INTRAVENOUS UROGRAPHY 1

INTRAVENOUS UROGRAPHY
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

Moderators:
Professors:
▪ Prof. Dr. G. Sivasankar, M.S., M.Ch.,
▪ Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
▪ Dr. J. Sivabalan, M.S., M.Ch.,
▪ Dr. R. Bhargavi, M.S., M.Ch.,
▪ Dr. S. Raju, M.S., M.Ch.,
▪ Dr. K. Muthurathinam, M.S., M.Ch.,
▪ Dr. D.Tamilselvan, M.S., M.Ch.,
▪ Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

DEFINITION
RADIOGRAPHIC STUDY OFTHE RENAL
PARENCHYMA,PELVIS,URETERSAND
URINARY BLADDERAFTER INTRAVENOUS
INJECTION OF CONTRAST MEDIA
3
Dept of Urology, GRH and KMC, Chennai.

TERMINOLOGY
▪ Urogram
Visualization of kidney parenchyma,
calyces and pelvis resulting from IV
injection of contrast.
▪ Pyelogram
Describes retrograde studies visualizing
only the collecting system.
▪ IVP is misnomer
4

Moses Swick
HISTORY
▪ Introduction of excretory
urograpy was done in
1929, by American
urologist Moses Swick.
▪ He injected an
organically-bound iodide
compound—later named
Uroselectan—into a vein,
taking X-rays as the
material cleared the body
through the urinary tract.
5

INDICATIONS
American College of Radiology (ACR) guidelines
▪ To evaluate the presence or continuing presence of
suspected or known ureteral obstruction.
▪ To assess the integrity of the urinary tract status
post trauma.
▪ To assess the urinary tract for suspected congenital
anomalies.
▪ To assess the urinary tract for lesions that may
explain hematuria or infection
▪ Investigation of HTN in young adults not controlled
6

Contraindications
Absolute contraindication – Contrast Allergy
Relative contraindications
▪ Renal failure (raised serum creatinine level >1.5
mg/dL)
▪ Hepatorenal syndrome
▪ Generalized allergic conditions
▪ Multiple myeloma
▪ Pregnancy
▪ Infancy
▪ Thyrotoxicosis
▪ Diabetes
7

Advantages
▪ Clearly outlines of the entire urinary system
so can see even mild hydronephrosis.
▪ Easier to pick out obstructing stone when
there are multiple pelvic calcifications.
▪ Can show non-opaque stones as filling
defects.
▪ Demonstrate renal function and allow for
verification that the opposite kidney is
functioning normally.
8

Disadvantages
▪ Need for IV contrast material
▪ Contrast agent may provoke anaphylactoid reactions,
nephropathy.
▪ Multiple delayed films (Can take hours as contrast
passes quite slowly into the blocked renal unit and
ureter.)
▪ May not have sufficient opacification to define the
anatomy and point of obstruction.
▪ Requires a significant amount of radiation exposure
and may not be ideal for young children or pregnant
women
9

Anatomy
▪ The parenchyma of the
kidney is divided into two
major structures: superficial is
the renal cortex and deep is
the renal medulla.
▪ Grossly, these structures take
the shape of 8 to 18 cone-
shaped renal lobes, each
containing renal cortex
surrounding a portion of
medulla called a renal
pyramid (of Malpighi).
▪ Between the renal pyramids
are projections of cortex
called renal columns (of
Bertin).
10

▪ Nephrons, the urine-
producing functional
structures of the kidney, span
the cortex and medulla.
▪ The tip, or papilla, of each
pyramid empties urine into a
minor calyx(8-12)
▪ Minor calyces empty into
major calyces (2-4), and
major calyces empty into the
renal pelvis, which becomes
the ureter.
11

Shape & Size
▪ Shape
 Bean shaped
 Convex laterally & linear
medially
 Contour – smooth &
regular
▪ Size
 12-15cm in length
 Right kidney appears
smalller than left
 Length – 31/2 verterbral
bodies
 Children – 4 vertebral
bodies
12

Position
▪ Lumbar fossa
▪ Left kidney slightly
higher than right
▪ Upper pole of left kidney
–T11-12
▪ Upper pole of Right
kidney –T12-L1
▪ Lower limit – well above
iliac crest at the level of
L3 or L3-4 IV disc
▪ Medial border – parallel
to psoas margin
13

Renal Axes
▪ Long axis of the kidney is
parallel to the lateral border
of the psoas muscle and lies
on the quadratus lumborum
muscle.
▪ In addition, the kidneys lie at
an oblique angle, that is the
superior renal pole is more
medial and anterior than the
inferior pole.
▪ Their transverse axes form an
approximately 45° angle with
the sagittal plane
14

Intravascular Radiological
Contrast Media (IRCM)
▪ Iodine is the main element which imparts Radio opacity
▪ All currently used IRCM are chemical modifications of
a 2,4,6-tri-iodinated benzene ring.
▪ They are classified on the basis of their physical and
chemical characteristics, including their chemical
structure, osmolality, iodine content, and ionization in
solution.
▪ In clinical practice, categorization based on osmolality
is widely used.
15

HIGH
• IONIC
MONOMERS
• Contain sodium
or meglumine
salts
• 2 ORGANIC
SIDECHAINS &
CARBOXYL
GROUP
• 1500-1900
MOSM/KG H2O
• EG:
DIATRIAZOATE –
Urograffin ,
angiograffin, &
Urovision.
• IOTHALAMATE
ISO
OSMOLAR
• NON IONIC
DIMERS
• EG: IOTROL
• IODIXANOL
LOW
• NON IONIC
MONOMERS:
• ORGANIC SIDE
CHAIN+HYDROXYL
GROUP
• EG:IOHEXOL
IOPAMIDOL IOVERSOL
IOPROMIDE
• AGENTSOF CHOICE
• LOWTOXICITY since do
not dissociate in the
body
• IONIC DIMERS:
• 2 IONIC MONOMERS-
CARBOXYL GROUP
• EG: IOXAGLATE
• ADR:3%
• Expensive than HOCM
16

17

18

Patient Preparation
▪ Complete urine and blood examination to assess the renal function.
▪ The patient is given mild laxatives about twelve to twenty four hours
prior. The patient is kept nil by mouth over night
▪ In active healthy patients, food or liquid restriction or administration of
laxative has little value.
▪ With modern contrast media overhydration should be avoided but
dehydration is unnecessary.
▪ Pretesting does not provide reliable information regarding sensitivity to
contrast media and is therefore not performed before the injection
▪ Take informed consent
19

▪ Dose of contrast :patient size ,radiologist preference
▪ 200mg of I per pound body weight: 20-30 g ,50-100ml
▪ Pediatric – 1ml/kg
▪ Bolus injection given through IV access
▪ Rapid : < 60 sec-better nephrogram
▪ Slow: 2-3 min ,less side effects
▪ Density of nephrogram = plasma level of contrast
▪ Drip infusion: 40-45g of I in 250-400 ml of fluid; not practised nowadays
20

▪ Bolus injection gives immediate peak plasma
level followed by rapid decline due to
 Vascular mixing
 Extravascular diffusion
 Renal excretion
▪ Diagnostic quality depends on
 Amount of iodine excreted
 Volume of urine formed to distend PCS
21

Technique
▪ Venous access via the median
antecubital vein is the preferred
injection site because flow is
retarded in the cephalic vein as it
pierces the clavipectoral fascia.
▪ The gauge of the cannula/needle
should allow the injection to be
given rapidly as bolus to
maximize the density of
nephrogram. Usually 18 gauze
cannula is used
▪ Upper arm or shoulder pain may
be due to stasis of contrast in
vein which may be relieved by
abduction of the arm.
22

Scout Film ( plain film of
abdomen)
• State of bowel preparation
• Calcified density in the renal tract
• To check exposure factors & positioning
• Skeletal abnomality – spinal deformities in
congenital disorders, skeletal metastases,
metabolic bone changes as in rickets
• Abdominal masses
• Foreign bodies
23

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 bowel
preparation, check exposure
factor, and location of
radiopaque stones or any
radiopaque artifacts.
24

Film Sequence
➢ 1-3 minutes Antero-posterior- film coned to the renal area
➢ 5 minutes Antero-posterior-film coned to the renal area (to see if
excretion is symmetrical; if poor opacification, further injection of
contrast)
➢ Apply ureteral compression
➢ 10 minutes Antero-posterior (5mins after compression; 10mins from
contrast administration – Pyelographic phase
➢ “Flush”, “X” or “Release view”- - full length view at 20 minutes
(ureter & bladder images after release of compression)
➢ Upright post void Antero-posterior
25

26

27

28

29

Contraindications to Ureteral
Compression
▪ Evidence of obstruction on the 5-minute
image
▪ Abdominal aortic aneurysm or other
abdominal mass
▪ Severe abdominal pain
▪ Recent abdominal surgery
▪ Suspected urinary tract trauma
▪ Presence of a urinary diversion
▪ Presence of a renal transplant
30

Additional Views &
Modifications
▪ Plain films – Additional oblique views to assist
the location of potentially intra renal opacities
▪ 5min film – Second injection of contrast to
improve opacification of PCS if inadequate
▪ 15 mins release film
 When the bladder is poorly filled additional delayed
films
 Small suspected calculus in distal ureter confirmed
with oblique films
31

▪ Delayed films – 3, 6, 12, 24 hrs for delayed
opacification
 Early nephrogram but collecting system not visualised
 Long standing HUN – Rim sign
 In certain congenital lesions such as nonvisualised
upper calyceal system with ectopic or obstructed
ureter
 Unrewarding in total absence of an early nephrogram
▪ Immediate after micturition film –VU reflux
▪ Rapid sequence urography
 Renal artery stenosis
 2, 4, 6 min
 To compare rate of excretion of each kidney
32

▪ Prone film
 For viewing filling of ureteral areas that are not
seen in supine position
 Useful in renal ptosis, lesions on the anterior
bladder wall, bladder herniation
▪ Erect film
 For demonstrating renal ptosis, bladder hernias,
cystocoeles
 Demonstrates layering of calculi in cysts or
abscesses
33

▪ Hypertensive urogram
 Discontinued
 Work up for renal hypertension in pts younger than 50
years
 Findings – small kidney (smaller than the opposite
kidney by more than 1.5cm), delayed nephrogram,
hyperconcentration in late film
▪ Hydration urogram / Frusemide IVU
 20 mg of Frusemide IV after 15 min film
 Suspected PUJO not evident of standard IVU
 Provoke HUN & pain
34

WHAT TO LOOK FOR IN IVU
➢Size, shape, position and axis of kidneys
➢External cortex and inner medulla
➢Calyceal system
➢Renal pelvis and ureteropelvic junction
➢Ureter
➢Uretero-vesical junction
➢Urinary bladder
➢Relation of ureter to spine and psoas muscle
RADIATION DOSE FROM IVU
➢1,465 mR/projection for males
➢1,047 mR for females
35

Phases of Nephrogram
▪ Spontaneous nephrogram
 Non opacified kidney outlined by retroperitoneal fat visible on plain film
▪ Vascular nephrogram
 Contrast reaches renal artery in 15 secs (arm to kidney time)
 Coexists with diffusion of contrast
 Lasts for few secs to 1 min
▪ Total body opacification phase
 Contrast freely filtered by glomeruli
 Due to opacification of pre & retro renal softtissue
 Lasts for 1 min
▪ Tubular Phase
 Contrast in proximal and distal tubules
 Density fades
▪ Pyelographic phase
 Contrast in the collecting system
36

Vasular (Angiographic
Nephrogram)
▪ Occurs during passage of contrast material through the cortical
microvasculature.
▪ Short lasting seen within 30 sec of rapid IV bolus
▪ Approx. 80% of renal blood flows to the cortex → renal cortex
looks much more radiodense as compared to medulla (CM
differentiation)
▪ If CM differentiation is not seen, the vascular nephrogram is
inadequate & must be interpreted with great caution
▪ Requires intact vascular system – indicator of disturbance in
blood flow to the kidney
37

Tubular (Urographic
Nephrogram)
▪ Appear after the contrast medium has been concentrated in PCT
▪ Density is greater approx 1 min of injection of IV bolus at which time
peak plasma level is reached
▪ Radiodensity of medulla equals to that of cortex → homogenous with
no CM differentiation
▪ Permits accurate evaluation of fundamentals of renal radiology – size,
position, axis & contour
▪ Normal tubular nephrogram requires
 Normal blood flow
 Structural & functional integrity of nephrons
 Unobstructed flow of filtrate through the tubules
38

Failure to Visualise
Nephrogram
▪ Insufficient dose of contrast
▪ Acute or chronic renal failure
▪ End stage renal disease
▪ Absent kidney
▪ Renal artery occlusion / avulsion
39

Abnormal Density Patterns
▪ Immediate, faint & persistent nephrogram
▪ Increasingly dense nephrogram
▪ Immediate, dense & persistent nephrogram
40

Immediate, faint, persistent
nephrogram
▪ Peak density is seen on the first film exposed at the completion
of injection of contrast
▪ Density is disproportionate with amount of contrast material
injected.Though faint, persists for several hours
▪ Cause
 Reduction in number of functioning nephrons → immediate faint
nephrogram
 Severely impaired glomerular filtration & low plasm clearance rate of
contrast → persistent nephrogram
▪ Conditions
 Chronic glomerular disease
 Sudden loss of glomerular function – atheroembolic renal disease
41

Increasingly dense nephrogram
▪ Faint to begin with and
increasingly dense over a
period of hours to days
▪ Seen in
 Acute extrarenal obstruction
 Diminished perfusion
pressure of kidney – SHT,
RAS
 Intratubular obstruction –
calculus, casts, acute
papillary necrosis
 Acute renal vein thrombosis
 Acute glomerular disease
 Acute tubular necrosis
42

Immediate, dense, persistent
nephrogram
▪ As dense as normally expected to be at 1 min
▪ Level of density persists
▪ Pathogenesis
 Unimpaired glomerular filtration → immediate dense
nephrogram
 Diffusion of filtrate into interstitium due to damaged tubules
return of filtered material to the circulation → persistent
nephrogram
▪ Seen in
 Acute tubular necrosis
 Acute bacterial nephritis
43

44

45

Inhomogenous nephrograms
▪ Striated nephrogram / Sunburst nephrogram
 Fine linear strands of alternating lucency & density uniformly
oriented in direction similar to that of tubules & collecting ducts
 Seen in – Acute extrarenal obstruction, Acute bacterial nephritis,
acute pyelonephritis,AR-Infantile polycystic kidney disease,
Medullary cystic disease, Medullary sponge kidney
▪ Patchy nephrogram
 Patchy densities in nephrogram
 Seen in – Polyartertitis nodosa, scleroderma, Necrotising angitis
▪ Cortical rim nephrogram
 Only thin rim of peripheral cortex is opacified that is perfused by
capsular collateral arteries
 Reliable indicator of underperfusion of kidney
 Seen in – Infarction of kidney, segmental RA occlusion, Renal vein
thrombosis (some cases)
46

SUNBURST NEPHROGRAM
CORTICAL RIM NEPHROGRAM
PATCHY NEPHROGRAM
47

▪ The size of the kidneys should be assesed during
neprographic phase
▪ The normal kidney may range from 9 to13 cm in
cephalocaudal length, with the left kidney
inherently larger than the right by 0.5 cm and the
kidneys slightly larger in men than in women
▪ Significant discrepancies (right kidney 1.5 cm
larger than the left kidney,left kidney 2 cm larger
than the right kidney) require explanation.
48

5 & 10 MINUTE FILM
▪ At this stage the calyces, renal pelvis and part
of the ureters will be visible.
▪ Nephrogram will be reduced but both kidneys
should have the same density
49

•In normally functioning kidneys, contrast is first seen in the calyces at 2 mins
following bolus injection.
50

▪ On the 5-minute image, the nephrogram
should be receding as the collecting system
becomes opacified.
▪ On the 10-minute image, the pyelogram is
the dominant urographic element.
▪ Alterations in this temporal sequence require
explanation.
51

▪ Visualization of the collecting system and
renal pelvis can be augmented with the use of
abdominal compression,Trendelenburg
position, and other gravity maneuvers such
as placing the patient with the side of interest
in the ipsilateral posterior oblique position
▪ The appearance of the calices and renal pelvis
should be examined closely
52

▪ Early and mild obstruction is indicated by
subtle rounding of the forniceal margins
▪ More severe and prolonged obstruction
evidenced by progressive loss of the papillary
impression and eventual clubbing of calices.
53

➢Ureters
➢Ureters begin to transport opacified urine about 3 mins post injection
➢Maximum ureteral filling occurs between 5-10 minutes.
54

▪ At the release of compression, the bolus of contrast material–laden
urine entering the ureters provides optimal visualization throughout
their length
▪ Persistence of a standing column of contrast material on several
images may indicate obstruction or ureteral ileus (nonobstructive
dilatation).
▪ Medial deviation of the ureter should be considered when the ureter
overlies the ipsilateral lumbar pedicle.
▪ Lateral deviation should be considered when the ureter lies more
than 1.5 cm beyond the tip of the transverseprocess, but comparison
with the position of the contralateral ureter should always be made
55

▪ An absolute ureteral diameter exceeding 8 mm is
considered a criterion for dilatation.
▪ Asymmetry of ureteral caliber is a more significant
finding.
▪ Early in its course, high-grade ureteral obstruction
may be associated with only minimal ureteral
dilatation.
▪ More chronic forms of obstruction and other chronic
ureteral conditions are typically associated with
greater degrees of ureteral dilatation
56

Bladder
▪ By 15–30 minutes after the injection
of contrast material, the bladder is
often sufficiently filled, and the 15-
minute KUB radiograph may be
adequate for evaluation.
▪ As the bladder distends with
contrast the intraluminal contrast
material should be spheric and
smoothly marginated and the wall
progressively less evident.
▪ Bladder wall thickening and
irregularity of the luminal contrast
material should be noted
57

▪ The postvoid image may also be helpful in
evaluating patients with upper urinary tract
dilatation.
▪ Persistence of the dilatation on the postvoid
image suggests fixed obstruction,
▪ The postvoid image is most helpful in
assessing residual volume.
58

CONGENITAL ANOMALIES &
VARIATIONS

Unilateral Agenesis
60

Renal Ectopia
▪ Failure of complete
ascent of the kidney
to its normal position
▪ IVU- abnormally
placed kidneys
61

Crossed fused Renal ectopia
▪ Two complete
pelvicalyceal systems
on one side usually
one above the other
▪ Ureter from the lower
renal pelvis crosses
the midline and enters
bladder normally
62

Crossed Fused Ectopic Kidney
63

Horshoe Kidney
▪ Kidneys placed lower than normal
▪ Malrotation of pelvis
▪ Lower pole calyces of both sides
deviated towards midline
▪ Ureters have characteristic
vaselike curve
▪ Pelvicalyectasis
▪ Renal calculi
▪ Intravenous urogram (IVU) shows an
altered renal axis with medially
directed lower renal poles, which
suggests horseshoe kidney. Also
note the dilated collecting system of
the left kidney, resulting from a
uretero pelvic junction obstruction;
this is a frequently associated
finding
64

Horshoe Kidney
65

• Minor form – bifid renal
pelvis
• Ureteral duplication
• Incomplete – ureters fuse in
their course
• Complete – 2 ureters open
seperately in bladder, lower
moiety inserted
orthoptically & upper
moiety ectopically
• “Drooping lily” sign-
obstructed upper moiety
ureter, in a completely
duplicated system, may
produce downward and
lateral displacement of the
functional lower moiety
collecting system,
DUPLEX COLLECTING SYSTEM
66

DROPPING LILY SIGN
67

URETEROCOELE
Contrast filled structure with a thin
smooth radiolucent wall surrounded
by contrast containing urine in the
bladder- “Cobra’s head’ appearence
68

Retrocaval Ureter
▪ The ureter may have a
sickle, S or reverse J
appearance before
crossing behind and
medial to the IVC.
▪ The ureter descends
medial to right lumbar
pedicle.
▪ Proximal ureter is
dilated.
69

Congenital Hydronephrosis
• Due to functional obstruction at the pelvi-ureteral junction
• Aetiology- cong. Bands, adhesions, neuro muscular inco-
ordination, abberent vessels
• Advanced cases - large soft tissue mass replacing the renal
parenchyma; No opacification of collecting system
• Lesser degrees of obstruction
• Thin rim of renal substance outlining kidney.
• Later films – crescent shaped opacities produced by
dilated stretched tubules surrounding the enlarged non
opacified calyx
• Delayed films – slow filling of calyces & renal pelvis
• Mildest form- minimal deviation from the normal
appearance
70

Grading of Hydronephrosis
▪ Grade 1 (mild)
 dilatation of the renal pelvis without dilatation of the calyces (can
also occur in the extrarenal pelvis)
 no parenchymal atrophy
▪ Grade 2 (mild)
 dilatation of the renal pelvis (mild) and calyces (pelvicalyceal
pattern is retained)
 no parenchymal atrophy
▪ Grade 3 (moderate)
 moderate dilatation of the renal pelvis and calyces
 blunting of fornices and flattening of papillae
 mild cortical thinning may be seen
▪ Grade 4 (severe)
 gross dilatation of the renal pelvis and calyces, which appear
ballooned
 loss of borders between the renal pelvis and calyces
 renal atrophy seen as cortical thinning
71

72

Grade 3
73

PUJO
▪ The balloon on a string
sign This sign refers to
the appearance of a high
and somewhat eccentric
exit point of the ureter
from a dilated renal
pelvis and is a typical
finding of ureteropelvic
junction obstruction
74

Polycystic kidney
▪ Autosomal dominant
➢ Plain films- cyst calcification
➢ IVU- enlarged kidneys with
compression and displacement
of calyces by intrarenal cyst
▪ Autosomal recessive
▪ B/L symmetrical enlargement
of kidneys
▪ Streaky nephrogram
▪ Calyces maybe distorted
75

Polycystic Kidney
▪ B/l enlarged kidneys
▪ Asymmetric (left>
right)
▪ Multiple parenchymal
defects “Swiss cheese”
nephrogram
76

Polycystic Kidney
77

Malrotated Kidneys
78

Persistence of Fetal
Lobulations
79

Dromedary hump
▪ Prominent cortical hump in the interpolar region of the left kidney.
▪ On a compression image obtained in a later phase of the
sequence, the hump is subtended by a normal collecting system.
▪ Normal variants of the renal contour, caused by the splenic
impression onto the superolateral left kidney.
▪ Dromedary humps are important because they may mimic a renal
mass, and as such is considered a renal pseudotumour.
80

Atrophic Small Smooth Kidney
▪ Chronic
glomerulonephritis
▪ Arteriosclerosis
▪ Papillary necrosis
▪ Embolic disease
▪ Hypotension
▪ Alport syndrome
▪ Nephrosclerosis
▪ Amyloidosis (late)
81

Papillary Necrosis
82

Papillary Necrosis
Central Excavation with “Ball onTee”
apperance
83

Papillary Necrosis
▪ Excavation extending
from the caliceal
fornices
▪ “LOBSTER CLAW”
deformity
84

Renal masses
▪ Small lesions → Localised bulge with increased
thickness of the renal substance; Deforms or displaces
or distends a calyx
▪ Medium sized lesions → Localized or generalized
enlargement of the kidneys; Displacement or
distortion of renal pelvis, ureter or adjacent structures
▪ Very large lesions → Non functioning kidneys;
Calycine spreading;Visceral displacement
85

Renal Mass
▪ Loss of renal contour
▪ Displacement and splaying of calyces
86

Features of Malignant Masses
▪ Pathognomonic – Invasion
of collecting system
producing amputation of
calyx or intraluminal filling
defect.
▪ Suggestive
 Vascular mass
 Calcification
 Tumor shell – wall is thick &
irregular
 Absent mobility with
respiration & change in
position
87

URETER
88

89

▪ Standing column of
contrast from Rt.PUJ
toVUJ
▪ Stone impacted atVUJ
▪ Edema in the right side
of interureteric ridge
(arrow)
90

Transitional Cell Carcinoma
▪ Multiple filling defects
in Left renal pelvis and
ureter
▪ “Goblet” appearance
below the filling defect
– typically seen in
lesions that grow
slowly into the lumen
of the ureter
91

▪ Ureteral filling defects may
be single or multiple and can
usually be attributed to
luminal, mural, or extrinsic
causes.
▪ Urographic image shows
multiple filling defects in the
left renal pelvis and ureter.
▪ Multifocal transitional cell
carcinoma was confirmed in
this case.
92

93

Bladder Pathologies
▪ Overlapping intestines
▪ Intravesical gas
▪ Intravesical solid/fb
▪ Calculi
▪ Clots
▪ Diverticulum
▪ Intramural lesions
▪ Extrinsic compression
 Prostate enlargement
 Vaginal mass (“female
prostate defect”)
94

Clot within Bladder
BladderTumor
95

Bladder Diverticulum
96

97

98

Bladder transitional cell
carcinoma .
▪ Bladder image shows a filling
defect with a papillary
configuration along the right
bladder wall
▪ Note the irregular distribution
of contrast material
associated with the filling
defect (“stipple sign”)
99

100

101

Hemorrhagic Cystitis
Bladder shows contrast material with a
lobulated and irregular contour withing the
lumen of the bladder
102

GU Tb-plain KUB
▪ Disparity in renal size on plain films may indicate early increase in
size of the affected kidney due to caseous lesions or a shrunken
fibrotic kidney of autonephrectomy.
▪ Calcifications are seen in 30% to 50%
▪ A characteristic diffuse, uniform,extensive parenchymal, putty-
like calcification, forming a lobar cast of the kidney is seen with
autonephrectomy
▪ Calculi may also be seen in the collecting system or ureter
secondary to stricture formation.
▪ Ureteral calcifications are rare and are characteristically
intraluminal as opposed to the mural calcifications of
schistosomiasis
103

▪ . Bladder wall calcifications seen in late cases
of bladder contraction.
▪ Calcifications of the prostate and seminal
vesicles are seen in 10% of cases .
▪ Plain film findings suggestive of tuberculosis
may be seen in surrounding tissues such as
erosions of the vertebral bodies or
calcifications in a cold abscess of the psoas
muscle.
104

105

▪ Extensive calcification
which was non-
functional
▪ “Putty Kidney”
▪ Consistent with
autonephrectomy
106

GU Tb-IVU
▪ The most common findings being
hydrocalycosis,hydronephrosis, or
hydroureter due to stricture formation .
▪ Early signs include the moth-eaten
appearance of calyceal erosion and papillary
irregularity- best seen on early excretory
films.
107

108

▪ Cavitary lesions communicating with the
collecting system are characteristic ofTB.
▪ These lesions eventually enlarge as parenchymal
destruction ensues.
▪ Fibrotic distortion of the collecting system and
ureter is also seen.
▪ Calyceal obliteration and amputation,
hydrocalycosis, segmental or total
hydronephrosis, and a shriveled reduced
capacity renal pelvis may all be signs of renal
tuberculosis
109

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111

GUTB – Ureter & Bladder
▪ Scarring and angulation of the ureteropelvic junction (UPJ) may
also occur, the so-called “Kerr’s kink” .
▪ Tuberculosis of the ureter is commonly seen as a rigid,
straightened “pipe-stem”
▪ Ureter also beaded, corkscrew appearance due to multiple
strictures
▪ Ureterovesical junction obstruction is caused by tuberculous
cystitis or strictures of the distal third of the ureter.
▪ The cystogram films may show a small contracted bladder due to
excessive fibrosis
112

Kerr’s Kink
▪ Scarring & angulation
of ureteropelvic
junction
▪ Hiked up pelvis
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INTRAVENOUS UROGRAPHY 1

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INTRAVENOUS UROGRAPHY 1