and right colonic
flexure lie in front of the right kidney. the left part of the
transverse colon, the left colic flexure, and upper part of the
descending colon lie in front of the rest of the left kidney.
• Posteriorly, the psoas muscles lie behind each kidney. The
upper part of each kidney lies on the inner surface of the
respective twelfth rib.
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8. • Superiorly, the adrenal glands are sited on the superior
surface of each kidney.
• Inferiorly. Coils of small bowel supported on their mesentery
lie below each kidney.
• Medially, vertebral column lies between the two kidneys.
Immediately in front of it are the great vessels, the aorta on
the right and the inferior vena cava on the left and their
associated renal blood supply and drainage.
Blood Supply:
• Right and left renal arteries respectively, branches of the
abdominal aorta.
Nerve supply:
• Motor neurones from the autonomic nervous system.
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• The large muscles on
either side of the vertebral
column cause the
longitudinal plane of the
kidneys to form a vertical
angle of about 20° with
the midsagittal plane.
These large muscles
include the two psoas
major muscles. These
muscle masses grow larger
as they progress inferiorly
from the upper lumbar
vertebrae.

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• This gradual enlargement
produces the 20°
angle, wherein the upper
pole of each kidney is closer
to the midline than its lower
pole.
• These large posterior
abdominal muscles also
cause the kidneys to rotate
backward within the
retroperitoneal space. As a
result, the medial border of
each kidney is more
anterior than the lateral
border.

12. Ureters:
• These are two long tubes leading from the pelvis of each
kidney to the bladder, descending on either side of the
vertebral column and passing forward over the pelvic brim, to
enter obliquely into the posterior base of the bladder.
• Are constructed so that urine passes along them by peristaltic
action.
• There is an inner lining of mucous membrane supported on a
submucosal layer, then a layer of plain circular involuntary
muscle, and an outer layer of white fibrous tissue.
• The ureters have a length of approximately 20 cm and an
internal diameter up to 3 mm.
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13. Ureteric constrictions:
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• The ureters vary in diameter
from 1 mm to almost 1 cm.
• 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.
• The first point is the
ureteropelvic (UP)
junction, where the renal pelvis
funnels down into the small
ureter.

14. • The second is near the brim of
the pelvis, where the iliac blood
vessels cross over the ureters.
• The third 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.
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15. Bladder:
• Bladder is situated in the anterior part of the pelvic
cavity, behind and just above the symphysis pubis.
• Exact position depends on the degree of distension.
• Acts as a reservoir for urine from the kidneys and
subsequently expels it via the external urethra.
• It is a hollow muscular organ lying in the anterior part of the
pelvis outside the peritoneum.
• When empty it is pyramidal in shape and presents an apex
behind the smphysis pubis, a base anteriorly and a superior
and two inferolateral surfaces.
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16. • The ureters enter the postero lateral angles of the base and
the urethra leaves inferiorly at the narrow neck.
• The interior of the bladder is covered with mucous membrane
which thrown into folds, except in the trigone between the
ureteric orifices, in the contracted state and stretched more
smooth when the bladder is distended.
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17. Indications
• To see the anatomy and physiology of urinary system
• Trauma
• Calculi- renal, ureteric, bladder
• Congenital anomalies- ectopic kidney, horseshoe kidney, renal
agenesis
• Infective pathology
• Renal tumour
• Unknown Haematuria
• Renal hypertension
• Bladder pathology- diverticula, fistula
• Vesico ureteric reflux
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18. Contraindications:
• Hypersensitivity to iodinated CM
• Renal insufficency
• Hepato renal syndrome
• Thyrotoxicosis,
• Pregnancy, (Allow 28 days from childbirth)
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19. Contrast media:
• Low osmolar contrast media (LOCM)- 300- 600mgI/ml
• Adult dose : 50-100ml
• Paediatric dose : 1ml/kg
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20. Equipment:
• Any standard radiographic unit is suitable to perform the
procedure.
• High power x-ray generator.
• Immobilization band is usually not applied because the
resultant pressure may interfere with the passage of fluid
through ureters and may also cause distortion of canals.
• However, 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 pelves and calyces.
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22. Pt. preparation
• NPO for 5h prior to examination.
• Pts. should preferably be ambulant for 2h prior to the
examination to reduce bowel gas.
• Bowel preparation is necessary to reduce the bowel gas
pattern which may obscure the region of interest.
• The routine administration of bowel preparation use makes
the examination more unpleasant for the patients.
• Nowadays it is said to be unnecessary.
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23. • The technologist must check the patient's chart to determine
the creatinine and BUN (blood urea nitrogen) levels. Patients
with elevated blood levels have a greater chance of
experiencing an adverse contrast media reaction. Normal
creatinine levels for the adult are 0.6 to 1.5 mg/dl. BUN
levels should range between 8 and 25 mg/100 ml.
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24. • Nowadays, dehydration is not necessary and doesnot improve
image quality.
• Dehydration is contraindicated in the following situations:
1. Renal failure
2. Myeloma
3. Infancy
• If examination is to be performed on a pt who has previously
had a severe CM reaction, consideraton should be given to
administering methyl prednisolone 32mg orally 12 and 2 h
prior to CM injection.
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25. SIGNING INFORMED CONSENT FORM:
• 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 is fully aware of these potential risks and has
signed an informed consent form.
• If a child is undergoing venipuncture, the procedure should be
explained to both the child and the guardian, and the
guardian should sign the informed consent form.
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26. Technique
• Venous access via the median antecubital vein is the preferred
injection site because flow is retarded in the cephalic vein as it
pierces the clavipectoral fascia.
• The gauge of the cannula/needle should allow the injection to
be given rapidly as bolus to maximize the density of
nephrogram.
• Upper arm or shoulder pain may be due to stasis of contrast
in vein which may be relieved by abduction of the arm.
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27. Films
• Preliminary film:
 Supine, full length AP of
abdomen in inspiration.
 The lower border of
cassette is at the level of
symphysis pubis and the
x-ray beam is centred in
the midline at the level of
iliac crests.
 To demonstrate bowel
preparation, check
exposure factor, and
location of radiopaque
stones or any radiopaque
artifacts.
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28. • 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
Or
• 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.
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29. Films
• Immediate film :
 AP of the renal areas.
 This film is exposed 10-
14 s after the injection
(app. Arm to kidney
time)
 Aims to show the
nephrogram, i.e renal
parenchyma opacified
by contrast medium in
renal tubules.
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30. • 5-min film:
 AP of renal areas.
 To determine if excretion is symmetrical and is invaluable for
assessing the need to modify the techinque, eg a further
injection of CM if there has been poor initial opacification.
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31. • Compression band is now applied around the patient’s
abdomen and the balloon 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:
1. After recent abdominal surgery
2. After renal trauma
3. If there is a large abdominal mass or aortic aneurysm.
4. When the 5-min film shows already distended calyces.
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32. • 15 min film:
 Supine full length AP
 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.
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33. • Release film (full bladder) : coned view of bladder area
• Taken to show the bladder. If this film is satisfactory, the pt is
asked to empty the bladder.
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34. • After micturition film:
• Either a full length abdominal film or a coned view of the
bladder with the tube angled 15° caudad and centred 5 cm
above the symphysis pubis based on earlier findings.
• Main aim of films is to
 Assess bladder emptying
 To demonstrate return of dilated upper
tracts with relief of bladder pressure.
 Aid diagnosis of VJ calculi
 Dx of bladder tumors
 Demonstrate urethral diverticulum.
 Residual vol of urine.
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35. Additional films:
• Posterior obliques of
kidneys, ureters or bladder:
 To determine whether the
radiopaque shadow is in the ureter
or outside.
 Position: Pt. is rotated 30-35° in rt
or lt side depending on pathology
side.
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36. • Prone film:
 To investigate pelviureteric and ureteric obstruction as the
heavy contrast laden urine will more readily gravitate to the
site of the obstruction.
 To displace the overlying bowel gas towards periphery.
 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.
• Tomography- when there are confusing overlying gas shadows
in renal areas.
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37. • AP with caudal angulation:
 To separate the over shadows by stomach on left kidney.
 Position: AP position, film of kidney area with 25° caudal tube
angulation.
• Erect film: To determine where or not there is small ureteric
calculus, erect oblique film of area of ureter. To demonstrate
layering of calculi in cysts and abscesses.
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38. • Delayed films : may be necessary for up to 24 h after injection
to demonstrate the actual site of ureteric obstruction.
• Children: films are taken in 3 min, 15 min, aden post mic after
CM injection and further depending upon pathology.
• Pregnancy: film sequence is KUB and 15 min full film.
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39. Modification in case of pathology:
• In case of suspicious shadows in renal areas:
 Take lateral film of renal area.
 Take inspiratory and expiratory film of renal area to
demonstrate the relationship of opacities and filling defects of
renal tract.
• In case of renal hypertension: take fast sequences (1min, 3
min, and 5 min film).
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40. • Ectopic kidney: full film KUB region from immediate to last
film.
• Renal agenesis: full fim KUB from immediate to last film.
Delayed films upto 24 hours.
• Bladder diverticulum: Abnormal pouch formed within bladder.
Lateral film of bladder area.
• Vesicovaginal fistula: lateral film of bladder area.
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41. • VUJ obstruction: Oblique film of bladder area of obstruction
side.
• Suspected renal failure, er urography, inadequate bowel
preparation:
 High dose IVU (dose of CM upto 600mgI/kg body wt.) is
performed.
 Common sequences and further delayed sequences ( 1 hrs, 3
hrs, 6 hrs, 12 hrs and 24 hrs) if kidney function is not seen.
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42. Radiation protection
• Direct lead rubber gonad protection using a half apron.
• “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.
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43. Aftercare
• General psychological reassurance.
• Needle wound site dressed and checked for extravasation.
• Check patient understands how to receive the results.
• Ensure patient understands any preparation instructions are
finished.
• Escort to changing rooms and bid good-bye.
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44. Advantage/disadvantage
• 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,
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45. 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,
• it necessitates the use of radiation and contrast medium, and
• it provides no assessment of glomerular filtration rate.
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46. Complication
• 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 and pain during injection
• Extravasation of CM
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47. Some pathologies
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• Urinary obstructions:
• Calculi: most commonly form in the kidneys
• Ureteral calculi may form in lower portion at VUJ and pelvic
brim.
• Bladder calculi are uncommon but they are relatively larger
when present.

48. Congenital or hereditary diseases:
Disorder Description Radiographic findings
Renal agenesis Solitary kidney Hypertrophic single
functioning kidney
Supernumerary
kidney
More than two
kidneys
Hypoplstic 3rd kidney,
may or maynot be
fused
Malrotation Abnormal position Bizzare appearance of
parenchymal calyces
and pelvis.
Ectopic kidney Solitary kidney 2nd kidney in another
location (pelvis or
thorax)
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Horse shoe kidney Lower pole-
parenchymal fusion
Kidney malrotation
and possible
nephrogram
demonstrating
parenchymal fusion
Duplication More than one renal
pelvis or ureter
Double renal pelvis
in single kidney; two
ureters exit kidney
and empty into
bladder.
Ureterocele Located in distal
ureter (VUJ)
Round or oval dilated
ureter with
radiolucent halo.

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Renal agenesis
Ectopic kidney

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Ureteric calculus Rotated kidney

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Bladder diverticulum
Stag horn calculus

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Horse shoe kidney
Duplex bilateral

54. Polycystic kidney disease:
Polycystic kidney disease is a disorder marked by cysts scattered
throughout one or both kidneys. This disease is the most
common cause of enlarged kidneys. Its cause may be genetic
or congenital, depending on the type of polycystic disease.
These cysts alter the appearance of the kidney and may alter
renal function.
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55. 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.
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56. Lastly .….
• Contrast is what we give intravenously
• Dye is used on clothes and in cooking to change the color of
things—it is not given IV to patients!
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57. Conclusion
• Excretion urography has long been the cornerstone of the
imaging evaluation of urinary tract disease. However, other
imaging modalities such as USG,CT, and MRI are being used
with increasing frequency.
• The declining use of urography in clinical practice presents a
challenge for instruction in urographic technique and
interpretation.
• In addition, alternative modalities also have their limitations,
and despite their increasing use, the ideal “global” urinary
tract examination remains controversial.
• Nevertheless, urography may still be important in the
diagnosis of some urinary tract disease processes.
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58. References:
• A guide to radiological procedure by stephen chapman, fifth
edition
• Clark’s special procedure in radiography
• Dyer et.al., intravenous urography, technique and
interpretation, Radiographics,2001; 799-821
• www.xray-2000.co.uk
• Various other websites and ppts.
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