Excretionurography Also known as intravenous urography (IVU). Most frequently employed radiologic investigation of renal rainage. The contrast material is administered intravenously. Best method for adults unless use of other methods is specified and is used in examinations of upper urinary tracts of infants and children.

1. Presented by Dr Vrishit Saraswat
IInd Yr Resident
Guided by Prof Dr Dharmraj Meena
Department of Radiodiagnosis

2. 2
• Also known asintravenous urography (IVU).
• Most frequently employed radiologic investigationof
renal drainage.
• Thecontrast material is administeredintravenously.
• Best method for adults unless use of other methods is
specified and is used in examinations of upper urinary
tracts of infants andchildren.

3. • Urogram: Visualization of kidney parenchyma,calyces
and pelvis resulting from IV injection of CM.
• Pyelogram: Describesretrograde studies visualizingonly
the collectingsystem.
• So,IVPis misnomer, should beIVU
• Excretion urography usednowadays.
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4.  Kidneys:
 Apair of bean-shapedorgansapproximately 12cmlong.
Theyextend from vertebral level T12to L3when the
body isin the erect position. Theright kidney is
positioned slightly lower than the left becauseof the
massof the liver.
 Internal structure
 Within the dense,connective tissue of the renal
capsule,the kidney substanceis divided intoanouter
cortex and aninnermedulla.
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5. • Cortex-contains glomeruli, Bowman's capsules, and proximal
and distal convoluted tubules. It forms renal columns, which
extend between medullarypyramids.
• Medulla-consists of 10 to 18 striated pyramids and contains
collecting ducts and loops of Henle. Theapex of eachpyramid
ends asapapilla 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.
• Renalpelvis-the dilated upper portion of the ureter that
receives the major calyces.
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6. 6

7. • Relations:
• Anteriorly, aportion 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 colon lie 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.
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8. • Superiorly, the adrenal glands are sited on thesuperior
surface of eachkidney.
• Inferiorly. Coils of small bowel supported on their mesentery
lie below eachkidney.
• 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 cavaon the left and their
associated renal blood supply anddrainage.
Blood Supply:
• Right and left renal arteries respectively, branches ofthe
abdominal aorta.
Nerve supply:
• Motor neurones fromthe autonomic nervous system.
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10. • Thelarge muscles on
either side of thevertebral
column causethe
longitudinal plane of the
kidneys to form avertical
angle of about 20° with
the midsagittal plane.
Theselarge muscles
include the two psoas
major muscles. These
muscle massesgrow larger
asthey progress inferiorly
from the upper lumbar
vertebrae.
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11. • Thisgradual enlargement
produces the 20°
angle, wherein the upper
pole of each kidney is closer
to the midline than its lower
pole.
• Theselarge posterior
abdominal muscles also
causethe kidneys to rotate
backward within the
retroperitoneal space.Asa
result, the medial borderof
each kidney is more
anterior than the lateral
border.
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12. 12
• Theseare 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 posterior base of the bladder.
• Are constructed sothat urine passesalong them byperistaltic
action.
• There is an inner lining ofmucous membrane supported on a
submucosal layer, then alayer of plain circular involuntary
muscle, and an outer layer ofwhite fibrous tissue.
• Theureters have alength of approximately 20 cm andan
internal diameter up to3 mm.

13. 13
• Theureters vary in diameter
from 1 mm toalmost 1 cm.
• Normally, three constricted
points exist along the courseof
each ureter.
• If akidney stone attempts to
passfrom kidney to bladder,it
may have trouble passing
through these threeregions.
• Thefirst point isthe
ureteropelvic(UP)
junction,where the renalpelvis
funnels down into the small
ureter.

14. • Thesecond is near the brim of
the pelvis, where the iliacblood
vesselscrossover the ureters.
• Thethird is where the ureter
joins the bladder, termed the
ureterovesical junction, or UV
junction.
• Most kidney stones that pass
down the ureter tend tohang up
at the third site, theUV
junction, and once the stone
passesthis point and moves into
the bladder, it generally haslittle
trouble passingfrom thebladder
and through the urethra to the
exterior.
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15. 15
• Bladder is situated in the anterior part of the pelvic
cavity, behind and just above the symphysispubis.
• Exactposition depends on the degree ofdistension.
• Acts asareservoir for urine from thekidneys and
subsequently expels it via theexternal urethra.
• It is ahollow 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, abaseanteriorly and asuperior
and two inferolateralsurfaces.

16. • Theureters enter the postero lateral angles of thebaseand
the urethra leaves inferiorly at the narrow neck.
• The interior of the bladder is covered with mucous membrane
which thrown into folds, except in the trigone between the
ureteric orifices, in the contracted state and stretched more
smooth when the bladder isdistended.
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17. 17
• Toseethe anatomy and physiology of urinary system
• Trauma
• Calculi- renal, ureteric,bladder
• Congenital anomalies- ectopic kidney, horseshoe kidney,renal
agenesis
• Infective pathology
• Renaltumour
• Unknown Haematuria
• Renalhypertension
• Bladder pathology- diverticula, fistula
• Vesicoureteric reflux

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• Hypersensitivity to iodinatedCM
• Renalinsufficency
• Hepato renal syndrome
• Thyrotoxicosis,
• Pregnancy,(Allow 28 daysfrom childbirth)

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• Low osmolar contrast media (LOCM)-300-600mgI/ml
• Adult dose : 50-100ml
• Paediatric dose : 1ml/kg

20. 20
• Any standard radiographic unit is suitable toperform the
procedure.
• High power x-raygenerator.
• Immobilization band is usually not applied becausethe
resultant pressure may interfere withthe passageof fluid
through ureters and may also causedistortion ofcanals.
• However, compression band is sometimes applied over distal
ends of ureters to retard flow of opacified urine into bladder
and to ensure adequate filling ofrenal pelves and calyces.

21. 21
• NPOfor 5h prior to examination.
• Pts. should preferably be ambulant for 2h prior to the
examination to reduce bowelgas.
• Bowel preparation is necessary to reduce the bowelgas
pattern which may obscure the region ofinterest.
• Theroutine administration of bowel preparationusemakes
the examination more unpleasant for thepatients.
• Nowadays it is said tobe unnecessary.

22. • Thetechnologist must check the patient's chart todetermine
the creatinine and BUN(blood urea nitrogen) levels. Patients
with elevated blood levels have agreater chance of
experiencing an adverse contrast media reaction. Normal
creatinine levels for the adult are 0.6to 1.5mg/dl. BUN
levels should range between 8and 25mg/100ml.
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23. • Nowadays, dehydration is not necessary and doesnotimprove
image quality.
• Dehydration is contraindicated in the followingsituations:
1. Renalfailure
2. Myeloma
3. Infancy
• If examination is to be performed on apt who haspreviously
had asevere CMreaction, consideraton should be given to
administering methyl prednisolone 32mg orally 12 and 2 h
prior to CMinjection.
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24. SIGNINGINFORMEDCONSENTFORM:
• Venipuncture is an invasive procedure that carries risks for
complications, especially when contrast media is injected.
Before beginning the procedure, thetechnologist must ensure
that the patient is fully aware of these potential risks and has
signed an informed consentform.
• If achild is undergoing venipuncture, theprocedure should be
explained to both the child and the guardian, and the
guardian should sign the informed consentform.
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25. 25
• Venous access via the median antecubital vein is the preferred
injection site because flow is retarded in the cephalic vein asit
pierces the clavipectoral fascia.
• Thegaugeof the cannula/needle should allow the injectionto
be given rapidly asbolus to maximize the density of
nephrogram.
• Upper arm or shoulder pain may be due to stasis of contrast
in vein which may be relieved by abduction of the arm.

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• Preliminary film:
 Supine, full length AP of
abdomen in inspiration.
 The lower border of
cassette is at the level of
symphysis pubis and the
x-ray beam is centred in
the midline at the level of
iliac crests.
 To demonstrate
preparation,
exposure factor,
bowel
check
and
location of radiopaque
stones or any radiopaque
artifacts.

27. • If necessary the position of overlying opacities may be further
demonstrated by:
• SupineAPof renal areas, in expiration. Thex-ray beam is
centred in the mid-line at the level of lower costal margin
Or
• 35 posterior oblique views,or,
• Tomography of the kidneys at the level of athird of the AP
diameter of the patient (app.8-11 cm).The optimal angle of
swing is 25-40 .
• Theexamination should not proceed until these filmsare
reviewed by radiologist and claimedsatisfactory.
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28. 28
• Immediate film :
 APof the renal areas.
 Thisfilm is exposed10-
14 safter the injection
(app.Arm to kidney
time)
 Aims to show the
nephrogram, i.e renal
parenchyma opacified
by contrast mediumin
renal tubules.

29. • 5-min film:
 APof renalareas.
 Todetermine if excretion is symmetrical and is invaluablefor
assessingthe need to modify the techinque, egafurther
injection of CMif there hasbeen poor initial opacification.
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30. • Compression band is now applied around the patient’s
abdomen and the balloon positioned midway betweenthe
ASIS i.e. precisely over the ureters astheycross the pelvic
brim. Theaim is to produce better pelvicalycealdistension.
• Compression is contraindicated:
1. After recent abdominalsurgery
2. After renaltrauma
3. If there is alarge abdominal massor aorticaneurysm.
4. When the 5-min film shows already distendedcalyces.
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31. • 15 min film:
 Supine full lengthAP
 There is usually adequate
distension of thepelvicalyceal
systemswith opaque urineby
this time.
 Compression is released when
satisfactory demonstration ofthe
pelvicalyceal system hasbeen
achieved.
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32. • Releasefilm (full bladder) : coned view of bladder area
• Takento show the bladder. If this film is satisfactory, the pt is
askedto empty thebladder.
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33. • After micturitionfilm:
• Either afull length abdominal film or aconed view of the
bladder with the tubeangled 15° caudad and centred 5 cm
above the symphysis pubis based on earlier findings.
• Main aim of films isto
Assessbladder emptying
Todemonstrate return of dilatedupper
tracts with relief ofbladder pressure.
Aid diagnosis of VJcalculi
Dxof bladder tumors
Demonstrate urethral diverticulum.
Residual vol of urine.
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34. 34
• Posterior obliques of
kidneys, ureters orbladder:
 Todetermine whether the
radiopaque shadow is in the ureter
or outside.
 Position: Pt. is rotated 30-35° in rt
or lt side depending on pathology
side.

35. • Prone film:
 Toinvestigate pelviureteric and ureteric obstruction asthe
heavy contrast laden urine will more readily gravitate to the
site of theobstruction.
 Todisplace the overlying bowel gastowardsperiphery.
 Position: Pt. lies prone after doing 15 min full film and after 4-
5 min. of lying prone (so that lower ureter is in dependent
part) full film istaken.
• Tomography- when there are confusing overlying gasshadows
in renalareas.
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36. • APwith caudal angulation:
 Toseparate the over shadows by stomach on left kidney.
 Position: APposition, film of kidney area with25° caudal tube
angulation.
• Erect film: Todetermine where or not there is small ureteric
calculus, erect oblique film of area of ureter. Todemonstrate
layering of calculi in cysts andabscesses.
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37. • Delayed films : may be necessary for up to 24 h after injection
to demonstrate the actual site of ureteric obstruction.
• Children: films are taken in 3 min, 15 min, aden post mic after
CMinjection and further depending uponpathology.
• Pregnancy: film sequence is KUBand 15 min full film.
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38. 38
• In caseof suspicious shadows in renalareas:
 Takelateral film of renalarea.
 Takeinspiratory and expiratory film of renal area to
demonstrate the relationship of opacities and filling defects of
renal tract.
• In caseof renal hypertension: take fast sequences (1min,3
min, and 5 minfilm).

39. • Ectopic kidney: full film KUBregion from immediate to last
film.
• Renalagenesis: full fim KUBfrom immediate to lastfilm.
Delayed films upto 24hours.
• Bladder diverticulum: Abnormal pouch formed withinbladder.
Lateral film of bladderarea.
• Vesicovaginal fistula: lateral film ofbladder area.
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40. • VUJobstruction: Oblique film of bladder area ofobstruction
side.
• Suspected renal failure, er urography, inadequatebowel
preparation:
 High dose IVU(dose of CMupto 600mgI/kg body wt.)is
performed.
 Common sequences and further delayed sequences ( 1 hrs, 3
hrs, 6 hrs, 12 hrs and 24 hrs) if kidney function is not seen.
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41. 41
• Direct lead rubber gonad protection using ahalfapron.
• “Pregnancy” rule should befollowed.
• 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 alead rubber sheet over upper thighs
below lower edge of symphysispubis.
• When bladder and lower ureters are not included then female
canalso be given gonad protection.

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• General psychological reassurance.
• Needle wound site dressed and checked for extravasation.
• Checkpatient understands how to receive theresults.
• Ensurepatient understands any preparation instructionsare
finished.
• Escort to changing rooms and bidgood-bye.

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• Thestrengths of urographyare:
 rapid overview of the entire urinary tract,
 detailed anatomy of the collectingsystem,
 demonstration of calcifications,
 it is sensitive forobstruction, and
 low cost,

44. Theweaknesses are that:
• it depends on kidneyfunction,
• it provides little assessment of parenchymal structure (eg.
cystic vs.solid),
• the perinephric spaceis not demonstrated,
• it necessitates the use of radiation and contrast medium, and
• it provides no assessmentof glomerular filtration rate.
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45. 45
• Dueto CM:
Reactions due to CM: mild, moderateand severe.
• Dueto technique:
• Incorrectly applied abdominal compression mayproduce
intolerable discomfort orhypotension.
• Swelling and pain during injection
• Extravasation of CM

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• Urinary obstructions:
• Calculi: most commonly form in the kidneys
• Ureteral calculi may form in lower portion atVUJand pelvic
brim.
• Bladder calculi are uncommon but they are relativelylarger
when present.

47. Disorder Description Radiographic findings
Renalagenesis Solitary kidney Hypertrophic single
functioning kidney
Supernumerary
kidney
More than two
kidneys
Hypoplstic 3rd kidney,
may or maynot be
fused
Malrotation Abnormal position Bizzare appearance of
parenchymal calyces
and pelvis.
Ectopic kidney Solitary kidney 2nd kidney inanother
location (pelvis or
thorax)
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48. Horse shoe kidney Lower pole-
parenchymal fusion
Kidney malrotation
and possible
nephrogram
demonstrating
parenchymal fusion
Duplication More than onerenal
pelvis or ureter
Double renal pelvis
in single kidney;two
ureters exit kidney
and empty into
bladder.
Ureterocele Located in distal
ureter (VUJ)
Roundor ovaldilated
ureter with
radiolucent halo.
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49. Renalagenesis
Ectopickidney
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50. Ureteric calculus Rotated kidney
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51. Bladder diverticulum
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Staghorn calculus

52. Horseshoe kidney
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Duplex bilateral

53.  Polycystic kidney disease is adisorder marked by
cystsscattered throughout one or both kidneys. This
diseaseis the most common cause of enlarged
kidneys. Its causemaybe genetic or congenital,
depending on the type of polycystic disease.
 Thesecystsalter the appearanceof the kidneyand
mayalter renal function.
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54. 54
 Radio nuclide imaging for renal functionevaluation.
 Ultrasound.
 C.T.for investigation of trauma and renalmasses.
 RenalAngiography.
 Retrograde pyelography,
 Urethrography.
 Magnetic resonanceimaging.

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• Contrast is what we giveintravenously
• Dye is used on clothes and in cooking to change the color of
things—it is not given IVtopatients!

56. 56
• Excretion urography haslong been the cornerstone of the
imaging evaluation of urinary tractdisease. However, other
imaging modalities such asUSG,CT,and MRI are being used
with increasingfrequency.
• Thedeclining useof urography in clinical practice presentsa
challenge for instruction in urographic technique and
interpretation.
• In addition, alternative modalities also have theirlimitations,
and despite their increasing use, the ideal “global” urinary
tract examination remainscontroversial.
• Nevertheless, urography may still be important inthe
diagnosis of some urinary tract diseaseprocesses.

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