The document provides a comprehensive overview of intravenous urography (IVU), detailing its purpose, procedure, and the anatomy of the urinary system. It discusses the anatomical features of the kidneys, ureters, and bladder, alongside the methods and precautions involved in conducting the IVU test, including indications, contraindications, and patient preparation. Additionally, it outlines various imaging techniques during the procedure and the importance of contrast media in visualizing renal structures.

1. RADIOGRAPHIC PROCEDURE :IVU
PRESENTED BY:PRATIVA KHANAL
BSC.MIT 2ND
YEAR
NMCTH

2. INTRODUCTION
• Also known as excretion urography
• Most frequently employed radiologic investigation of renal drainage.
• The contrast material is administered intravenously. Contrast excreted by
kidneys, rendering the urine opaque to x-rays and allowing visualization of
the renal parenchyma together with calyces, renal pelvis, ureters and
bladders.
• Pyelography - radiographic demonstration of the renal pelvis and calyces.
• So, IVP is a misnomer.
• Term “pyelogram” is reserved for retrograde studies visualizing only the
collecting system

3. ANATOMY
Organs of the urinary system:
• Kidneys
• Ureter
• Urinary bladder
• Urethra

4. KIDNEY-EXTERNAL ANATOMY
• KIDNEYS –held in place on the posterior body wall and protected by three
external layers of connective tissue
• 1.RENAL FASCIA
• 2.ADIPOSE CAPSULE: middle and thickest layer,consist of adipose tissue
that wedges each kidney in place and shield it from physical shock
• 3.RENAL CAPSULE:extremely thin layer of dense irregular connective
tissue that covers the exterior of each kidney like plastic wrap,Protect
kidney from infection and physical trauma

5. Kidney: Internal structure
• The parenchyma of kidney is divided into two major parts: 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 the renal pyramid(of Malpighi)
• Between the renal pyramids are the projections of cortex called renal
cortex of Bertini
• Nephrons, the urine producing functional structures of the kidney,
span the cortex and medulla

6. Kidney: Internal structure
• The tip, or papilla, of each pyramid
empties urine into minor calyx
• Minor calyces empty into major
calyces, and major calyces empty into
the renal pelvis, which becomes the
ureter
• Minor calyces:8-10 in number. Multiple
papillae drain into single calyx
• Major calyces:2-4 or more connects
minor calyces to renal pelvis

7. Position of kidney
• Located in lumbar fossa
• Left kidney is slightly higher than the right
• Upper pole of left kidney is at the level of T11-T12
• Upper pole of right kidney is at the level of T12-L1
• Lower limit of kidney is way above iliac crest, at the
level of L3 or L3-l4 IV disc.
• Medial border is parallel to psoas margin
• The psoas muscles cause the longitudinal plane of the
kidney to form a vertical angle of about 20 degree with
the mid saggital plane

8. ureter
• A pair of thick wall cylindrical tubes
• Convey urine from corresponding kidneys to U.B
• 25-30 cm long and has three parts:
• Abdominal ureter: from the renal pelvis to the
pelvic brim
• Pelvic ureter: from the pelvic brim to the
bladder
• Intravesical or intramural ureter: within the
bladder wall

9. Course
• The ureter begins its descent to the bladder by
running along the medial aspect of the psoas
muscle. Here, the ureter lies anteriorly and slightly
medial to the tips of the L2-L5 transverse processes
• It enters the pelvis anteriorly to the sacroiliac joint
at the bifurcation of the common iliac vessels (at
the pelvic brim) and then courses anteriorly to
the internal iliac artery down the lateral pelvic
sidewall
• At the level of the ischial spine it turns forward and
medially to enter the posterolateral wall of the
bladder, where it runs an oblique 1-2 cm course,
before opening into the bladder at the internal
ureteric orifice

10. NORMAL CONSTRICTIONS
Along their course the ureters are constricted
• At the ureteropelvic junction ,just inferior to the
kidney
• Point where the ureters cross the common iliac
vessels at the pelvic brim
• Crossing of ureter by ductus deferens in male
and broad ligament of uterus in female
• Where ureters enter the wall of the
bladder(narrow one)
• Opening at the lateral angle of trigone of bladder

11. URINARY BLADDER
• Muscular sac
• Has ability to expand and collapse
• Stores and expels urine
POSITION:
• Full bladder-spherical(Expands into the abdominal cavity)
• Empty bladder-lies entirely within the pelvis

12. SHAPE:
• Tetrahedral-when empty
• Ovoid-when distended
CAPACITY
• Average-120 to 320ml urine
• Loss of voluntary control over
micturition-at 800ml urine
PARTS
• Body:major part,collects urine
• Neck:funnel shaped extension of
the body connecting with urethra

14. PHYSIOLOGY
• For the delineation and differentiation of cysts and tumor masses within the
kidney , the renal parenchyma is opacified by the iv introduction of contrast
media.
• Once the contrast media enters the blood stream,it is conveyed to the renal
glomeruli and is discharged into the capsules with glomerular filtrate,which
is excreted as urine.
• With the reabsorption of water the contrast media becomes sufficiently
concentrated to render the urinary canals opaque

15. • In recent years, there has been a decline in the intravenous urogram
because of:
• Development of newer imaging modalities like CT Scan, USG, MRI
• Adverse effects of contrast media.
• Cost containment.

16. INDICATIONS
In Adults
• Suspected urinary tract pathology
• Investigation of persistent or frank hematuria
• Renal /ureteric calculi (prior to endourological procedure)
• complex urinary tract infection (including Renal TB)
• Ureteric fistulas and strictures
• Suspected transitional cell carcinoma
• Obstructive uropathy

17. In Children:
• Evaluation of VATER anomalies- 90% has Renal anomalies
• Malformation of genitalia –hypospadiasis
• Enuresis
• Constant or intermittent dampness in girls to rule out ectopically
inserted ureter
• Anorectal anomalies

18. CONTRAINDICATIONS
Absolute CIs:
• Past h/o severe adverse reaction to contrast media.
• HOCM carries 20% risk and LOCM decrease risk to 5% , and in those cases
radioisotope scan , USG, CT,
• MRI provide alternative means of investigations proven hypersensitivity
to iodine.
Relative CIs: (@ABCD MS)
• Asthma /significant allergic history
• B-blockers

19. • Chronic Renal insufficiency
• Cardiac disease –Cardiac failure /arrhythmias may be precipitated and in
these cases lower risk with LOCM
• Diabetes Mellitus
• Dehydration
• Multiple Myeloma
• Metformin therapy: Co-administration of metformin (glucophage)+ iv
contrast to diabetics may lead to acute alteration of renal function and lactic
acidosis, therefore metformin is withheld
• Sickle cell anemia

20. • Thyrotoxicosis
• Pregnancy
• A contrast material is excreted by a similar mechanism to creatinine, a
serum creatinine level above 200micromol/l would indicate a patient
who would unlikely to excrete contrast satisfactorily.
• So, cautions in diabetics and patients with severe disturbances of
liver and kidneys

21. Procedure: Equipments
• 600 mA fluoroscopy guided x-ray unit
• Abdominal compression equipment
• Medium/Regular film screen combination in variety of sizes.
• Pads and immobilization aids
• Intravenous administration equipment:50ml syringe, filling needle, skin
prep, sticky tape
• Selection of needles, venflon 19 gauge
• Torniquet or blood pressure cuff
• Emergency drugs and equipments

22. Contrast medium and injection data
• Contrast medium and injection data
• Ionic and non-ionic are available, both of which are excreted by
different mechanisms. The ionic group is excreted mainly by
glomerular filtration causing a peak concentration of iodine in the
renal cortex faster compared to nonionic which is mainly excreted by
proximal tubules
• The timing for first radiograph to demonstrate parenchymal phase
best will thus differ

23. • HOCM or LOCM 370 are acceptable but the following “high risk”
group should receive LOCM.
• Infants/small children/elderly
• Poorly hydrated patients
• Those with renal /cardiac failure
• Patients with diabetes, myelomatosis, sickle cell disease
• Patients with previous contrast medium reactions/ strong allergic
history

24. Adults Children
Non ionic contrast media( Iohexol-
omniopque)
300 mg I/ml-40-80 ml or
350 mg I/ml 40-80ml
240 mg I/ml 300mg I/ml
< 7 kg :4 ml/kg 3 ml/kg
> 7 Kg :3 ml/kg 2 ml/kg
Ionic contrast media 300 to 600 mg Iodine
equivalent/kg body weight.
Maximum of 40 gm of Iodine.
Meglumine iothalamate or
diatrizoate 60% containing
equivalent of 280 mg I/ I
ml of iodine. Dose is 1-2 ml /kg
body weight
Below 6 months: 10ml
6 months to 2 years:20ml
2-10 years:20-40ml

25. PATENT PREPARATION
• Bowel preparation is important as abdomen should ideally be free of
radio-opaque fecal matter and gas
• NPO (No food for 4-6 hr prior to examination)
• Should have plenty of oral fluids
• Laxatives- Dulcolax 2-4 tabs at bed time for 2 days prior to procedure
• Bowel preparation is now generally regarded as unhelpful and it is
unpleasant to the patient

26. IS FLUID DEPRIVATION INDICATEED ?
• Traditionally fluid was restricted prior to IVU in order to improve
opacification of collecting system
• However, dehydration increase risk of nephrotoxicity which may be
permanent in patients with DM, Multiple Myeloma, Hyperuricemia,
Sickle Cell Disease and pre-existing renal disease

27. • Risk of irreversible renal damage to renal function in previously
healthy kidney due to contrast agent is very low
• Also, with the advent of modern non-ionic contrast agents which do
not provoke an osmotic diuresis, degree of opacification is unlikely to
be significantly altered by dehydration.
• So, fluid restriction should be avoided and if there is a risk that the
patient is dehydrated before the IVU, this should be corrected first.

28. SIGNING INFORMED CONSENT FORM
• Venipuncture is an invasive procedure that carries risks for
complications, especially when contrast media is injected. Before
beginning the procedure, the technologist must ensure that the
patient is fully aware of these potential risks and has signed an
informed consent form.
• If a child is undergoing venipuncture, the procedure should be
explained to both the child and the guardian, and the guardian should
sign the informed consent form.

29. RADIATION PROTECTION
• “Pregnancy rule” should be applied
• 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 a lead rubber sheet over upper thighs
below lower edge of symphysis pubis
• When bladder and lower ureters are not included then
female can also be given gonad protection

30. •Most adverse reactions are likely to occur within few
minutes after injection. So, Emergency drugs (eg.
Adrenaline), Oxygen and Resuscitation equipments
should also be readily available
•Doctor (radiologist) should be available in the
department

31. Mode of injection
• Contrast media is usually given as a IV bolus injection within 30-
60
seconds
• The density of the nephrogram is directly proportional to
the plasma concentration of contrast media
• More iodine increases the density of the nephrogram
• Large doses of contrast media increase diuresis which distends
the collecting system thus increasing the diagnostic information
from the urogram

32. PROCEDURE
• Patient should be placed in supine position with pelvis at cathode side of the
tube
• A support should be placed under patient's knees to reduce lordotic curvature
of lumbosacral spine and provide comfort
• A scout film should be taken including the kidneys, ureters, bladder and urethral
regions on a large size film
• Contrast media should be injected intravenously into a prominent vein in the
arm
• Test injection of 1ml of contrast should be given and patient should
observed for 1 min to look for any contrast reactions
• Then the rest of the contrast should rapidly injected within 30-60 seconds

33. Classic series of plain flims
• Preliminary/Control film
• Immediate film- Nephrogram
• 5-min film
• 15-min compression film
• 15-min release film
• Post-micturition film

34. Stereotypical appearance of normal IVU
• Takes 15-20 seconds for contrast to reach renal arteries following iv
injection
• At this stage, its concentration is maximum in the vascular
compartment
• This falls rapidly as contrast medium begins to escape into the
extracellular compartment and undergoes rapid glomerular filtration
and enters renal tubules.
• In first minute of IVU, healthy kidneys (assuming a normal
cardiovascular system) shows diffuse enhancement-Nephrogram
• During this phase renal size and outline are seen.

35. • In roughly first half minute-contrast in the vascular compartment
dominated and cortex is much enhanced than the medulla.
• The differentiation is sometimes visible in the immediate film of IVU
seris( but regularly visible on the CT performed at this stage)
• In second half minute- contrast in the tubule increases and
enhancement of the kidneys in more diffuse.

36. • At 1 minute: Contrast begins to appear in the calyces
• After 1 minute: Contrast in the normal calyces begins to drain
immediately into the pelvis and ureter- Pyelogram
• On the release of the compression, there is transient increase in flow
down the ureter and release film offers the best chance of
demonstrating the ureters.
• Normal ureters exhibit peristalsis and on single film it is uncommon to
demonstrate the entire length of both( or even either) ureter.

37. Preliminary/Control film
• Plain film to demonstrate the urinary
tract prior to the administration of
contrast media
• kVp=70-80(low kvp), mAs= 60-70
• Supine full length AP view of the
abdomen on inspiration
• It provides valuable information and
sometimes indicates probable
diagnosis.

38. NEED OF CONTROL FILM
• To check exposure factor and centering
• To check state of bowel preparation
• Obvious pre-existing pathology-urinary tract calculi/calcification

39. IMMEDIATE FILM/NEPHROGRAM
• Immediate film shows nephrogram
• Exposed 10-14 seconds after contrast
injection
• Renal parenchymal is opacified by contrast
media in renal tubules
• Aim is to see renal outlines

40. 5- minute film
• 5 minute film shows nephrogram, renal pelvis, upper part of ureter
• Compression band is now applied on patient's abdomen and the
balloon is positioned on anterior superior iliac spine where ureters
cross pelvic brim. This is to produce better pelvicalyceal distension
• Compression inhibits ureteric drainage and promotes distension of
pelvicalyceal system, optimizing their visualization

42. 5-min film
BEFORE COMPRESSION AFTER COMPRESSION

43. Compression is contraindicated in
• Renal trauma
• Large abdominal mass
• Abdominal aneurysm
• After abdominal surgery
• If 5 minute film already shows dilated calyces or if calyces and pelvis
are not adequately opacified, obstruction exists and compression
band should not be applied.
• If compression is applied, a film is taken after 5 minutes of
compression i.e. 10 minute film, centred on kidneys to demonstrate
distended collecting system and proximal ureters

44. 15-min Compression film
• AP view of renal areas
• Adequate distension of pelvicalyceal system
with opaque urine
• Compression is removed when satisfactory
demonstration of pelvicalyceal system has
been achieved

45. 15-min release film
• Supine AP film
• To show whole urinary system

46. Post Micturition film
• Based on the clinical findings and
radiological findings of earlier films , either a
full length abdominal film or a coned view
of the bladder with tube angled 15 degree
caudad and centered 5 cm above pubic
symphysis
• It is used to assess for residual urine,
bladder mucosal lesions, diverticula,
bladder tumor, outlet obstruction and
vesiculoureteric reflux

47. Main aim of films is to
• Assess bladder emptying
• To demonstrate return of dilated upper tracts with relief of bladder
pressure
• Aid diagnosis of VUJ calculi
• Diagnosis of bladder tumors
• Demonstrate urethral diverticulum

48. Special views in IVU
• Oblique view: To project the ureter away from spine and to separate
overlying radio opaque shadows mimicking calculi. Oblique
views are also used for visualisation of posterolateral aspects of
bladder; differentiation of extrinsic or intrinsic renal, ureteral or
bladder masses and for doubtful urethral masses.
• Erect film is used to
• Provoke emptying of urinary tract;
• Demonstrate layering of calculi in cysts and abscesses;
• Detect urinary tract gas not seen in other films;
• Have optimum demonstration of renal ptosis, bladder hernia,
cystocele and areas of obstruction in ureter

49. • Prone film is used for
• Viewing of ureteral areas not seen in supine films,
• Demonstration of renal ptosis and bladder hernia
• Delayed films in IVU are taken 1-24 hours after injection. Patients should
always be instructed to void prior to delayed films so that a calculus in the
distal ureter is seen well.
Usual sequence of delayed films is after 1 hr, 3hrs, 6 hrs, 12 hrs and 24 hrs
Delayed films are used in
• Cases of obstruction where early nephrogram is seen but collecting system is
not seen.
• Long standing hydronephrosis in which renal parenchyma is seen but
collecting system is not visualised until many hours later.
• Congenital lesions like non-visualised upper calyceal system with ectopic or
obstructed ureter

50. Modifications of Urogram
Diuretic urogram:
• It is useful when intermittent obstruction is suspected but
cannot be confirmed by standard urogram. Therefore the use
of diuretics shows an acutely developing hydronephrosis if true
intermittent hydronephrosis is present.
• I.V. frusemide is used to induce diuresis which distends the
renal pelvis. The dose of Lasix is 0.3-1 mg/kg in adults and
0.5 mg/kg in children.
• The film is taken 5-10 minutes after administering the diuretic.

51. Modifications of Urogram
• Tailored Urogram: It modifies the urogram to provide the information
needed to include or exclude the clinical problem and tailor the
urogram for that. The study is terminated as soon as the desired
information is available.
• Hypertensive Urogram:It is also called minute sequence urogram.
Films are taken 1, 2, 3, 5 minutes after injection of contrast media.
Although the findings are of value, IVU cannot be used for screening
of hypertensives as there are many false positive and false negative
results.

52. Modifications of Urogram
• Drip infusion urography: Contrast is given in 500 ml normal saline. Now,
this procedure is not widely used.
ADVANTAGES:
Nephrogram persists for longer time.
Enhanced diuresis from the additional contrast media and water
volume will distend the collecting system and ureters more fully.
 Collecting system is visualised for longer times.
No significant increase in contrast reactions.
Ureteral compression need not be used because excellent ureteral
visualization is usually obtained.
Administration is easy

53. DISADVANTAGES:
• Overloads the patient with more Iodine than necessary.
• Calyceal blunting may be produced, suggesting abnormal dilatation.
• May lead to pyelosinus extravasation and pain in patients with
partial obstruction.
• Increased diuresis may decrease visualization if there is low fixed
specific gravity.
• May cause CCF in patients with borderline cardiac complaints.
• An initial vascular nephrogram is not obtained.

54. Modifications of Urogram
Limited urography: The procedure is useful for follow up of earlier
pathology. Films taken :
• a.KUB
• b.15 min
• c.Post void.
Emergency urography: Done in the cases of ureteric colic. Films taken:
• a.KUB
• b.15 min

55. Complications
Due to contrast:
• Minor reactions (5%): Nausea, vomiting, mild rash, light headache,
mild dyspnoea.
• Intermediate reactions (1 %): Extensive urticaria, facial oedema,
bronchospasm, laryngeal oedema, dyspnoea, hypotension.
• Severe reactions (0.05%): Circulatory collapse, pulmonary oedema,
severe angina, myocardial infarction, convulsions, coma, cardiac or
respiratory arrest.

56. Complications
Due to technique:
• Upper arm or shoulder pain.
• Extravasation of contrast at the injection site.

57. AFTERCARE
• 1. Observation for 6 hours.
2. Watch for late contrast reactions.
3. Prevention of dehydration.
4. In high risk patients-renal function tests should be done to
watch for deterioration

58. ADVANTAGES
• The strength of urography are:
• Rapid overview of the entire urinary tract,
• Detailed anatomy of the collecting system
• Demonstration of calcifications
• It is sensitive for obstruction
• Low cost

59. DISADVANTAGES
• It depends on the kidney function
• Provides little assessment of the parenchymal structures
• The perinephric spaces is not demonstrated
• May miss small stones
• It provides no assessment of the glomerular filtration rate

60. Horseshoe Kidney: Flowervase Appearance
• The connection of
the horseshoe
kidneys in the
isthmus is usually
seen better on
nephrogram phase of
IVU

61. Ectopic Ureter: Drooping lily appearence
•The lower pole moiety is
displaced inferolaterally by an
upper pole hydronephrosis

62. Ureterocele:Cobra head appearance
•Seen as a non opacified
structure surrounded by
urine in the bladder

63. Medullary sponge kidney:
•Ectasia(fusiform or cystic) of the
collecting ducts within the renal
pyramids give paint brush
appearance

64. Polycystic Kidney Disease
• The calyces have a classical
stretched pattern due to
presence of multiple cysts

65. Crescent/Rim sign
• Contrast may be seen with
a curvilinear configuration
just peripheral to the
calyces
• This appearance has been
termed `crescents' and is
thought to represent
contrast stasis in collecting
ducts displaced around
distended calyces

66. REFLUX NEPHROPATHY
• Small Kidney
• Widespread cortical loss (esp. at upper
pole)
• Clubbing of calyces

67. CALICEAL DIVERTICULUM

68. COLLAPSED BLADDER

69. TRANSITIONAL CELL CARCINOMA

70. REFERENCES
• Textbook of Radiology, David Sutton, 7th edition
• Fundamentals of Radiology, Brynts and Helms
• Radiological procedure,Bushan N Lakhar

71. •THANK YOU