This document describes retrograde pyelography, a medical imaging procedure used to visualize the kidneys and ureters. It begins by introducing retrograde pyelography and its indications. These include evaluating the kidneys when normal visualization is not possible on other exams or when investigating hematuria, filling defects, or ureteral fistulas. The document then discusses patient preparation, anesthesia used, technique, required films, complications, and compares retrograde pyelography to other imaging modalities like MRI uretherography and CT urethrography. In summary, retrograde pyelography involves injecting contrast through ureters under fluoroscopy to visualize the pelvicalyceal system and evaluate various conditions of

1. RETROGRADE
PYELOURETEROGRAPHY
PRESENTED BY:
DR. DILIP SHAH

2. INTRODUCTION
• It is the roentgenographic demonstration of the renal pelvis and
ureter by the retrograde injection of radio-opaque material through
the ureters.

3. INDICATIONS
• 1. Absent or unsatisfactory visualisation of the collecting system on IVU.
2. Unexplained hematuria, when the ureters have not been completely
visualised by IVU.
3. Evaluating persistent intraureteral or intrapelvic filling defects on
IVU.
4. Demonstrating the exact site of ureteral fistula.
5. Brushing and/or biopsy of suspected lesions.
6. Evaluating the collecting system in patients who cannot receive
intravenous contrast medium.

4. CONTRAINDICATION
• Acute urinary tract infection
• Recent instrumentation like cystoscopy or other transurethral endoscopy- the
small mucosal laceration may lead to contrast extravasation into the corpus
spongiosum thus leading to septic infection.
• Pregnancy

5. CONTRAST MEDIA
• Ionic contrast media can be used safely, however if there is any
specific contraindication like known hypersensitivity etc., Non ionic
contrast media may be used.
• The Ionic contrast media is preferred
due to its low cost.
• The strength of contrast media should be
150-200 mg I/ml.
• Contrast media should not be too dense as it will obscure small
lesions in the ureters and the pelvis.

6. PROCEDURE
• Patient Preparation
• Bowel preparation with cathartics is not routinely performed.
Preliminary Film
• Full length supine AP abdomen before the examination is started.
Anaesthesia
• May be performed under local anaesthesia although general
anesthesia is often required. Sterile precautions are mandatory

7. TECHNIQUE
• In the Operation theatre:
• The surgeon catheterizes the ureter via a cystoscope and advances the ureteric catheter to the
desired level. Contrast medium is injected under fluoroscopic control and spot films are exposed.
In the X-Ray Department
• With ureteric catheter(s) in situ, the patient is transferred from the operation theatre to the
X-ray department if necessary.
• Urine is aspirated and under fluoroscopic control.
• Contrast medium is slowly injected. About 3-5 ml is usually enough to fill the pelvis
but the injection should be terminated before this if the patient complains of pain or fullness in
the loin.

8. FILMS
• Using the undercouch tube
(a) Supine PA film of the kidney
(b) Both 35° anterior obliques of the kidneys. Low kVp (65-75 kVp) technique is
used to visualise calculi and contrast medium.
(c) If there is pelvi-ureteric junction obstruction, the contrast medium in the pelvis
is aspirated. The films are examined and if satisfactory, the catheter is withdrawn,
first to 10 cm below the renal pelvis and then to lie above the ureteric orifice. About
2ml of contrast medium is injected at each of these levels and films taken.

10. • AFTER CARE
1. Post anesthetic observation.
2. Prophylactic antibiotics may be used

11. COMPLICATIONS
• 1. Due to anaesthesia
• Complications of general anaesthesia.
2. Due to the contrast medium
• Contrast medium can be absorbed from the renal pelvis, giving rise to adverse
reactions. However, the risks are much less than with excretory urography
• Chemical pyelitis-if there is stasis of contrast medium.
• Extravasation due to overdistension of the pelvis.

12. • 3. Due to technique
• Introduction of infection
• Mucosal damage to the ureter
• Perforation of the ureter or pelvis by the catheter

13. COMPARISON OF MRMCU AND RGU
WITH NEWER MODALITIES
• Advantages of MR - MCU and RGU
1. These studies are most valuable to detect congenital anomalies, posterior urethral
injuries, and with urethral and periurethral tumours.
2. It is a better imaging modality for assessing the post traumatic pelvic anatomy &
non-invasive method for measuring stricture length.
3. It clearly shows the extent of scar tissue as well as prostatic displacement.
4. MR uretherography is more accurate in estimating the length of obliterative
urethral stricture than RGU combined with Voiding cystouretherography

14. Limitations of conventional RGU combined with
voiding cystouretherography:
• 1. It does not provide accurate length of the defect because of poor
prostatic urethral filling.
2. It does not provide information regarding extent of fbrosis of
corpora spongiosa or prostatic displacement.
3. The stricture length is overestimated if bladder neck does not
relax.

15. Advantages of CT urethrography
• 1. C.T. voiding uretherography is more comfortable to the patient
because it requires adaptation only in one position.
2. Less time consuming; takes only few seconds
3. Comparison of lual size & stricture length for follow up is
possible.
4. Extraluinal pathology can be detected
5. Good patient compliance
6. Ability to survey whole urinary tract from kidney to urethra.

16. Retrograde pyelogram
demonstrating
the pelvicalyceal system and ureter
down to the vesicoureteric
junction.

17. URETERAL
STENOSIS
Two views of the retrograde pyelography
showing stenosis of the lower portion of the
right ureter at the level of the iliac vessels.
There is severe dilatation of the medial and
proximal portions of the right ureter and
hydronephrosis.

18. URETERAL
STRICTURE

19. A case ofTCC
Filling defect is seen in the
right ureter –
RAT BITE SIGN

20. Goblet sign or
Champagne glass sign:
•irregular ureteric
narrowing with proximal
shouldering termed the
goblet sign
•Focally dilated
intraluminal mass
Causes of goblet cells
• TCC of ureter
•Metastatic disease in to
ureter
•Endometriosis involving
ureter

21. Retrograde pyelogram shows the area of narrowing at the site
of ureteral implantation into the bladder (arrow).

22. Retrograde pyelogram shows rounded filling defects in many
calyces representing papillary necrosis.

23. Retrograde pyelogram with pyelosinus extravasation due to
overdistension of the collecting system.

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