A presentation about Intravenous Urography (Also known as Intravenous Pyeography). The presentation contains 41 slides, and is divided into 4 parts : 1 - Introduction. 2 - The procedure. 3 - Examples for abnormal findings. 4 - Studies comparing IVU accuracy with KUB & USG with CT Scan. This presentation was prepared and presented by me in the tutorials of the Radiology Department of Sebha Medical Center.

1. Intravenous Urography (IVU)
Dr.Abdalla Mutwakil Gamal
Radiology Department
Sebha Medical Center

2. Contents
Introduction
The procedure
Examples for abnormal findings
IVU vs KUB & USG vs NCCT

3. Introduction

4. Definition
- X-Ray + Contrast
- Other names

5. Indications
1 – Hematuria
2 – Renal Colic
3 – Recurrent urinary tract infection
4 – Suspected urinary tract pathology

6. Contraindications
They are the general contraindications to water
soluble agents :
- Contrast allergy
- Hepatorenal syndrome
- Thyrotoxicosis
- Pregnancy
- Raised serum creatinine

7. Advantages of IVU
- Detailed anatomy of the collecting systems
- Demonstration of major calcification
- Sensitive for acute obstruction
- Low cost

8. Limitations of IVU
- It depends on kidney function
- Do not differentiate solid or cystic lesion
- Requires contrast medium and radiation.
- Missing small stones.
- Quality of study may be limited by
inadequate bowel preparation, bowel ileus,
swallowed air and technician variability.
- Inconvenience of a long filming sequence.

9. The procedure

10. Equipments

11. Contrast
LOCM 370 (LOCM = Low osmolar contrast material)
Adult dose = 50 – 100 ml , Pediatric dose = 1ml for each kg

12. Patient preparation
- Eating and drinking
- Moving around
- Bowel preparation
- Metformin

13. Preliminary film (control film)

14. Technique
- Dye injection
- Precautions during dye injection
- Taking x-rays

15. Films
Immediate
film
5-15 min film
(Nephrogram
phase)
30-min film
(Ureterogram
phase)
45-min film
(Cystogram
phase)
Postvoiding
film

16. Immediate film (Nephrogram phase)
A.P. of the renal areas to show the
nephrogram, i.e. the renal parenchyma
opacified by the contrast medium in the
renal tubules.
(taking it after injection equals about 10 to
14 seconds which is the approximate arm-
to-kidney time).

17. 5-15 minutes film (Secretory phase)
inspect :
- Both Kidney contour
- Contrast is filling both the Pyelum or not,
- is there any delayed filling?

18. 30 minutes film (Ureterogram phase)
inspect:
Is there any collecting systems and ureters
dilatation or filling defect? (normal ureter
filling is rarely demonstrate the whole ureter
from proximal to distal as there is a
peristaltic wave )

19. 45 minutes film (Cystogram phase)
inspect :
- Bladder size and shape
- Contrast is filling the bladder or not
- Bladder surface is smooth or rough
- Is there any diverticlula, filling defect or
prostate indentation?

20. Postvoiding film
look for:
- Residual urine
- Contrast left on upper tract? (normally there
is no contrast left on upper urinary tract on
postvoiding film)

21. Patient Aftercare
- Needle wound site dressed and checked
for extravasation.
- Check patient understands how to receive
the results.
- Ensure patient understands any
preparation instructions are finished
- Escort to changing rooms and bid good-
bye.

22. Sample Report
- Clinical Information:
- Description:
- Impression:

23. Description
- A supine view of the abdomen demonstrates a normal bowel gas pattern, with no evidence
of free intraperitoneal air, pathologic calcification, or soft tissue mass. The bony structures
are unremarkable.
- Following the administration of intravenous contrast, prompt and symmetric bilateral
nephrograms are identified.
- The kidneys are normal in size, contour, axis, and position.
- Prompt excretion is noted bilaterally into normal renal collecting systems and ureters, with
no evidence of intraluminal filling defect or mucosal irregularity.
- The bladder is smooth-walled, with no evidence of intraluminal filling defect or mucosal
abnormality.
- There is no significant post void residual.

24. Examples for abnormal findings

25. Example for Findings – Before dye injection
Stone in the left ureter

26. Example for Findings – Before dye injection
classic lobar pattern of calcification,
which is pathognomonic of end-stage
renal tuberculosis. Ureteral
calcification is also noted, which is
fainter in upper parts (arrowheads)

27. Example for Findings – Kidneys
Horseshoe Kidney - Tissue Bridge Across
Midline Causes Abnormal Orientation of Renal
Axis

28. Example for Findings – Kidneys
Extravasation of Contrast from Left Kidney
Secondary to High Grade Obstruction

29. Example for Findings – renal collecting system and ureters
Pyelo-ureteric Junction Obstruction Shows as
Dilation of Right Renal Pelvis and Calyces.

30. Example for Findings – renal collecting system and ureters
Dilation of Left Renal Pelvis and Calyces
Above the Obstructing Calculus

31. Example for Findings – renal collecting system and ureters
Stab wound of right ureter shows
extravasation (at arrow) on intravenous
urogram.

32. Example for Findings – renal collecting system and ureters
Crossed Renal Ectopia on the Left Kidney and
Absent Right Kidney.

33. Example for Findings – Urinary Bladder
Round shadow on right side of bladder later
shown to be a bladder cancer.

34. Example for Findings – Urinary Bladder
Nodular squamous cell carcinoma of the
bladder. Dilated left lower ureter probably
secondary to obstruction by tumor.
Nonvisualization of the right ureter caused
by complete occlusion

35. Example for Findings – Urinary Bladder
Intravenous urography showed no
obstructive uropathy, but symmetric
diverticula could be seen near both ureteral
orifices (arrows). These lesions, known as
Hutch diverticula, are usually congenital
rather than occurring as a result of a
neurogenic bladder or an infection or
obstruction.

36. Benign prostatic hyperplasia. White = bladder.
Dark = benign enlargement of prostate,
pushing down on inferior bladder

37. IVU vs KUB & USG vs NCCT

38. USG & KUB vs IVU
S J Andrews, P T Brooks, D C Hanbury, et al. Ultrasonography and abdominal radiography versus
intravenous urography in investigation of urinary tract infection in men: prospective incident
cohort study. BMJ 2002;324:454. http://www.bmj.com/content/324/7335/454. Accessed April 5,
2014.
Participants: Consecutive series of men (n=114) referred to the department of urology for investigation of
proved urinary tract infection.
Results: Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being a
poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder and
ultrasonography detected more abnormalities than intravenous urography alone. No important
abnormality was missed by this combination (sensitivity 100% and specificity 93%).
Conclusions: Ultrasonography with abdominal radiography is as accurate as intravenous urography in
detecting important urological abnormalities in men presenting with urinary tract infection. This
combination is safer than intravenous urography and should be the initial investigation for such patients.
Additional determination of urinary flow rate is useful for the assessment of an incompletely emptying
bladder.

39. USG & KUB vs IVU
Zafar Amin, Abdul Salam. ROLE OF ULTRASOUND AND INTRAVENOUS UROGRAPHY IN PATIENTS
WITH RENAL COLIC. Pakistan Armed Forces Medical Journal. 2011; 7(4).
http://www.pafmj.org/showdetails.php?id=529&t=o . Accessed April 5, 2014.
Materials and Methods: One hundred and eleven consecutive patients with clinically suspected urinary tract
calculi were selected for study. At first they underwent sonography along with x-ray KUB and then IVU.
We evaluated the sensitivity, specificity, negative /positive predictive values and accuracy of US X-ray
KUB combination and IVU for detecting renal / ureteric calculi while final diagnosis (gold standard)
obtained from the results of clinical course/urological procedures.
Results: Out of 111 consecutive patients 46 (41 %) were normal and 65 (59 %) patients had KUB calculi.
US along with x-ray KUB detected 59 patients and missed 6 patients and likewise IVU detected 61
patients out of 65 patients. Sensitivity, specificity, and accuracy of both these modalities are almost
similar with IVU having slightly upper edge.
Conclusion: IVU remains an important investigation in the assessment of calculus and other causes of
urinary tract obstruction. Ultrasound in combination with x-ray KUB is an excellent modality having almost
similar diagnostic capability as IVU in detecting KUB calculi along with many more significant advantages,
as it has less radiation dose, relatively inexpensive, universally available, easily applicable and high
diagnostic efficacy.

40. NCCT vs IVU
N Khan, Z Anwar, AM Zafar, F Ahmed, et al. A comparison of non-contrast CT and intravenous
urography in the diagnosis of urolithiasis and obstruction. African Journal of Urology . 2012;
18(3). http://www.ajol.info/index.php/aju/article/view/84103 . Accessed April 5, 2014.
Subjects and methods: This is a retrospective review of radiological and clinical data of patients with
suspected urolithiasis or ureteric obstruction who had both NCCT and IVU performed within 30 days of
each other. The data were analyzed using the statistical packages Epidata™ and SPSS™. The number
of calculi, presence of hydronephrosis and hydroureter, cysts and ureteric wall thickening were evaluated
in both NCCT and IVU. Additionally, perinephric stranding in NCCT and delayed excretion in IVU were
also evaluated.
Results: Of the 139 patients (87 male and 52 female), 102 patients (73.4%) had positive findings on
NCCT and 71 (51.1%) on IVU. On NCCT 133 stones were detected in 80 patients (57.6%), 67 (48.2%) in
the kidney, 63 (45.2%) in the ureter and 3 (2.2%) in the bladder. The findings on NCCT were
hydronephrosis in 43 (31%), hydroureter in 34 (24.5%), perinephric stranding in 7 (5%), ureteric wall
thickening in 4 (2.8%), renal mass and renal cyst in 1 (0.7%) each. On IVU 86 stones were detected in 46
patients (33.1%), 53 (38.1%) in the kidney, 31 (22.3%) in the ureter and 1 (1.4%) in the bladder. The
findings on IVU were hydronephrosis in 31 (22.3%), hydroureter in 18 (13%), delayed excretion in 5
(3.6%), renal cyst and ureteric wall thickening in 1 (0.7%) each. Incidental findings were more common on
NCCT (23/139, 16.6%) than IVU (2/139, 1.4%).
Conclusions: NCCT compared with IVU had a higher detection rate for ureterolithiasis, especially for
stones in the distal ureter. An added benefit of NCCT was the detection of significant additional findings.