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It is the radiographic examination of the
urinary tract including the renal parenchyma,
calyces and pelvis after the intravenous
injection of the contrast media.
Use decreased significantly in recent years
CT, US, MR is replacing
Remains primary modality for visualization
of pelvicalyceal system and ureter
Introduction of excretory urograpy was done in 1929,
by American urologist Moses Swick.
He injected an organically-bound iodide
compound—later named Uroselectan—into a vein,
taking X-rays as the material cleared the body
through the urinary tract.
1937-Berger made several recommendations
•High dose of contrast agents
Visualization of kidney
calyces and pelvis resulting
injection of contrast.
Describes retrograde studies
only the collecting system.
So, IVP is misnomer, should be
Describes visualization of
Visualization of urethra
Combined study to
visualize bladder and urethra.
One more word about terminology….
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
American College of Radiology (ACR) guidelines published
To evaluate the presence or continuing presence
of suspected or known ureteral obstruction.
To assess the integrity of the urinary tract status
To assess the urinary tract for suspected
To assess the urinary tract for lesions that may
explain hematuria or infection
Investigation of HTN in young adults not
Clear outline 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.
need for IV contrast material
may provoke an allergic response
multiple delayed films (Can take hours as contrast
passes quite slowly into the blocked renal unit and
May not have sufficient opacification to define the
anatomy and point of obstruction.
Requires a significant amount of radiation exposure
and may not be ideal for young children or pregnant
The parenchyma of the kidney is divided into two major
structures: superficial is the renal cortex and deep is the
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
Between the renal pyramids are projections of cortex
called renal columns (of Bertin).
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 calyces empty into major calyces, and major
calyces empty into the renal pelvis, which becomes the
Relations of kidneys
Superiorly, the suprarenal (adrenal) glands sit adjacent to
the upper pole of each kidney
On the right side, the second part of the duodenum
(descending portion) abuts the medial aspect of the
On the left side, the greater curvature of the stomach
can drape over the superomedial aspect of the kidney,
and the tail of the pancreas may extend to overlie the
The spleen is located anterior to the upper pole of left kidney and is
connected by the splenorenal (lienorenal) ligaments
Inferiorly to these organs, the colon typically rests anteriorly to the
kidneys on both sides
Posteriorly, the diaphragm covers the upper third of each kidney,
with the 12th rib most commonly crossing the upper pole
The kidneys sit over the psoas (medially) and the quadratus
lumborum muscles (laterally)
High osmolar contrast media
Low osmolar contrast media
Iso osmolar contrast media
All currently used IRCM are chemical modifications of a 2,4,6-tri-iodinated
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
2,4,6 tri iodinated compound
3 5 variation various brands
dissociates iodinated anion
High-osmolar contrast media (HOCM) are the oldest agents.
They are relatively inexpensive, but their utility is limited.
They are monomers (single benzene ring)
that ionize in solution with a valence of -1.
Their cation is either sodium or meglumine.
Iso -osmolar contrast media
The most recent class of agents is dimers that consist of a
molecule with two benzene rings (again, each with 3 iodine
atoms) that does not dissociate in water(nonionic).
Dose of 200mg of iodine per pound body wt-dose of 20-30g.
Injection completed within 60 sec-rapidly injecting as bolus
with 50 ml syringes.
Slow injections decrease side effects but provides less dense
Another method –drip infusion technique,infusion kit with
40-50g iodine delivered in 250-400ml fluid.
system & ureter
longer time-more flexibility in
Ureter compression not
Overloads with more iodine
may produce CCF
increased Diuresis- decrease
Initial vascular nephrogram not
PREPARATION OF THE PATIENT
Complete urine and blood examination to assess the renal function.
The patient is given mild laxatives(1-2 oz castor oil) about twelve to
twenty four hours before the proposed x-ray examination. (A night
before the urographic examination) .Eliminates fecal material and
reduces amount of gas in bowel.
The patient is kept nil by mouth over night and is dehydrated by stopping
the fluid intake.
Most uroradiologist believe that with modern contrast media
overhydration should be avoided but dehydration is unnecessary.
In practice adviced omit fluids after 11pm,omit breakfast which
decreases chance of vomiting and produce slight dehydration.
The dehydration helps in better concentration of the contrast and
clearer x-ray pictures.
The patient should not be dehydrated if suffering from renal failure
as it may lead to severe fluid and electrolyte imbalance.
Sensitivity to the dye (Hypaque or Urographin)checked. Necessary
precautions are taken to avoid the allergic reactions.
Take informed consent.
Physiology of contrast excretion
Following bolus I.V. injection, very rapid plasma concentration is followed by rapid decline
Rapid mixing in vascular compartment
Diffusion into extravascular, extracellular space
I.V. injection Contrast media
Osmotically inert &
by renal tubules
by renal tubules
Extrarenal routes for contrast
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
Upper arm or shoulder pain may be due to stasis of contrast
in vein which may be relieved by abduction of the arm.
Plain film of the abdomen
•State of bowel preparation
•Calcific density in the renal tract
•Soft tissue masses
•To observe the abdominal parities
•To check exposure factors
Oblique views- optional
Dose: adults- 50ml of 350-370 strength water soluble contrast
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
To demonstrate bowel
preparation, check exposure
factor, and location of
radiopaque stones or any
If necessary the position of overlying opacities may be further
Supine AP of renal areas, in expiration. The x-ray beam is centred
in the mid-line at the level of lower costal margin
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.
1-3 minutes Antero-posterior- film coned to the renal area
5 minutes Antero-posterior-film coned to the renal area
Apply ureteral compression
10 minutes Antero-posterior
“Flush”, “X” or “Release view”- - full length view at 20
Upright post void Antero-posterior
Contraindications to ureteral
Evidence of obstruction on the 5-minute image
Abdominal aortic aneurysm or other abdominal
Severe abdominal pain
Recent abdominal surgery
Suspected urinary tract trauma
Presence of a urinary diversion
Presence of a renal transplant
WHAT TO LOOK FOR IN IVU
Size, shape, position and axis of kidneys
External cortex and inner medulla
Renal pelvis and ureteropelvic junction
Relation of ureter to spine and psoas muscle
RADIATION DOSE FROM IVU
1,465 mR/projection for males
1,047 mR for females
The size of the kidneys should be assesed during
The normal kidney may range from 9 to13 cm in
cephalocaudal length, 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,left kidney 2 cm larger than the
right kidney) require explanation.
•In normally functioning kidneys, contrast is first seen in the calyces
at 2 mins following bolus injection.
Value of compression
On the 5-minute image, the nephrogram should be receding
as the collecting system becomes opacified.
On the 10-minute image, the pyelogram is the dominant
Alterations in this temporal sequence require explanation.
Visualization of the collecting system and renal pelvis can be
augmented with the use of abdominal compression,
Trendelenburg position, and other gravity maneuvers such
as placing the patient with the side of interest in the
ipsilateral posterior oblique position
The appearance of the calices and renal pelvis should be
Early and mild obstruction is indicated by subtle rounding of
the forniceal margins
more severe and prolonged obstruction evidenced by
progressive loss of the papillary impression and eventual
clubbing of calices.
Ureters begin to transport opacified urine about 3 mins post injection
Maximum ureteral filling occurs between 5-10 minutes.
At the release of compression, the bolus of contrast material–
laden urine entering the ureters provides optimal visualization
throughout their length
Persistence of a standing column of contrast material on
several images may indicate obstruction or ureteral ileus
Medial deviation of the ureter should be considered when the
ureter overlies the ipsilateral lumbar pedicle.
lateral deviation should be considered when the ureter lies
more than 1.5 cm beyond the tip of the transverseprocess, but
comparison with the position of the contralateral ureter should
always be made
demonstrates acute medial
deviation of the right
ureter produced by an
aneurysm of the internal
Ureteral filling defects may be single or multiple and can
usually be attributed to luminal, mural, or extrinsic causes.
Urographic image shows
multiple filling defects in
the left renal pelvis and
Multifocal transitional cell
carcinoma was confirmed
in this case.
An absolute ureteral diameter exceeding 8 mm
is considered a criterion for dilatation
Asymmetry of ureteral caliber is a more significant
Early in its course, high-grade ureteral obstruction may
be associated with only minimal ureteral dilatation.
More chronic forms of obstruction and other chronic
ureteral conditions are typically associated with greater
degrees of ureteral dilatation
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 intraluminal
contrast material should be spheric and smoothly marginated
and the wall progressively less evident.
Bladder wall thickening and irregularity of the luminal
contrast material associated with a bladder base defect is
typical of changes of bladder outlet obstruction from
Contour abnormalities from cellule or diverticulum
Bladder transitional cell carcinoma.
Bladder image shows a filling defect
with a papillary configuration along
the right bladder wall
Note the irregular distribution of
associated with the filling defect
The postvoid image may also be helpful in evaluating patients
with upper urinary tract dilatation.
Persistence of the dilatation on the postvoid image suggests
The postvoid image is most helpful in assessing residual
Extravasation of contrast medium
Local pain, erythema, swelling
Usually resolve with local therapy
Rarely, significant tissue necrosis and skin-sloughing
occur (even with small amounts)
severe, may lead to compartment
Severe edema, loss of pulses, necrosis
More common with injection in hand or foot
Initial recommended treatment of
- Elevation of affected extremity above heart
- Ice packs (15-60min/3 times per day)
- Close observation for 2-4 hrs
Immediate plastic surgery consultation
for the following indications
Extravasated volume exceeds 100 cc of nonionic contrast
Altered tissue perfusion
Decreased capillary refill over or distal to injection site
Increasing pain after 2-4 hours
Change in sensation distal to site extravasation
U/L-Absent renal outline &
pelvicalyceal system, 99mTc
DMSA most sensitive test.
B/L-Uncommon & incompatible
Failure of complete ascent
of the kidney to its normal
IVU- abnormally placed
Crossed fused renal ectopia
Two complete pelvicalyceal
systems on one side usually one
above the other
Ureter from the lower renal
pelvis crosses the midline and
enters bladder normally
Kidneys placed lower than
Malrotation of pelvis
Lower pole calyces of both
sides deviated towards
Ureters have characteristic
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
uretero pelvic junction
obstruction; this is a frequently
Minor form – bifid renal pelvis
Incomplete – ureters fuse in their
Complete – 2 ureters open
seperately in bladder, lower moiety
inserted orthoptically & upper
“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,
Contrast filled structure
with a thin smooth
surrounded by contrast
containing urine in the
bladder- “Cobra’s head’
The ureter may have a
sickle, S or reverse J
appearance before crossing
behind and medial to the
The ureter descends medial
to right lumbar pedicle.
Proximal ureter is dilated.
Due to functional obstruction at the pelvi-ureteral junction
Aetiology- cong. Bands, adhesions, neuro muscular inco-ordination,
• large soft tissue mass replacing the renal parenchyma
• No opacification of collecting system
Lesser degrees of obstruction
• Nephrogram- thin rim of renal substance outlining
• Later films – crescent shaped opacities produced by
dilated stretched tubules surrounding the enlarged non
• Delayed films – slow filling of calyces & renal pelvis
•“Wine glass appearance”
Mildest form- minimal deviation from the normal
Grading of hydronephrosis
Gr 1-dilatation of renal pelvis without dilatation of
calices,prominent reflex of renal sinus without signs of
Gr2-dilatation of renal pelvis and calices ,pelvicalyceal
pattern is maintained,no signs of parenchymal atrophy
Gr3-moderate dilatation of renal pelvis and calyces ,blunting
of fornices and flattening of papillae,mild cortical thinning
may be seen
Gr4-gross dilatation of renal pelvis and calyces which appear
ballooned ,loss of borders between renal pelvis and
calyces,renal atrophy seen as cortical thinning.
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
Plain films- cyst calcification
IVU- enlarged kidneys with
compression and displacement
of calyces by intrarenal cyst
B/L symmetrical enlargement of
Calyces maybe distorted
Dromedary hump. Tomogram
from excretory urography
demonstrates a prominent cortical
hump in the interpolar region of the
On a compression image
obtained in a later phase of the
sequence, the hump is subtended by
a normal collecting system element,
indicating that it represents normal
Medullar y sponge kidney
Brush like linear
striations in renal papillae
Enlargement of kidney
Localised bulge with increased
thickness of the renal substance
Deforms or displaces or distends
Medium sized lesions
Localized or generalized enlargement
of the kidneys
Displacement or distortion of renal
pelvis, ureter or adjacent structures
Very large lesions
Non functioning kidneys
Bladder transitional cell carcinoma
Bladder image shows a filling defect
with a papillary configuration along
the right bladder wall
Note the irregular distribution of
associated with the filling defect
GU Tb-plain KUB
Disparity in renal size on plain films may indicate early
increase in size of the affected kidney due to caseous lesions
or a shrunken fibrotic kidney of autonephrectomy.
Calcifications are seen in 30% to 50%
A characteristic diffuse, uniform,extensive parenchymal,
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.
Ureteral calcifications are rare and are characteristically
intraluminal as opposed to the mural calcifications of
. Bladder wall calcifications seen in late cases of bladder
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.
The most common findings being
hydrocalycosis,hydronephrosis, or hydroureter due to
stricture formation .
Early signs include the moth-eaten appearance of calyceal
erosion and papillary irregularity- signs are best seen on early
Cavitary lesions communicating with the collecting system
are characteristic of TB.
These lesions eventually enlarge as parenchymal destruction
Fibrotic distortion of the collecting system and ureter is also
Calyceal obliteration and amputation, hydrocalycosis,
segmental or total hydronephrosis, and a shriveled reduced
capacity renal pelvis may all be signs of renal tuberculosis
Scarring and angulation of the ureteropelvic junction (UPJ)
may also occur, the so-called “Kerr’s kink” .
Tuberculosis of the ureter is commonly seen as a rigid,
straightened “pipe-stem” ureter also beaded, corkscrew
Ureterovesical junction obstruction is caused by tuberculous
cystitis or strictures of the distal third of the ureter.
secondary stone formation on top of this stricture .
The cystogram films may show a small contracted bladder
due to excessive fibrosis
“A tailored urographic study allowing optimal visualization of
sequentially opacified portions of the urinary tract may provide
diagnostic detail in certain portions of the urinary system beyond the
current capabilities of other imaging modalities. This can be
accomplished only with good technique, an understanding of the
limitations of the procedure, and adherence to basic rules of
interpretation. 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.”
The professors of forensic medicine, Derobert and Dehouve
(who also was a radiologist), together with Wolfromm, an
allergologist, wrote in 1964: “More patients died from lack of an
IVU than patients died because they were submitted for an IVU”
However,urography now faced the challenge of the
alternative methods of US and CT, and the new generation of
uroradiologists needed to develop strategies for using them