This study assessed the diagnostic value of obtaining an additional upright kidney-ureter-bladder (KUB) radiograph during routine intravenous urography (IVU). Of 164 patients who underwent IVU with an additional upright KUB, the upright view provided diagnostic benefit in 72 patients (43.9%), identifying issues like nephroptosis, better filling of the collecting system, differentiation of phleboliths from stones, and evaluation of emptying. While newer modalities have advantages, upright positioning remains a simple way for IVU to provide unique diagnostic information by leveraging gravitational effects.

1. Does an Extra Kidney-Ureter-Bladder (KUB)
Radiography Taken at ‘Upright Position’
During Routine Intravenous Urography
Provide Any Diagnostic Benefit?
Kamil Gurel, Safiye Gurel, Melike.E. Kalfaoglu, Cigdem Gökay
Abant Izzet Baysal University, Izzet Baysal School of Medicine,
Department of Radiology
Bolu/TURKEY

2. Introduction
• Intravenous urography (IVU) has long been
the main imaging evaluation of urinary tract
disease.
• However, the use of US, CT, and MRI has
surpassed the use of IVU in the last two
decades.

3. Introduction
• The declining use of IVU in clinical practice
presents a challenge for instruction in
urographic technique and interpretation.
• Nevertheless, IVU might still be important in
the diagnosis of some urinary tract disease
among other new modalities.

4. Purpose
• The aim of this prospective study is to
assess the value of taking a kidney-ureter-
bladder (KUB) radiography at upright
position during routine IVU in terms of
diagnostic benefit.

5. Methods and Materials
• September 2003-March 2006, 164 consecutive
patients were referred for IVU exam
In our department, a basal standart IVU exam
consists of totally 5 radiographies:
• Precontrast supine KUB
• Post-contrast supine KUB at 7th and 15th minutes
• Pelvic supine graphies for full bladder and post-voiding
• When needed, additional compression and/or oblique radiographies

6. • For all patients, an additional post-contrast
15th
min. upright KUB radiography was
obtained
• Two reviewers analyzed the 15th
min.
upright KUB comparing to 15th
min. supine
KUB radiographies together, resulting in a
consensus interpretation.
Methods and Materials

7. Methods and Materials
• This study is approved by our institutional
review board and informed consent was
obtained from patients.

8. Methods and Materials
• Statistical Evaluation
Evaluations were expressed in
percentages.

9. Results
• 164 patients
80 women, 84 men
Mean age 44,5 ±15,4 years

10. Clinical Data:
Urolithiasis………………………. (n=95)
Collecting system dilatation....... (n=21)
Flank pain……………………….. (n=10)
Urinary tract infection.....……..... (n=10)
Hematuria.………………………..(n=6)
Renal Cyst.…………………….... (n=5)
Control after ESWL ...………...... (n=3)
Others (bladder ca,…)………….. (n=14)
Results

11. Diagnostic benefits of 15th
min. upright KUB
72 (43,9%) of 164 patients
1. Nephroptosis (n= 40)
2. Better filling of collecting system (n=9)
3. Differentiation of pheloboliths from urolithiasis (n=10)
4. Emptying of collecting sistem (n=51)
5. Milk of calcium (n=2)
Results

12. 1.Nephroptosis (Asymptomatic)
Downward displacement of kidney by more than two
vertebral bodies or 5 cm
40 patients (24.3%)
[bilateral (n=15), unilateral (n=25)]
Results

13. Supine Upright
57 yo, F, Right renal cyst and minimal pelvicaliectasia on US

14. 43yo, M, Right flank pain
Supine Upright

15. 2. Better filling of collecting system
9 patients (5.4%)
[ureteral filling (n= 8),
upper pole infindibular filling (n=1) ]
Results

16. 24 yo, F, nephrolitiasis
Supine UprightPre-contrast

17. Supine Upright

18. 48yo, M,48 yo, M, urinary tract infection
Supine Upright

19. Results
3.Differentiation of pheloboliths from
urolithiasis
10 patients (16.4%) (lower urinary tract)

20. Supine Upright
44 yo, M, ureterolithiasis suspicion

21. L ureter
Supine Upright

22. Results
4. Emptying of collecting sistem
51 patients (31%)

23. 10, yo, F, minimal pelvicaliectasia at right kidney on US
Supine Upright

24. Results
5. Milk of calcium
2 patients (1.2%)

25. Discussion
• Recently IVU has almost been accepted
as outdated.
• On the other hand alternative modalities
have their own limitations, and despite
their increasing use, the ideal “global”
urinary tract examination still remains
controversial

26. Assessment of Selected Imaging Modalities in the Evaluation of the Urinary Tract*
Variable
Intravenous
Urography
CT US
MR
Imaging
Cystoscopy-
Retrograde
Pyelography
Collecting system ++++ ++/+++ 0/+ ++ ++++
Parenchyma +++ ++++ ++ ++++ 0
Renal masses
(cysts, solid
tumors)
++ ++++ +++ ++++ 0
Function ++++ ++++ 0 ++++ 0
Calculi +++ ++++ ++ 0 ++
Ureter ++++ +++ 0 ++ ++++
Bladder ++/+++ +++ 0/+ +++ ++++
Abdomen-
retroperitoneum + ++++ +++ ++++ 0
Cost ++++ + ++++ + 0
Ionizing radiation ++ + ++++ ++++ +++
Note.—Assessment was performed with a scale from 0 to ++++, with 0 being the worst and ++++
the best. *Dyer RB, et al. Intravenous Urography: Tecnique and Interpretation. Radiographics 2006;
1(4):800-821.discussion 822-824.

27. Discussion
Nawfel RD, et al. Patient Radiation Dose at CT Urography and Conventional
Urography. Radiology 2004; 232:126-132.
• The patient effective dose,
therefore radiation risk for CT
urography was 1.5 times
greater than that for
conventional urography
•Radiation risk is increased for
smaller patients in CT
urography and for larger
patients in IVU.

28. • CT urography performed with multi–
detector row CT may eventually replace
IVU. However, the increased radiation risk
from this examination compared with IVU
should be considered in the context of the
amount of information that is necessary for
the diagnostic task.
*Nawfel RD, et al. Patient Radiation Dose at CT Urography and Conventional
Urography. Radiology 2004; 232:126-132.

29. Discussion
‘Upright positioning’ seems to:
• Be possible-technically- only in IVU
• May be a part of routine IVU
• Can supply data about verification of urine
flow
• Can provide better filling
• Show positional change in gravity-related
layering, nephroptosis and phleboliths

30. Discussion
Weak points of this study are:
• There is no control grup (for comparison of
total number of films and patient radiation
dose)
• Absence of interobserver variability
assessment

31. Conclusion:
• IVU, a cornerstone in urinary system
imaging, has slowly been withdrawn from
routine clinical practice in the era of CT or
MR urography.
• However, the capability of using gravitational
forces by obtaining simply an upright
radiography still provides some diagnostic
benefits, in which CT or MR urography might
easily miss.