IVU- Intravenous urography project in intravenous urography

1. A
PROJECT
ON
IVU
(INTRAVENOUSUROGRAPHY)
2017
BY - Suman acharaya
Iwamura college of health science

2. Acknowledgement
I would like to express my deepestappreciation to all
those who provided me the possibility to complete this report. A
specialgratitude Igive to our final year project manager,as well as
co-ordinbator ofradiography Mr.sailendrarajpandey,whose
contributionin stimulating suggestions and encouragement, helped
me to coordinate my projectespecially in writing this report.
I also take this opportunity to express a great sence of
graduate towards administration departmentiwamura collegeof
health science for providingme such a greatopportunity to manage
our CCP in such a good hospitalie, Madhyapur hospital, Bhaktapur
diatricthospital, Iwamura Hospital.
Finally I would like to thank all others who directly and
indirectly helped me to accomplish my report.

3. COMPRIHENCIVE CLINICAL PRACTICE
INTRODUCTIONTO CCP
 CCP stands for comprehensive clinicalpractice.[where
comprehensive means including or dealing with all around or nearly all
aspectof something.]
 So CCP means clinically practice of all the techniques, equipment
which we have studied theoretically to grave all the skills, knowledge
of technique and ability to modifythe techniques according to
condition without doing any mistakes in cooperative way.
INCASE OF DIAGNOSTIC RADIOLOGY
Incase of diagnostic radiology CCP is the clinical practice of all
the techniques of TECHNIQUE II ,all the positioning of TECHNIQUE I
,viewing and get to know use of all the radiologicalequipment which we
have studied theoretically in class with the cooperative manner in discipline
way.
Objectives ofCCP
 To know exactly what radiology means practically.
 Introduction to hospital.
 To know all the rules and regulations of particular hospital.
 For observation of real radiological equipmentand their properuses.
 To get practice of all the techniques and position of Technique I and II.
 For direct dealing with patient.
 Practice for the radiological contrast and their adverse reaction.
 To know about certain indication and contraindication for special
procedures.

4.  Information and practice for radiation protection.
Main TargetsOF CCP
1) Team Cooperation
2) Dealing with patient(Patient Care)
 Primary care
 1st
Check the OPD card properly
 Then enter the patient to x-ray room
 Keep the patient record in record book
 Check the emergencycases
 Give priority to old and child patient 1st
.
 Secondary care
 It includes
 positioning of patient and preparation for the examination(eg:-ring
necklace)
 Instructed to sit or stand according to need
 Instructed to inspire or expire
 Not to ask unnecessary questions
 Requestnot to move
 Making them comfortable and convincing

5.  Aftercare
 Not to move patient unnecessarily immediately after examination
 Convince patient to wait outside for report for few min
 During giving report request patient to go to Dr room again for the
diagnosis.
Modifications oftechniques
 During practical we have to modify differenttechniques
 Incase of unstable patient we have to do CXR AP incase of PA
 Full inspiration and and expiration is not checked every time
 Rotation is done according to mobility
 In RTA cases all the views are taken in supine(CXR ,C-spine , skull
lat as trans lat)

6. INTRAVENOUS UROGRAPHY
INTRODUCTION
 Radiologic Investigations of the renal drainage, or collecting system
are performedby various proceduresclassifiedunder the general term
Urography.
 There are three technique for urography which are:
 Intravenous Urography
 Antegrade Urography
 Retrograde Urography
 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 togetherwith calyces,renal
pelvis, ureters and bladders.
 It is also known as ExcretionUrography.
 Previously the study was known as Intravenous Pyelogram (IVP)
suggesting the study of renal parenchyma(i.e. renal pelvis and
calyces),howeverthis study is not limited to these structures only, so,
IVP is a misnomer.
 Now, the term “Pyelogram” is reserved for studies visualizing only the
collecting system.

7. Terminology
 Urogram
Visualization of kidney parenchyma, calyces and pelvis resulting
from IV injection of contrast.
 Pyelogram
Describes retrograde studies visualizing only the collecting system.
So, IVP is misnomer,should be IVU
 Cystography
Describes visualization of the bladder
 Urethrography
Visualization of urethra
 Cystourethrography
Combined study to visualize bladderand 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
to patients!

8. ANATOMY INCLUDED
 Organs of the Urinary System:
 Kidneys 2
 Ureters 2
 Urinary Bladder 1
 Urethra 1
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

9. position. The right kidney is positioned slightly lower than the left
because of the mass of the liver.
Internalstructure
• Within the dense,connective tissue of the renal capsule,the kidney
substance is divided into an outer cortex and an inner medulla.
• 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.

10. • Renal pelvis-the dilated upper portion of the ureter that receives the
major calyces.
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 colonlie 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.
• Superiorly, the adrenal glands are sited on the superior surface of each
kidney.
• Inferiorly. Coils of small bowel supported on their mesenterylie 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.
URETER
• 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
posteriorbase of the bladder.

11. • Are constructed so that urine passes along them by peristaltic action.
• There is an inner lining of mucous membrane supported on a
submucosallayer, 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.
BLADDER
• Bladder is situated in the anterior part of the pelvic cavity, behind
and just above the symphysis pubis.
• Exact positiondepends 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.
• The ureters enter the postero lateral angles of the base and the
urethra leaves inferiorly at the narrow neck.
• The interior of the bladderis covered with mucous membrane which
thrown into folds,exceptin the trigone between the ureteric orifices,
• in the contracted state and stretched more smoothwhen the
bladderis distended.

12. RADIOGRAPHIC ANATOMY
Pelvic calacyealsystem
 There are usually seven pairs of minor calyces,
 Minor calyx pairs combine to form two or three
major calyces,which in turn drain via their
infundibula to the pelvis.
 The pelvis may be intrarenal or partially or entirely
extrarenal.
 The hilum of the kidney lies medially, that of the left
at L1 vertebral level and that of the right slightly
lower at L1/L2 level, owing to the bulk of the liver
above.
 At the hilum, the pelvis lies posteriorly and the renal
vein anteriorly with the artery in between.
1. Right upper-pole (major) calyx
2. Right middle (major) calyx
3. Right lower-pole (major) calyx
4. Left upper-pole (major) calyx
5. Left lower-pole (major) calyx
6. Minor calyx (infundibulum of)
7. Papilla
8. Infundibulum
9. Fornix
10. Bifid left renal pelvis
11. Right renal pelvis
12. Right ureter
13. Left ureter: vascular impression
14. Upper pole right kidney15. Right
psoas outline
16. Gas in body of stomach
17. Gas in transverse colon
18. Intravesical ureter

13. INDICATIONS
 Suspected urinary tract pathology
is one of the most common pediatric infections. It distresses the child, concerns
the parents, and may cause permanent kidney damage.
 Ureteric fistulas
is an abnormal connection between two hollow spaces (technically,
two epithelialized surfaces), such asblood
vessels, intestines, or other hollow organs
 Strictures
Narrowing of the urethra caused by injury,
instrumentation, infection and certain non-infectious
forms of urethritis
 persistent or frank hematuria
presence of red blood cells (erythrocytes) in the urine
 Suspected transitional cell carcinoma
 Renal/ ureteric calculi(Nephrolithiasis)
Refers to calculi in the kidneys, but renal calculi and
ureteral calculi (ureterolithiasis) are often discussed in
conjunction. The majority of renal calculi contain calcium.
 Duplex collecting system
Incomplete fusion of upper and lower pole moieties
resulting in complete or incomplete duplication of the
collecting system

14.  Hydronephrosis
refers to distension and dilation of the renal
pelvis and calyces, usually caused by urinary
retention due to obstruction of the free flow
of urine from the kidney
 Complex UTI(including tuberculosis).
 Renal papillary necrosis (RPN)
an ischemic coagulative necrosis involving variable
amounts of pyramids and medullary papillae. RPN never
extends to the renal cortex.
 Congenital ureteropelvic junction (UPJ) obstruction
 Pyonephrosis
The presence of clinical signs of infection with
hydronephrosis on CT is considered a more sensitive
indicator of pyonephrosis than many of the CT findings
alone .
 Pyonephrosis
asymptomatic or When symptomatic, symptoms include
recurrent urinary tract infections, stone formation and
even a palpable flank mass.
 conginital abnormalities
 Neurological disorders affecting urinary tract
a problem in which a person lacks bladder control due to a brain, spinal cord, or
nerve condition.

15.  Enuresis(involuntary urination) and H/o recurrent UTI
Repeated inability to control urination
CONTRAINDICATIONS
1. Allergy
Any patient with a predilectionto allergic reactions may predispose
them to a reaction after the administration of contrast media. Given the
increased risk of severe life-threatening anaphylaxis related to the
administration of contrast media in the setting of history of atopy, the risk
versus benefits should be discussedbeforefollowing through with the
procedure.A premedicationregimenmay be used to reduce the risk of
anaphylaxis.
2. Asthma
A history of asthma may be indicative of a higher likelihood of
developing a contrast reaction
3. Cardiacstatus
Attention must be turned to patients with significant cardiac disease
(congestive heart failure, aortic stenosis,severe cardiomyopathy,
and/or pulmonary hypertension), as higher volumes and osmolality of
contrast material may result in an increased risk for a contrast reaction.
4. Renal insufficiency
The major predisposing risk factors include pre-existing renal
insufficiency(defined as serum creatinine level > 1.5 mg/dL)and
diabetes.Other risk factors include dehydration, cardiovascular disease,
the use of diuretics, advanced age (>70 years old), hypertension, and
hyperuricemia.Obtaining multiple contrast-enhanced studies within a 24-
hour period is also thought to increase the risk for contrast-induced
nephrotoxicity

16. 5. Miscellaneous
Relative contraindications to the use of high osmolality iodinated
contrast media (HOCM) in patients with pheochromocytoma,sickle cell
disease,and multiple myeloma have been reported.Although the
administration of low osmolality or iso-osmotic contrast media may be
beneficialin patients with pheochromocytomaand sickle cell disease,little
evidence suggests that these agents mitigate the risks associated with
multiple myeloma.
Contraindications to compressioninclude the following:
 Evidence of obstructionon the 5-minute image
 Abdominalaortic aneurysm or other abdominal mass
 Severe abdominal pain
 Recentabdominal surgery
 Suspectedurinary tract trauma
 Presence of a urinary diversion
 Presence of a renal transplant
PotentialContrastReactions(and treatments for)
Though the incidence is lessened,reactions to nonionic contrast
injections are the same as for ionic agents. Most reactions occur within 5
minutes of injection.
Staying calm and reassuring is imperative to the patient’s well being.
Mild:
metallic taste nausea
Dizziness vomiting (emesis basin)
flushing (slow, deep breathing) chills (blanket warmer)
Diaphoresis vasovagal (fear of needles)

17. Moderate: urticaria (benadryl) swelling of parotids
facial edema transient bronchospasm
transient hypotension delayed skin reaction (keep patients
20 min)
headache tachycardia
Severe: prolonged hypotension/circulatorycollapse (Adrenaline
[epinephrine] improves cardiac output and relaxes bronchial smooth
muscles).
pulmonary edema arrhythmias (Inderal)
angina (nitroglycerine) convulsions
severe bronchospasm (adrenaline) coma
cardiac arrest (sodium bicarbonate) paralysis
Death
Precautionsfor Adverse reaction
The safestmethod is to Consider an alternative imaging method if possible,
if not then:
 Should Use a non-ionic low or iso-osmolarcontrast agent.
 For patient with H/O previous CM rxn, use differentnon-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 supervisionand leaving the cannula in place and
observing for 30 min.
 Be ready to treat promptly any adverse reaction and ensure that
emergencydrugs, equipmentand doctors are ready

18.  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-assessedbefore
restarting metformintreatment.
 If the patient is asthmatic, premedicationin the form of steroids is
administered 2 days prior.
METERIALS USED
Venipuncture
 contrast (amount dependenton bodyweight, typically around 100cc)
 syringes
 butterfly needles (19 or 21 gauge)
 venipuncture arm board
 alcohol wipes
 tourniquet

19. Reaction supplies
 emesis basin
 towels
 emergencydrugs/crashcart
Filming
 lead marker set

20.  compressiondevice
 10” x 12” & 14” x 17” cassettes
 gonadal shields
 positioning sponges
CONTRAST MEDIA
 Non-ionic, Iodinated,Watersoluble,LOCM or IOCM
 Usually omnipaque and ultravist is used.
CM Dose:
 For adult:
 1ml/kg body weight for concentration of 300mgI/ml
 The concentration can be increased upto 600mgI/mlif the
patient is well hydrated.
 For Children(2-12 years)
 1.5ml/kg bodyweight 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
PATIENT PREPERATION
 No food for 4-6 hour prior to examination.
 Bowel prep is considered as not necessarybecause 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

21. 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
 Properhistory of patient must be taken, like allergic reactions, asthma,
diabetes,etc. and precautions should be taken accordingly.
 Traditionally, dehydration prior to IVU was done in order to improve
opacificationof collecting system.But due to the developmentof quality
and content of contrast media, (non-ionic contrast medium )dehydration
is not necessaryfor the opacificationinstead,
 It increases risk of nephrotoxicity which may be permanent in
patients with
Diabetes mellitus
Multiple myeloma (cancer formed by malignant plasma cell).
Hyperuricemia
SCD(scikle cell disease)
Pre-existing renal disease,Thereforedehydration is not
suggestednowadays.
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.
 need for IV contrast material
SIGNING INFORMED CONSENT FORM

22.  Venipuncture is an invasive procedure that carries risks for
complications,especially when contrast media is injected. Before
beginning the procedure,the technologistmust 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 consentform.
RADIATON PROTECTION
 “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 bladderand 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.
Technique
Exposures are generally in the 65-75 kV range, mA of 600-1000,with
exposure of <0.1 sec.Higher kV ranges reduce contrast of the renal
parenchyma.
 IV access is required for administration of a water soluble contrast
o nonionic contrast is preferred
 dose will vary as per the weight of the patient; generally up to 1.5 ml/kg
body weight is well tolerated by patient

23. 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 moststable, 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.
PROCEDURE

24.  The exact protocolfor IVU will vary according to the department,
however the standard protocolforIVU is summarized as:
1. Preliminary film
2. CM administration
3. Nephrographic film
4. 5 min renal film
5. Abdominalcompression
6. 10 min Renal and upper urinary tract film
7. 15 min release film of ureter and bladder
8. Bladder image
9. Modifications can be used in any steps if the image is not
satisfactory.
1- Preliminary/ScoutFilms
 Supine, full length AP of abdomenis taken.
 To demonstrate bowel preparation, check exposure factor, and
location of radiopaque stones or any radiopaque artifacts.
 If necessarythe 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° posterioroblique views, or,
 Tomographyof 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 proceeduntil these films are reviewed by
radiologistand claimed satisfactory.

25. 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.

26. 5-min film
 AP of renal areas.
 To determine if excretion is symmetrical and is invaluable for
assessing the need to modifythe technique, e.g. a further injection of
CM if there has been poorinitial opacification.
 It Shows nephrogram, renal pelvis, upper part of ureter.
 Compressionband is now applied around the patients abdomen
positioned midway between the ASIS i.e. preciselyover the ureters as
they cross the pelvic brim. The aim is to produce better pelvicalyceal
distension.
Compressionis 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.
10 min compression film:
 AP of renal areas.
 There is usually adequate distensionof the pelvicalyceal systems
with opaque urine by this time.

27.  Compressionis released when satisfactorydemonstration of the
pelvicalyceal system has beenachieved.
15 min film/Release film:
 Supine AP KUB.
 This film is taken to show the whole urinary tract.

28. Full bladder film:
 Coned view of bladderarea 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
After micturitionfilm:
 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:
 Assessbladderemptying/To see the Residual vol of urine
 To demonstrate VUR
 Aid diagnosis of VUJ calculi
 Dx of bladdertumors
 Demonstrate urethral diverticulum.

29. ADDITIONAL FILMS
Oblique films
 Posterioroblique 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.

30. 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 dependentpart) 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.
AP with caudalangulation:
 Position:AP position, film of kidney area with 25° caudal tube
angulation.
 To separate the over shadows by stomach on left kidney.
Erectfilm:
 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.
AP with caudalangulation:
 Position:AP position, film of kidney area with 25° caudal tube
angulation.
 To separate the over shadows by stomach on left kidney.

31. Erectfilm:
 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.
Delayed films:
 This can be Considerable upto 24 hours.
 It is done in c/o significant acute obstructionwhen 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 necessaryto 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 opacificationof 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 suspicionof ureteric colic is to omit all films after contrast until a
full length 15 min film is performed.

32. MODIFICATIONS
In case of Pregnancy:
 Rarely necessaryto 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.
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.
 Abdominalcompressionnot used.
 To improve visualization of left kidney child can be given a
carbonated beverage.
 The right kidney can be well seenthrough the liver in a 15-20 degree
caudal tilted view.
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.
Emergency urography:
 Done in cases of urinary colic.Films taken:
- Preliminary KUB and 15 min film after CM injection.

33. IN CASE OF PATHOLOGY/ABNORMALITIES
 In case of VUJ obstruction:
- Oblique film of bladderarea of obstructionside 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 bladderarea can be taken.
 Vesicovaginal fistula:
- lateral film of bladder area can be taken.
 In case of Hypertension:
- Minute sequence urogram is performedwhere, Films taken at
1,2,3,5 mins after injection of contrast media

34. AFTERCURE
 General psychologicalreassurance.
 Needle wound site dressedand 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.
 Escortto changing rooms and bid good-bye.
COMPLICATIONS
Due to CM:
 Reactions due to CM: mild, moderate and severe.
Due to technique:
 Incorrectlyapplied abdominal compressionmay produce intolerable
discomfortor hypotension.
 Swelling ,pain and infection during injection
 Extravasation of CM

35. ADVANTAGES
 Can show non-opaque stones as filling defects.
 rapid overview of the entire urinary tract,
 detailed anatomy of the collecting system,
 demonstration of calcifications,
it is sensitive for obstruction,and
 low cost,
DISADVANTAGES
 Requires a significant amount of radiation exposure and may not be
ideal for young children or pregnant women
 May not have sufficient opacification to define the anatomy and
point of obstruction.
 multiple delayed films (Can take hours as contrast passes quite
slowly into the blocked renal unit and ureter.)
 may provoke an allergic response
 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.
Congenitalanomalies
 Renal agenesis
 Supernumerary kidney
 Ectopic kidney (pelvic, intrathoracic)
 Crossed ectopia

36.  Horseshoe kidney
 Duplex kidney
 Ureterocele
What are the risks of intravenous pyelogram?
The dyes (also called radio contrast media) are of 2 types: ionic and
nonionic. Both types of dye contain iodine but differin 2 key ways: the rate
of adverse reactions and the cost.
Although the overall rate of adverse reactions is relatively low with both,
there is a greater incidence of adverse reactions with the less expensive
ionic dye than with the nonionic.
 Minor reactions, which are infrequent and do not last long, include
flushing, nausea, vomiting, and itching.
 A small percentage of people experience asevere reaction to the dye,
such as difficultybreathing, speaking, or swallowing; swelling of the lips
and tongue; low blood pressure;or loss of consciousness.People who
have had a severe reaction after receiving the dye once should not be
exposed to it again.
 Pregnant women should not have an IVP because of the risk
of radiation exposure to the unborn baby.
 People with known kidney disease or failure should not have an IVP
because the dye can worsen kidney function.
 Elderly people and those with diabetes,high blood pressure,heart
disease,or evidence of dehydration are at risk of developing kidney
failure following administration of the dye.
o To avoid this complication,the kidney function should be tested with a
blood test for creatinine, and the results should be known before the
IVP is performed.
o Those with diabetes who are taking metformin(Glucophage) will have
to discontinue this medicationprior to and for 2 days after the IVP.
They should inform their doctorof the test, and the doctorwill
coordinate their management during that time.

37. Retrograde pyelography
Retrograde pyelography (also known as retrograde
pyeloureterography)is a method of imaging the upper urinary collecting
system. After IVU and CTU were developed, it has been rarely performed
as a primary study, but it still has a few potential indications as a secondary
study.
Indications
 nonvisualization of ureteral segmenton IVU and CTU
o if there is still clinical concern for evaluating the collecting system
after an IVU or CTU, a retrograde pyelogram may be able to better
image the segmentof ureter
 better characterization of ureteral or pelvicalyceal abnormalities seen
on IVU or CTU
 access forbrush biopsies of a suspicious area of urothelium
Procedure
A catheter is placed in the ureter of interest, with its tip positioned at the
distal ureter. Water-soluble contrast appropriate for the urinary system is
instilled slowly to gently distend the upper collecting system.Spot images
are obtained of areas of interest.
Distention of the upper collecting system is painful, so overdistention is
avoided. Overdistentionalso results in pyelosinus and pyelovenous
backflow, degrading the image.
The patient may need to be rolled into decubitus positions to fill out the
lower pole calyces.
Post void images are obtained.

38. History and etymology
Retrograde pyelography was the first method devised forimaging the
urinary collecting system, and until the developmentof early IVU agents in
the 1930s,it was the only way of imaging the collecting system.
CONCLUSION
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.
REFRENCES
 GOOGLE
 A guide to RADIOLOGICAL procedures.
-CHAPMAN AND NAKIELNY
 Textbook of RADIOLOGY and imaging
-SATISH K. BHARGAVA.