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INTRAVENOUS UROGRAM ( IVU )
- 1. INTRAVENOUS UROGRAM ( IVU) DR .LEELA KRISHNA
- 2. OVERVIEW Congenital anomalies Inflammatory conditions Injuries Malignant condtions
- 3. SUPERNUMERARY KIDNEY Undersized/malrotated but normal Total number exceeds more than 2 Functioning ,kidney shaped Always smaller than normal , Lies above ,below infront or behind the usual kidney
- 4. RENAL AGENESIS Kidneyfails to develop M – abesnt seminal vesicle/ cyst /epididymis F – absent vagina /uterus Ipsilateral adrenal/ renal artery, vein Ureter, bladder anomalies VACTER/VACTERL Colon gas , kidney and psoas gas
- 5. RENAL HYPOPLASIA Congenitalrenal parenchymal anomaly ,in which few nephrons are present (oligonephronia ) Dwarf kidney (miniature version of normal kidney) with contralateral hypertrophy Orthotopic, ectopic,oligomeganephronia,ask upmark kidney C/S – thick walled arterioles ,clubbed calyces,slitscars,affects single kidney ,hypertrophied tubules ,inflammatory cells absent Calyces – less, glomerulus is abesnt ,
- 6. RENAL DYSPLASIA Congenitalparenchymal malformation with abnormal nephrons and mesenchymal stroma 1- primitive ducts , 2 – low cuboidal epithelium , 3 – cartilage ,4 – areas of loose connective tissue Assoc anomalies – ectopic ureter, posterior urethral valves abent abdominal muscles , D/D – post obstructive atrophy, after heminephrectomy / radiation , post inflammatory changes ,high grade renal artery stenosis, sterile VUR
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- 8. ANOMALIES IN POSITION NONROTATION REVERSE ROTATION
- 9. RENAL ECTOPIA Kidneycongenitally in abnormal location Length of ureter Ipsilateral - abdominal ,iliac,pelvic Crossed renal ectopia Blood supply – ectopic Assoc. cranial, caudal ,pelvic ectopia Complications – injury , obstruct labour,uvj/UPJ obstruction,decreased functin ( 50 )
- 10. CRANIAL ECTOPIA - (INTRATHORACIC KIDNEY ) Partially or completely herniated through foramen of bochdalek . It is not actually intrathoraic but lies below a localized eventration of membranous part of diaphragm Mistaken for mediastinal masses ,pericardial cysts ,neuroenteric cysts, pericardial cysts
- 11. PELVIC KIDNEY Whenit lies in true pelvis proceeds from superior margin of sacral promontory to superior margin of symphysis pubis Uni/bilateral crossed , solitary Leftkidney is involved in 70 % Assoc . Ectopic ureter, extrarenal pelvis , anomalies of rotation ,high ureter
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- 13. CROSSED ECTOPIC KIDNEY Kidney is located in opposite of the body opposite the orifice of its attendant ureter Four varities – a) with fusion b) With out fusion c) Soilitary d) Bilateral
- 14. CROSSED ECTOPIA WITHOUT FUSION
- 15. HORSESHOE KIDNEY Parenchymaof each kidney lies on opposite of the kidney and two kidneys are connected by ishmus usually at lower poles , isthmus – normal tissue Ectopic.lies lower than normal kidney Branches from aorta,external/internal iliac,IMA Fuse in midline/laterallycrosses midline drain parenchyma on opposite side IVU – wide istmus , right renal pelvis is lateral,left pelvis is anterior,ureter crosses istmus ,laterally nd medially 9 FLOWER VASE APPEARANCE )
- 16. CONTD….. Assoc withUPJ/ VUR,ectopic retrocaval ureter , anorectal ,cardiovascular, vertebral, anomalies IVU - U / L shaped ( narrow isthmus - pelvis lies anterior,/medial , wide isthmus – anteror /medial ) Shows – midline fusion and narrow isthmus , anterior pelvis COMPLIICATIONS - injury, stones, UPJ obstruction ,primary renal carciniod tumour, wilms tumour
- 17. DISC( CAKE ,LUMPKIDNEY ) Rare variation of midline fusion when the kidney is a single disc Lies lower than horse shoe kidney often in pelvis ,drained by single ureter Seen as single confluent mass or renal tissue with renal collecting systems lying side by side / one collecting system anterior to the other
- 18. CROSSED FUSED RENALECTOPIA Superior - kidney crosses midline ,lies superior ,pelvis rotated anteriorly Sigmoid / s- crossed lies inferiorly and pelvis laterally , resident kidney medially Lump -fused , irregular - pelvis anteriorly Unilateral L - crossed lies inferiorly ,transerversly Unilateral disc - fused along medial concave border , pelvis lies anteromedially and anterolaterally Inferior – lies inferior , upper pole of crossed fused with lower pole of other kidney , pelvis lies anteriorly
- 19. CONGENITAL LARGE SEPTAOF BERTIN Cortical tissue extending from the cortex to the renal sinus and separate the medulla into segments Consists of normally functioning nephrons TEAT – congenitally large septum has an UDDER shape – papillae and calyces like small teats ,calyces having short infundibulae
- 20. LARGE COLUMNS OFBERTIN Aberrant papillae - draining into either middle of long infundibulum /renal pelvis Factory siren sign – 2 or more calyces curve around congenitally large septum of bertin and drains into T shaped infundibulum
- 21. UNIPAPILLARY KIDNEY Hasonly one paillae with /with out calyx Single renal lobe ,ducts of belini drain directly into renal pelvis Assoc with anomalies like hypoplasia ,genesis , ureteral ,verterbral ,brachial arch anomalies
- 22. MICROCALYX Presents asatiny projection of contrast material representing an infundibulum and may be mistaken for disease. Diverticula, dilated, collecting ductsand cavities do not have tiny paillae at their termination
- 23. ABERRANT OR ECTOPICPAPILLA Open directly into pelvis / into long infundibulum Normally or small sized Calyx always assoc with it Smooth ,round filling defect , thin opaque rim of contrast surrounding papllae so called HALO SIGN Assoc large septum of bertin
- 24. CALCYCEAL DIVERTICULUM OUtpouchingof calyx into CM junction Complications- persistent infectiions, stone formation D/D - rupture of cyst/abscess ,papllary necrosis stenosis of calyceal infundibulum, ruptured calcyceal fornices Type 1 – minor calyx Type 2 – infundibulum Type 3 – renalpelvis
- 25. ANOMALIES IN RENALPELVIS AND URETER Duplex kidney Duplex ( duplicated )system Bifid system Double ureters Upper pole ureter Ectopic ureter Intravesical ureterocele Ectopic ureterocele
- 26. Single renalparenchyma drained by two pelvicalcyceal systems Incomplete fusion of upper and lower pole moeities resulting in complete/incomplete duplication of collecting system Drains into single ureter, bifid ureter, double ureter Usually larger than normal Assoc congenitally large septum of bertin , pronounced fetal lobulations present DUPLEX KIDNEYS
- 27. CONTD…. UPJ obstructionis more common More in lower pole renal pelvis Complete ureteral duplication – hydronephrois /dysplasia ( upper pole) , chronic pyelonephritis ( lower pole ) Longer than opposite normal > 3 cm,parenchymal thickness upto 1 cm
- 28. NUBBIN SIGN Urographicappearance of a tiny non- functioning or poorly functioning lower pole of a duplex kidney Resembles a non duplicated kidney with the mass in lower pole D/D – parenchymal atrophy secondary to vuj reflux, infection, dysplasia secondary to aberrant ureteral bud insertion during development
- 29. `DROOPING LILY SIGN Sign of duplicated renal collecting system Refers to inferolateral displacement of opacified lower pole moeity due to an obstructed upper pole moiety
- 30. BIFID URETER Bifidureters drain duplex kidney join to form a single ureter. May join extravesical(MC) or intravesical Y /V junctions YO – YO phenomenon Assoc with vuR, ureterocele ,stenosis,atresia UPJ obstruction
- 31. BIFID URETER IVU showingtype A bifid ( left ) type c bifid ( right )
- 32. INVERTED Y URETER Proximal end of single ureter splitting distally to form inverted y Two ureteral orifices are found in the bladder on the same side Assoc with ectopic ureterocele / nsert into seminal versicle
- 33. DOUBLE URETERS Theyremain completely separate to the point where they insert in the bladder or beyond They travel through blader wall through a commontunnel even one ureter is ectopic More common in females UPJ is more common
- 34. URETERAL TRIPLICATION Type1 - lowerpole – lateral angle of trigone,upper pole –medial ,caudal ,ectopic – lowerpole Type 2 - bifid ureter , single separate ureter Type 3 –trifid ureter in single orifice
- 35. BLIND ENDING URETERICBUD Blind ending hollow structure wall has all layers of normal ureter May arise from the bladder or joins the ureter at an acute angle Assoc with horseshoe, ectopic,crossed fused ectopic Fills by ureteroureteral reflux
- 36. URETERAL DIVERTICULA TRUE- saccular,oval ,round contains all layers of ureteral wall ,communicates through stroma D/D – bladder diverticulum/ large ureterocele /marked hydroureter FALSE – small / do not penentrate full thickness , hyperplastic epithelium Upper,middle 1/3 rd , premalignant
- 37. ECTOPIC PATHWAY Upperpole ureter - opens anywhere (below and medial to lower pole ureter) ------ WEIGERT R MEYER RULE(85%) Shape of shepherd cook ,circles the superior and medial aspect ,lateral angle of trigone –urethra Females – it opens post wall of urethra /urethrovaginal septum Males – upper third of prostatic urethra More the extreme location – dysplastiic kidney UTI ,pelonephritis,recurrent epidymoorchitis
- 38. ECTOPIC URETERAL ORIFICES Ectopic - proximal lip of bladder neck or beyond Obeys weigert –R meyer rule Normal – lateral to trigone,medial and inferior ,further Cranial – lateral to outerangle of trigone, outside blader in diverticulum Caudal - male ( upper third of prosticurethra /vas Females ( posterior part of urethra/urethrovaginal septim /wall of vagina,hymen )
- 39. URETEROCELE Balloning ofdistal end of ureter Assoc. single/duplex kidney Abnormality of mucosa Ectopic – defect of muscle coat of ureter and bladder wall itself (poor detrusor backing )
- 40. INTRAVESICAL URETEROCELE Orificeof ureter and ureterocele – with in bladder Simple ureterocele Opens in normal zone , - but stenotic / non obstructed Adults,acquired - fibrotic narrowing /inflammation/trauma Stones, persistent infection Superior, inferior surfaceupper ,lower pole ureter IVU – COBRA HEAD SIGN /SPRING ONION
- 41. EXTRAVESICAL URETEROCELE Uretrocelelies in the submucosa of bladder and some extends into bladder neck Complications – obstruction, reflux, stone ,upperpole dyspalsia mass in upper pole of kidney, radiolucent filling defect in bladder,
- 42. POLYCYSTIC KIDNEY DISEASE Contrast in preserved tubules next to unopacified tubules Autosomal reccesive Renal prarenchyma replaced by numerous tiny cysts Perinatal, neonatal, infantile, juvenile Ologohydraminos,potters syndrome
- 43. PKD – AUTOSOMALDOMINANT IVP – SWISS CHEESE PATTERN Multiple well defined non perfused areas ( cysts ) Strectched out calyces Assoc. Cysts , aneursms, heart dieases
- 44. MEDULLARY SPONGE KIDNEY Paint brush like appaerence Produced by cystic dilatation of medullary collecting ducts Weak assoc. wilms disease, pheaochromocytoma,horshe shoe kidney
- 45. ACUTE BACTERIAL PYELONEPHRITIS Renalenlargement Impaired excretion Nonhomogenous nephrogram Attenuation of collecting system Mucosal edema Poor definition of renal margins Pyeloureteral dilatation
- 46. CHRONIC PYELONEPHRITIS Asymmetryand Irregular renal outline with upper pole parenchymal atrophy Loss of renal cortical thickness over blunted and dilated calcyces
- 47. RENAL PAPILLARY NECROSIS Enlarged kidney with central paiilary necrosis with marginal extrasavation – LOBSTER CLAW appearance Sequestered , sloughed papillae causing filling defect – RING SIGN Multile calcyces affected – RIM like CALCIFICATION Tissue necrosis - blunted/ clubbed calcyces
- 48. GUTB – IVP: Parenchymal scars & Irregularity of the papillary tips - “moth-eaten” calices Small cavities in the papillae communicate with the collecting system fibrotic reaction develops, stenosis and strictures of the caliceal infundibula - Infundibular strictures can lead to localized caliectasis or phantom calyx. Scarring of renal pelvis (Kerr kink)
- 49. Earliest abnormality – -Indistinct feathery outline Irregularity of surface of one or more papillae or calyces with normal renal size and contour. Fuzzy & irregular calices due to papillary necrosis. Normal calices MOTH EATEN APPEARANCE
- 50.
- 51. INFUNDIBULAR STENOSIS CAUSING PHANTOMCALYX Phantom calix Infundibular stenosis
- 52. PHANTOM CALYX Decreased nephrographicopacity and nonfilling of the collecting system elements at the lower pole of left kidney – phantom calyces RGP
- 53. GOLF ON ATEE Collecting system shows contrast material in a large papillary cavity, the “golf ball” (∗). Blunted calyx, the “tee,” is adjacent (arrow).
- 54. Cortical scarringwith dilatation & distortion of adjoining calyces coupled with strictures of the pelvicaliceal system. Cause luminal narrowing either directly or by causing kinking of the renal pelvis at the UPJ. KERR KINK
- 55. HIKED UP PELVIS Cephalicretraction of the inferior medial margin of the renal pelvis at the ureteropelvic junction (UPJ)
- 56. Autonephrectomy. Diffuse,uniform, extensive parenchymal calcifications forming a cast of the kidney with autonephrectomy. End stage of GuTB. PUTTY KIDNEY
- 57. If the ulceror stricture extends to the renal pelvis or the pelvic ureteral junction, urine outflow obstruction may occur. IVUmay show delayed function, clubbed calyces, or absence of function. Some show Hydronephrosis - irregular margins and filling defects owing to caseous debris. If tuberculous infection extends directly to the rest of the kidney, the entire kidney becomes a bag of caseous necrotic pus. The kidney enlarges initially but subsequently may return to normal or become atrophic. infection may extend into peri- / pararenal space + psoas
- 58. dilatation resulting from atonyand prolonged bacilluria PIPE STEM irregular segments of ureter due to mucosal ulcerations necrosis of ureteral musculature is accompanied by fibrosis - stricture formation- 50%. severe thickening of the wall produces a rigid shortened ureter with narrow lumen cork- SCREW TERMINAL SEGMENT
- 59. Rigid ureter:irregular and lacks normal peristaltic movement, fibrotic strictures noted. distortion, amputation and irregularity of the upper pole calices. PIPE STEM URETER
- 60. Fusion ofmultiple strictures may create a long, irregular narrowing. Several nonconfluent strictures can produce a “beaded” or “corkscrew” ureter BEADED / CORK SCREW
- 61. Ulcerations causingmucosal irregularity of ureter. SAW TOOTH
- 62. Urinary lithiasis Fillingdefect in case of radioleucent partial stag horn calculus
- 63. RENAL INJURIES Absenceof unilateral excretion suggests major vascular injury ( renal artery avulsion ) Disruption of pelvicalyceal system may be seen as extravasation of opacified urine Large retroperitoneal ,perinephric hematomas – soft tissue sweling with loss of psoas shawdow
- 64. Ureteric injury Excretoryintravenous urography if CT is not available: demonstrates contrast leakage and spillage outside the course of the urinary system.
- 65. RENAL CELL CARCINOMA Calcification - curvilinear ,punctate/flocculent ( central ) Focal bulge in the renal contour such as Tilting of renal axis ( exophytic medial mass) Lower pole mass (horizantal plane) Displacement of adjacent calcyces ,renal pelvis ,ureter Absence of contrast excretion - renal vein occlusion
- 66. Seen as fillingdefects in the pelvis Surface – smooth ,stipped,serrated,frondlike Calyceal obliteration ,fiilling defects with distended cakyces STIPPLESIGN –trapping of contrast material with in interstices of tumour will give a stippled effect ( H/S/O – tcc ) TCC PELVIS
- 67. URETER Tumor seenas ovoid filling defect arising from one of the walls GOBLET /CHAMPAGNE GLASS SIGN – dilatation below ureter Retrograde cathetrer may coil in infratumoral space (BERGMANN sign )
- 68. Ureteral tumours Dueto the small caliber of the ureter, tumours are more likelyto obstruct the kidney at small tumour size. Obstruction may lead to hyrdonephrosis with or without hydroureter and may also result in a non-functioning kidney or delayed nephrogram.
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