IVU is the radiographic examination of urinary tract including renal parenchyma, calyces and pelvis after intravenous injection of contrast media. Study was carried out at UCMS, Bhairawa, Nepal.

1. Presenter = Sandip Gautam
Bsc.MIT 1st Batch , 4rth year
UCMS, ( TUTH ), Nepal

2. URINARY SYSTEM ; ANATOMY

3.  Cross-section of kidney;-

5. Anatomy – Urinary System
 Extends from kidneys to urethral meatus
 Comprised of kidneys, ureters ,the bladder and urethra
 Kidney: Kidneys situated in the lumbar region ,either side
of vertebral column, between 12th thoracic and third
lumbar vertebrae and are behind the peritoneum.
 Both kidneys are oblique in position, with their upper pole
near the vertebrae and lower poles more anteriorly than
upper poles.
 Apprx 10 cm in length
 Right kidney placed 1cm lower than the left kidney
 Kidneys consists of outer cortex and inner medulla
containing million of nephrons with complex filtering
system and minute blood vessels.
 Urine flows into collecting system and into calyces which

6. Contd
 Ureters : Ureters are approx 25-30cm in length and
extend downward from renal pelvis at the level of second
lumbar vertebrae, usually overlying the tips of the
transverse processes, to the pelvis.
 Ureters sweep anteriorly around the pelvic sidewall, finally
approaching the midline to terminate in the ureteric orifice,
2.5cm apart in the posterior wall of the bladder
 Bladder: Bladder is situated in the anterior part of the
pelvic cavity, behind and just above the symphysis pubis.
Its exact position depends on the degree of distension.

7. INTRODUCTION
 IVU is the radiographic examination of urinary tract
including renal parenchyma, calyces and pelvis after
intravenous injection of contrast media.
 Intravenous pyelogram (IVP) is a misnomer as it implies
visualization of pelvis and calyces without the parenchyma.
The term pyelogram is reserved for retrograde studies
visualising only the collecting system.
 Contrast excreted by kidneys, rendering the urine opaque to x-
rays and allowing visualization of the renal parenchyma together
with the calyces, renal pelvis, ureters and bladder

8. Contd.
 Is better termed excretion urography rather than
intravenous pyelography (IVP) because with the
modern methods, the whole urinary tract and not just
the pelvi-calyceal system is demonstrated.
 Depends upon the ability of the kidney to concentrate
and excrete circulating contrast media.
 Is much less frequently used than in the past, being
largely replaced by CT, MRI, and US.

9. INDICATION
S
 To evaluate abdominal masses ,renal cysts and renal
tumours,
 To rule out urolithiasis (calculi or stones of the kidneys
or urinary tract),
 To find out abnormal dilation of the pelvicalyceal
system (i.e.Hydronephrosis),
 To evaluate the effect of trauma,
 Preoperative evaluation of the function, location,size and
shape of the kidneys and ureters,
 Pyelonephritis (infection of the upper urinary tract that
may be acute or chronic haematuria, pyuria),
 Renal hypertension(to evaluate functional symmetry of
the renal collecting system)

10. Contd.
 Duplicate collecting system (two renal pelvi or
ureters from the same kidney),
 Horse shoe kidney (fusion of the kidneys usually at
the lower pole),
 TB of the urinary tract,
 Malformation of the urinary tract ;e.g.polycystic
disease, PUJ obstruction, VUJ obstruction,
 Ectopic kidney.
 Renal Colic or flank pain
 Screening of entire tract especially in cases of
haematuria or pyuria.

11. Indications for children:
 VATER anomalies: These patients have vertebral,
anal, tracheo-oesophageal, and renal anomalies.
Renal anomalies are seen in 90% of patients.
 Malformation of urinary tract, eg Polycystic disease
 Neurological disorders affecting urinary tract
 Malformation of genitalia, family history of urinary
tract anomalies, urinary tract infection
 Anorectal anomalies
 Differentiation of function of both kidneys

12. Contraindications
 Pregnancy,
 Advanced renal failure,
 History of severe reaction to the contrast media,
 Iodine sensitivity,
 Cardiac diseases

13. Can be performed with caution in the following
cases;-
 Diabetic patients,
 Very small children,
 Patients with sickle cell disease,
 Myelomatosis
 Patients with previous reaction to the CM (except
severe).
IN THESE CASES NON-IONIC LOCM SHOULD BE
USED.

14. Contrast media and its doses
 Ionic and non-ionic contrast media are available.
 Both are excreted by different mechanisms , The ionic group is
excreted mainly by glomerular filtration causing a peak
concentration of Iodine in the renal cortex faster compared to
nonionic which is mainly excreted by proximal tubules.
 If possible non-ionic LOCM contrast media are used as it
causes less nephrotoxicity than the ionic contrast media inspite
of having lower cost.
 300mg to 600mg I equivalent/kg body weight contrast media
can be used.
 Dose: For adult: 50-100ml ( 1ml/kg)
For children: 1ml/kg

15. Most commonly used CM
Non-ionic CM are
1 Omnipaque (iohexol) 300 or 350mgi/ml
2 0ptiray (ioversal) 300,320 or 350mgi/ml
3 Ultravist (iopromide) 300 or 370mgi/ml
Ionic CM are
1 Urograffin (sodium meglumine
diatrizoic acid)
60%meg+Na
76%meg+Na(w/v)

16. Patient’s preparation:-
 Ask for any history of Diabetes mellitus,
Pheochromocytoma, Renal disease, or allergy to
drugs and any specific foods.
 No food for 6-8 hrs. prior to the examination.
 Whenever possible the patient should be ambulant
so as to avoid the accumulation of intestinal gas.
 Fluid restriction is contra-indicated in patients who
are in renal failure or who have myelomatosis and
for infants & children.

17. Contd..
BOWEL PREPARATION:
 Low residue diet eg non veg foods ,plenty of oral
fluids
 Laxatives,e.g.dulcolax (biscodyl) is recommended to
eliminate fecal matter from the colon and to reduce
amount of gas in the colon.
 This should be taken on each of the two preceding
nights.
 Castor oil is an effective catharsis when administered
in the dose of 30-60ml. Is contraindicated in the case
of abdominal case of unknown cause, old and
debilitated patients.
 In addition to oral laxatives, use of suppository in the
morning is also recommended.

18. Contd.
 The patient is asked to micturate immediately before
the examination.
 Before starting the examination,blood urea and
creatinine level should be checked,it should be in
normal range.
 The report of the US done before the examination,
makes the examination easier so patient should
brought the report.

19. Mode of contrast injection:-
 It is usually given as a IV bolus injection within 30 to
60 seconds.
 The density of the nephrogram is directly
proportional to the plasma concentration of contrast
media.
 More iodine increases the density of the
nephrogram.

20. Radiation Protection:
 “Pregnancy” rule should be followed i.e 10 days rule .
Exposure must be taken within 10 days of menstrual
cycle before ovulation.
 If whole of the 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 ureter are not included then
female can also be given gonad protection.
 More number of exposures should be avoided to limit
radiation hazards.

21. Procedure:-
 Patient is placed in supine position with pelvis at the
cathode side of the tube.
 A scout (control) film is taken including the kidneys,
ureters, bladder on a large size film.
 Contrast media is injected intravenously into a
prominent vein in the arm.

22. Contd.
 Test injection of 1ml of contrast is given and patient
is observed for any contrast reactions.
 Then, the rest of the contrast is rapidly injected within
30-60 seconds

23. Filming technique:-
 STANDARD PROTOCOLS:-
 Plain x-ray KUB/Scout film
 Immediate film
 5 min film
 If compression is applied : 10 min film
 15 min film
 35 min film
 Full bladder film
 Post micturation or post void film

24. Plain X-Ray KUB/Scout film
 It provides valuable information and sometimes indicates probable
diagnosis.
 Plain film is to demonstrate the urinary tract prior to administration of
contrast medium.
 Supine full length AP film of the abdomen in inspiration is taken.
 To show calcification which may be later masked by contrast media.
 To check exposure factor – KVp should be low to increase chance of
detecting calcification in the urinary tract.
 Small renal calculi may be hidden by bowel shadows – so at least
two views of renal area may be required.
 Simple routine: - To expose a full length radiograph in inspiration
-Coned view of kidney in expiration
The change in position of the kidneys at these different phases
of respiration will show whether a calcification is intrarenal because
its position is constantly related to kidney.

25. Contd..
 Pelvis should be adjusted so that the anterior superior iliac spines
are equidistant from table top.
 Lower border of cassette should be at level of symphysis pubis.
 Centring- mid point of line joining to ASIS – directed to the centre of
casette.
 Place a radiographic markers to assist anatomy
It is also useful in assessing followings;-
 Calculus,
 Intestinal abnormalities,
 Intestinal gas pattern,
 Calcification,
 Abdominal mass and
 Foreign body.

27. Immediate film
 This is AP view of the renal areas.
 This film is exposed 10-14 seconds after the
injection(approximate arm to kidney time).
 It aims to show the nephrogram,i.e.the renal
parenchyma opacified by contrast medium in the renal
tubules.
 Fast bolus arriving at glomeruli will produce a high
concentration in nephrons and thus a denser
nephrogram

29. 5 min film
 It is also called pyelogram.
 It shows the nephrogram,renal pelvis,upper part of
the ureters,AP of the renal areas.
 This film is taken to determine if excretion is
symmetrical and is invaluable for assessing the
need to modify the technique e.g. a further injection
of contrast medium if there has been poor initial
opacification.

31. Contd..
 A compression band is now applied around the
patient`s abdomen and the balloon positioned
midway between the anterior superior iliac spines
i.e.precisely over the ureters as they cross the pelvic
brim.
10 min film:
 The aim is to produce better pelvicalyceal distension.
 If compression is applied ,a film is taken after 5
minutes of compression i,.e.10 min film centred on
kidneys .
 It is done to demonstrate distended collecting
system and proximal ureters.

32. Contd.
Compression is contraindicated in the following
cases;-
 after recent abdominal surgery,
 after renal trauma,
 if there is a large abdominal mass,
 when the 5-min film shows already distended
calyces

34. 15 min film
 Visualization of complete ureters, including
kidneys and bladder, are seen in this film.
 If the ureters have not been well demonstrated,
prone film at this stage may be helpful.
 Visualizations of the ureter is better in prone
position as they fill better.

36. 35 min film:
 It gives complete overview of the urinary tract,
kidney, ureter, bladder.
 Bladder distension can be evaluated.

37. Full bladder
•To evaluate the
shape of urinary
bladder
•To visualise
compressive
pathology

38. Post void film(Post micturition film)
 This film taken immediately after voiding.
 It is used to assess for following;-
 Residual volume,
 Bladder mucosal lesions,
 Diverticula,
 Bladder tumour,
 Outlet obstruction,
 VUR(vesico ureteric reflux)
 ALL FILMS ARE TAKEN IN FULL EXPIRATORY PHASE
ONLY.

40. Special films in IVU
Oblique view;-
• To project the ureter away from spine .
• To separate overlying radio opaque shadows
mimicking calculi.
• To visualise posterolateral aspects of bladder.
• To differentiate ureteral or bladder masses.

41. Contd…
Prone film;-
 To see ureteral areas not seen in supine
films.
 To demonstrate renal ptosis and bladder
hernia.

42. Contd..
Erect film;-
• To provoke emptying of urinary tract.
• To demonstrate layering of calculi in cysts and
abscesses.
• To detect urinary tract gas not seen in other
films.

43. Contd..
 Delayed films;-These are taken 1-24 hours after
injection. Patients should always be instructed to
void prior to delayed films so that a calculus in the
distal ureter is seen well.
 Usual sequence of delayed films is after 1hr, 3hrs,
6hrs,12hrs and 24hrs.

44. Contd…
Delayed films are used in:
• Cases of obstruction where early nephrogram is seen
but collecting system is not seen.
• Long standing hydronephrosis in which renal
parenchyma is seen but collecting system is not
visualised until many hours later.
• Congenital lesions like non-visualised upper calyceal
system with ectopic or obstructed ureter.

45. Filming in
children
 Films are taken at 2 min (supine) and 7 min
(prone) after contrast administration.
 To improve visualization of left kidney, either
carbonated beverage can be given to the child as
gas filled stomach displaces bowel or right
posterior oblique view is taken.
 The right kidney can be well seen through the liver
in a 15-20 degree caudal tilted view.

46. Modifications of urogram
1.Diuretic urogram;-
 Useful when intermittent obstruction is
suspected but cannot confirmed by standard
urogram. Therefore the use of diuretics shows
an acutely developing hydronephrosis if true
intermittent hydronephrosis is present.
 I.V. Frusemide (lasix) is used to induce diuresis
which distends the renal pelvis.
 The dose of Lasix is 0.3-1mg/kg in adults and
0.5mg/kg in children.
 The film is taken 5-10 min after administering the
diuretic.

47. Contd…
2.Tailored urogram;-
 It modifies the urogram to provide the
information needed to include or exclude the
clinical problem and tailor the urogram for that.
 The study is terminated as soon as the desired
information is available.

48. Contd..
3.Hypertensive urogram;-
 It is also called minute sequence urogram.
 Films are taken 1,2,3,5 min after injection of CM.
 Although the findings are of value, IVU cannot be
used for screening of hypertensives as there are
many false positive and false negative results.
4.Limited urography;-
 Is useful for follow up of earlier pathology.
 Films taken;KUB,15 min, post void.

49. Contd.
5.Emergency urography;-
 Done in case of urinary colic.
 Films taken ;KUB,15 min.
6.High dose urography;- Done in case of
 Renal failure
 Ureteric obstruction
 Poor bowel preparation
 Retrocaval ureter
 Suprarenal tumours
 Percutaneous nephrostomy
 Emergency urography

50. Contd..
 Used in mild renal impairment,it provides more
information about calyces than on US/CT.
 If US/CT cannot exclude obstruction(e.g.in
presence of multiple cysts)
Note;-
Patient should be well hydrated with normal
metabolic and CVS function at the time of the
procedure. Low osmolar non ionic contrast
media should be used.

51. Contd..
7) Drip infusion urography:-
 Contrast is given in 500 ml normal saline. Now , this procedure is not widely used.
Advantages;-
 Nephrogram persists for longer time.
 Enhanced diuresis from the additional contrast media and water volume will distend
the collecting system and ureters more fully.
 Collecting system is visualized for longer times.
 No significant increase in contrast reaction.
 Ureteral compression need not to be used because excellent ureteral visualization is
usually obtained.
 Administration is easy
Disadvantages:-
 Overloads the patient with more Iodine than necessary.
 Calyceal blunting may be produced, suggesting abnormal dilation.
 May lead to pyelosinus extravasation and pain in patients with partial obstruction.
 Increased diuresis may decrease visualization if there is low fixed specific gravity.
 An initial vascular nephrogram is not obtained.

52. Contd..
Two basic rules should always be remembered;-
make sure that the drugs are available for
treatment immediately before the contrast
injection.
When contrast drugs have been injected
intravenously, never leave the patient alone until
the examination is completed and the patient
feels well.

53. Required drugs ( to avoid complications and
reaction )
Appropriate emergency drugs and equipments must
always be readily available are;-
 Antihistamines: targets the histamine H1 receptor and
used to treat allergic reaction
 Steroids: reduce inflammation asssociated with allergies
 Epinephrine: used to treat allergic reactions . Improve
breathing, stimulate heart, raise a dropping blood
pressure, reduce swelling .
 Atropine: is a anticholinergic and reduce saliva and other
fluids secretions in the body
 Syringes
 Normal saline to open vein
 Oxygen cylinder

54. Contd.
 Complications may be due to technique and due to
contrast.
 Due to technique;-
-Upper arm or shoulder pain.
-Extravasations of contrast at the injection site.
 Treatment;-
 Elevation of affected extremity above the heart.
 Ice packs (15-60 min,3 times per day for 1-3days)
 Call to visit with referring physician (for any
extravasations over 5 ml)

55. Due to contrast
1) Mild (minor) reactions(5%);-
o Nausea, vomiting, mild rash, light headache,
sensation of heat
Management;-
 Reassure the patient
 Tell him/her not to worry; the rxn will soon go
away
 Loosen the patient’s clothing if it is tight
 Tell the patient to take deep breath in and out
 Give IM or IV antihistamine in case of allergy

56. Contd….
2) Moderate or intermediate reactions(1%);-
o may vomit,rapid pulse,may become very short of
breath,skin may be pale, extensive urticaria
Treatment;-
 Keep calm and reassure the patient
 Raise the patient`s head and shoulder if he is
short of breath
 If vomiting occurs, turn the patient’s head to one
side to prevent aspiration of vomit
 If there are signs of collapse(pale
skin,sweating,rapid pulse),raise the patient`s feet
and lower the head
 Stay with the patient all the time

57. 3) Severe reactions;-
o Pale skin,
o sweating,
o very swallow breathing,
o cardiac arrest,
o rapid and very weak pulse,
o loss of consciousness,
o convulsions,
o Coma,
o Myocardial infarction
These are emergency situation so must act quickly.

58. Contd.. (Severe reactions):
Treatment;-
 Call for the seniors
 Keep the patient warm and start artificial
respiration,if the patient stops breathing.
 If oxygen available ,give it to the patient if breathing
is difficult.
 If patient is not breathing, manage open airway,
heartbeat, start CPR.
 If pulse is slow, give IV atropine 0.01mg for an
adult.

59. Contd..
 If pulse is very fast, inject epinephrine 1:1000 IV
upto 1ml,start an IV saline infusion,repeat
epinephrine, inject 50 mg dexamethasone IV and
admitted in the ward.
AFTER CARE:
o Observation for 6 hours
o Watch for late contrast reactions
o Prevention of dehydration.
o In high risk patients-renal function tests should be
done to watch for deterioration.

60. Pathologies
1) Horse shoe kidney: In this disorder, the
patient's kidneys fuse together to form a horseshoe-
shape during development in the womb.

61. 2) Hydronephrosis:
 Hydronephrosis describes urine-filled dilation of
the renal pelvis and/or calyces as a result of
obstruction.

62. Strictures
:
 An abnormal narrowing of a bodily passage
 Intravenous urography showing lower ureteric
stricture (arrow head).

63. Nephrolithiasis:
 Nephrolithiasis (kidney stones) is a disease affecting the
urinary tract. Kidney stones are small deposits that build
up in the kidneys, made of calcium, phosphate and other
components of foods

64. Polycystic kidney
disease:
 Polycystic kidney disease (PKD) is an
inherited kidney disorder. It causes fluid-filled cysts to
form in the kidneys. PKD may impair kidney function
and eventually cause kidney failure. PKD is the fourth
leading cause of kidney failure

65. Renal
Tuberculosis:
 Tuberculosis of the genitourinary system-Urinary
tract tuberculosis

66. References:
1) A guide to radiological procedure, 5th edition
2) Radiological procedure a guideline, Arya
publication
3) Review of radiology , Rajat and Virendra
Jain
4) Wikiradiography
5) Slideshare.com
6) Various Net resources

67. Thank You