Retrograde pyelography is an x-ray imaging technique used to visualize the kidneys and ureters. A catheter is inserted into the ureter and contrast dye is injected under fluoroscopy. Images are taken of the renal pelvis, ureters and bladder. It is used to evaluate abnormalities seen on intravenous urograms or investigate causes of hematuria when the ureters were not fully visualized. The procedure has some risks but is less risky than intravenous urography. It can demonstrate various conditions like ureteral strictures, filling defects, diverticula or stenosis. Care is taken during injection to avoid overdistension and complications.

1. Retrograde Pyelography
Dr. Yash Kumar Achantani
OSR

2. DEFINITION
It is the roentgenographic demonstration of the renal
pelvis and ureter by the retrograde injection of radio-
opaque material through the ureters.

3. INDICATIONS
• Absent or unsatisfactory visualisation of the
collecting system on IVU.
• Unexplained hematuria, when the ureters have not
been completely visualised by IVU.
• Evaluating persistent intraureteral or intrapelvic
filling defects on IVU.
• Demonstrating the exact site of ureteral fistula.
• Brushing and/ or biopsy of suspected lesions.
• Evaluating the collecting system in patients who
cannot receive intravenous contrast medium

4. CONTRAINDICATIONS
• Acute urinary tract infection.
• Recent instrumentation.
• Pregnancy

5. CONTRAST MEDIUM
• Ionic contrast media can be used safely, however if
there is any specific contraindication like known
hypersensitivity etc., Non ionic contrast media may
be used. The Ionic contrast media is preferred due to
its low cost. The strength of contrast media should be
150-200 mg/ml.
• Contrast media should not be too dense as it will
obscure small lesions in the ureters and the pelvis

6. PROCEDURE
Patient Preparation
• Bowel preparation with cathartics is not routinely
performed.
Preliminary Film
• Full length supine AP abdomen before the
examination is started.
Anaesthesia
• May be performed under local anaesthesia although
general anesthesia is often required. Sterile
precautions are mandatory.

7. Technique
• The surgeon catheterizes the ureter via a cystoscope
and advances the ureteric catheter to the desired level.
Contrast medium is injected under fluoroscopic
control and spot films are exposed.
• Urine is aspirated and under fluoroscopic control
contrast medium is slowly injected. About 3-5 ml is
usually enough to fill the pelvis but the injection
should be terminated before this if the patient
complains of pain or fullness in the loin.

8. Films
(a) Supine PA film of the kidney
(b) Both 35° anterior obliques of the kidneys. Low kVp
(65-75 kVp) technique is used to visualise calculi and
contrast medium.
(c) If there is pelvi-ureteric junction obstruction, the
contrast medium in the pelvis is aspirated. The films are
examined and if satisfactory, the catheter is withdrawn,
first to 10 cm below the renal pelvis and then to lie
above the ureteric orifice. About 2ml of contrast
medium is injected at each of these levels and films
taken.

9. AFTER CARE
1. Postanaesthetic observation.
2. Prophylatic antibiotics may be used.

10. COMPLICATIONS
• Complications of general anaesthesia.
• Contrast medium can be absorbed from the renal
pelvis, giving rise to adverse reactions. However, the
risks are much less than with excretory urography.
• Chemical pyelitis-if there is stasis of contrast
medium.
• Extravasation due to overdistension of the pelvis.
• Introduction of infection.
• Mucosal damage to the ureter.
• Perforation of the ureter or pelvis by the catheter.

12. On the scout image, there are ureteral catheter positioned in the
transplant ureter (right) and native left ureter.
Normal retrograde
pyelography of a
native and transplant
kidney

13. The transplant ureter, the ureteral anastomosis, and the distal right
ureter are normal in appearance.
Other than mild blunting of the left renal calyces, the left ureter and
upper collecting system are also normal.

14. Retrograde pyelogram demonstrating
the pelvicalyceal system and ureter down
to the vesicoureteric junction.

15. Retrograde pyelogram with pyelosinus extravasation due to
overdistension of the collecting system.

16. Retrograde pyelogram shows rounded filling defects in many
calyces representing papillary necrosis.

17. Goblet sign or
Champagne glass sign:
• irregular ureteric
narrowing with proximal
shouldering termed the
goblet sign
• Focally dilated
intraluminal mass
Causes of goblet cells
• TCC of ureter
• Metastatic disease in to
ureter
• Endometriosis involving
ureter

18. A case of TCC
Filling defect is seen in the
right ureter –
RAT BITE SIGN

19. URETERAL
STRICTURE

20. Retrograde pyelogram shows the area of narrowing at the site
of ureteral implantation into the bladder (arrow).

21. URETERAL DIVERTICULA

22. URETERAL STENOSIS
Two views of the retrograde pyelography showing stenosis of the
lower portion of the right ureter at the level of the iliac vessels. There
is severe dilatation of the medial and proximal portions of the right
ureter and hydronephrosis.