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››
„The Intravenous Urogram is the classic routine investigation of
Uroradiology
„Technically satisfactory IVU demonstrates clearly and
completely both the renal parenchyma & the collecting system
including the calyces, renal pelvis, ureters and the urinary
bladder and gives an indication of their function
 „Introduction of excretory urography was done in
  , by American urologist Moses Swick.
He injected an organicallybound iodide
compound²later named Uroselectan²into a vein,
taking Xrays as the material cleared the body
through the urinary tract.

0



„ 
erger made several recommendations

ÔMoutine tomography
ÔHigh dose of contrast agents
ÔUreteral compression
INDICATIONS:
„Persistent or frank haematuria
„Menal or ureteric calculi
„Ureteric strictures or fistulas
„Complex urinary tract infection

CONTMAINDICATIONS:
„No absolute contraindication
„Melative contraindications
ÔMenal & hepatic failure
ÔMultiple myeloma
ÔPregnancy
ÔPrevious reaction to contrast media
ÔH/o allergy
ÔInfancy
ÔThyroid disease
ÔDiabetes
 PATIENT PMEPAMATION
„Dehydration : Effective fluid restriction may produce a slightly
detectable increase in urographic density but the nephrogram is
uneffected, hence no longer considered applicable

„owel preparation

„Psychological preparation

„Informed consent
 EXPOSUME FACTOMS

Kv(p) 66
mA Sufficiently high to allow short
exposure times
Film/Screen combination Medium speed
 Physiology of contrast excretion
Following bolus I.V. injection, very rapid plasma concentration is followed by rapid decline
„Mapid mixing in vascular compartment
„Diffusion into extravascular, extracellular space
„Menal excretion
I.V. injection Contrast media

Anion(I)
Cation

Osmotically inert & non reabsorbable Meglumine Sodium

Not reabsorbed Freely reabsorbed

by renal tubules by renal tubules
Extrarenal routes for contrast
excretion:
„Hepatic
„Small bowel
„Sweat
„ saliva
„Tears
„Gastric juice
 PMOCEDUME
„Plain film of the abdomen
(Scout film)
ÔState of bowel preparation
ÔCalcific density in the renal tract
ÔSoft tissue masses
ÔTo observe the abdominal parieties
ÔTo check exposure factors
& positioning

„Oblique views

„Contrast administration:
bolus/infusion
Dose: adults ml of

 strength water soluble contrast
children
ml/kg body wt.
 FILM SEQUENCE
„
minutes Anteroposterior film coned to the renal area

„ minutes Anteroposteriorfilm coned to the renal area

„Apply ureteral compression

„ minutes Anteroposterior

„Melease compression

„³Flush´, ³X´ or ³Melease view´  full length view

„Upright post void Anteroposterior

„Nephrotomographywhenever anatomic information is obscured

„Mole of delayed films rule of eight

Contraindications to ureteral compression:

„Suspected or proven aortic aneurysm

„Evidence of obstruction in early urogram films

„Mecent abdominal surgery

„Severe hypertension

„Abdominal pain on application of compression

„Mecent acute injury

„Menal transplantation

„Abdominal distension
 rHAT TO LOOK FOM IN IVU

„Size, shape, position and axis of kidneys

„External cortex and inner medulla
„Calyceal system
„Menal pelvis and ureteropelvic junction
„Ureter
„Ureterovesical junction
„Urinary bladder
„Melation of ureter to spine and psoas muscle

MADIATION DOSE FMOM IVU

„,46 mM/projection for males
„,4 mM for females
„Total dose to the gonads / exam mM ±males
 mMfemales
 UMOGMAPHIC INTEMPMETATION
„Nephrogram Provides information regarding arterial
perfusion of the kidney as well as the functional & structural
integrity of the nephrons

ÔVascular/ capillary/cortical nephrogram due to

distribution of contrast media in the cortical microvasculature

ÔUrographic/parenchymal nephrogram due to entry of

contrast in the proximal tubules

ÔFading of contrast continous flow of contrast in the tubules

reduced plasma conc. of C.M.
NEPHMOGMAPHIC PATTEMNS
Immediate Faint Persistent Nephrogram
„Due to severe impairment of Glomerular filtration
ÔProliferative/necrotising disorders
ÔMenal vein thrombosis
ÔChronic severe ischaemia

Immediate Dense Persistent Nephrogram

„Due to unimpaired glomerular filtration
ÔAcute tubular necrosis
ÔAcute renal failure
ÔAcute on chronic renal failure
ÔAcute hypotension
Increasingly Dense Nephrogram
ÔAcute obstruction . Acute Pyelonephritis
ÔAcute Hypotension . Multiple Myeloma
ÔAcute tubular necrosis . Menal vein thrombosis
ÔAcute glomerulonephritis .Amyloid, Acute papillary necrosis
Increasingly Dense Nephrogram
Mim Nephrogram

ÔSevere hydronephrosis

ÔAcute complete arterial occlusion

Striated Nephrogram

ÔAcute ureteric obstruction

ÔInfantile polycystic disease

ÔMedullary sponge kidney

ÔAcute pyelonephritis
 „Pyelogram
ÔIn normally functioning kidneys, contrast is first seen in the calyces at  mins
following bolus injection.

w


 „Ureters
„Ureters begin to transport opacified urine about
mins post injection
„Maximum ureteral filling occurs between  minutes.
„ladder
MINUTE SEQUENCE IVP
„Evaluation of renovascular
hypertension
„Minimum series includes
films at ,,
minutes, post
injection
„Criteria
ÔDelayed visualisation of
contrast in the collecting
system on the affected side
ÔDecreased renal size
ÔDelayed washout of contrast
ÔNotching of the proximal
ureter
HIGH DOSE
UMOGMAPHY
„Indicated for imaging the
kidneys in patients with
mild renal impairment
„Prerequisites
.Adequate hydration
ÔOptimal metabolic & CVS
condition
ÔHigher contrast medium
dose
ÔUse of low osmolality
agent

FINDINGS IN CMF
„Meduced renal size
„Parenchymal thinning
„Normal pevicalyceal anatomy
ADVEMSE MEACTIONS

„Minor reactions flushing,arm pain, nausea, vomiting,

headache, rigors and mild urticaria.

„Intermediate reactions
ÔMore severe degrees of the above mentioned symptoms
ÔModerate degrees of hypotension and bronchospasm

„Severe life threatening reactions

ÔSevere manifestations of above symptoms
ÔSevere bronchospasm
ÔUnconsciousness
ÔLaryngeal oedema
ÔPulmonary oedema
ÔSevere cardiac dysaarrythmias
ÔCardiac arrest
ÔCardiovascular and pulmonary collapse

„Death
 IVU findings in certain entities
Menal agenesis

„ U/L
U/LAbsent renal outline &
pelvicalyceal system, mTc
DMSA most sensitive

/LUncommon &
„ /L
incompatible with life
 Menal Ectopia

Failure of complete
ascent of the kidney to
its normal position

IVU abnormally placed

kidneys

Pancake kidney
 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
 Horseshoe kidney

Kidneys placed lower

than normal
Malrotation of pelvis
Lower pole calyces of
both sides deviated
towards midline
Ureters have
characteristic vaselike
curve
Pelvicalyectasis
Menal calculi
 Duplex collecting system

Minor form ± bifid renal

pelvis

Ureteral duplication
„ Incomplete ± ureters fuse
in their course
„ Complete ±  ureters
open seperately in
bladder, lower moiety
inserted orthoptically &
upper moiety ectopically
„ ³Drooping lily´ sign
 Ureterocele

Contrast filled structure

with a thin smooth
radiolucent wall
surrounded by contrast
containing urine in the
bladder ³Cobra¶s head¶
appearence
 Metrocaval ureter

The ureter may have a

sickle, S or reverse J
appearance before
crossing behind and
medial to the IVC.
The ureter descends
medial to right lumbar
pedicle.
Proximal ureter is
dilated.
 Congenital Hydronephrosis
„Due to functional obstruction at the pelviureteral
junction
„Aetiology cong. ands, adhesions, neuro muscular
incoordination, abberent vessels
„Advanced cases
Ô large soft tissue mass replacing the renal
parenchyma
ÔNo opacification of collecting system
„Lesser degrees of obstruction
Ô Nephrogram thin rim of renal substance outlining the
kidney
ÔLater films ± crescent shaped opacities produced by
dilated stretched tubules surrounding the enlarged
non opacified calyx
ÔDelayed films ± slow filling of calyces & renal pelvis
„Mild forms
Ô³rine glass appearance´
„Mildest form minimal deviation from the normal
appearance
 Polycystic kidneys

Autosomal dominant
„ Plain films cyst calcification
„ IVU enlarged kidneys with
compression and
displacement of calyces by
intrarenal cyst
Autosomal recessive
„ /L symmetrical
enlargement of kidneys
„ Streaky nephrogram
„ Calyces maybe distorted
 Medullary sponge kidney

rush like linear

striations in renal
papillae
Enlargement of kidney
Menal calculi
 Acute urinary obstruction

Increasingly dense ³obstructive´

nephrogram
Moderate kidney enlargement
Delayed calyceal opacification
Minimal to moderate
pelvicalyectasis
Standing column of the ureter
Spontaneous pyelosinous
extravasation
 Chronic urinary obstruction
„ Kidney size
large(partial
obstruction)
small(complete obst)
„ Nephrogram density
 normal or reduced
„ Parenchymal thickness
reduced
„ Pyelogram
Hydronephrosis
„ Ureterdilatation &
tortuosity
mucosal striations
 Menal Vein Thrombosis

„Enlarged kidney with faint or absent

Nephrogram

„Pelvicalyceal filling maybe absent or the

PCS stretched
& compressed by oedematous renal
parenchyma

„Marely, increasingly dense nephrogram,

sometimes wiyh striation

„Later stages Menal atrophy

 Menal masses

Small SOL

„ Localised bulge 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, ureter or adjacent
structures
„ Malrotation
Very large lesions
„ Non functioning kidneys
„ Calycine spreading
„ Visceral displacement
 Menal tuberculosis

Early stage
„ Irregularity or destruction of
one or more papillae
Later stage
„ Calcification
Menal

Parenchymal
Calcification within caseous pyonephrosis
Punctate Proceeds to Tuberculous Autonephrectomy
calcification
„Cavities irregular, communicates
with the collecting system
„Fibrosis leading to obstruction
 Hydronephrosis, hydrocalicosis
ladder wallThickened and trabeculated
 small capacity bladder
„Concentration of contrast medium is
poor in proportion to the degree of
obstruction
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