INTRAVENOUS PYELOGRAPHY

Danielle AquinoKevin BacilesJustin ClaroLuisa ManaloDona SisonUrography is a general term for the radiographic investigation of the renal drainage or collecting system.The plain abdominal radiographic image provides very little information about the urinary system. The gross outline of the kidneys may be faintly demonstrated because of the fatty capsule surrounding the kidneys. However, in general, the urinary system blends in with the other soft tissue structures of the abdominal cavity, thus requiring contrast media to radiographically visualize the internal, fluid filled portion of the urinary system. This radiographic procedure in which contrast media is injected intravenously is termed as an INTRAVENOUS UROGRAM. General radiographic examination of the urinary system is termed urography. The excretory techinque of urography is used in examinations of the upper Urinary tracts in infants and children and is generally considered to be the preferred technique in adults unless use of the retrograde technique is definitely indicated. Since the contrast medium is administered intravenously and all parts of the urinary system are normally demonstrated, the excretory technique is correctly referred to as intravenous urography. The term pyelography refers to the radiographic demonstration of the renal pelves and calyces. For years the examination has been erroneously called an intravenous pyelogram (IVP). Excretion urography has long been the cornerstone of the imaging evaluation of urinary tract disease. However, other imaging modalities such as,CT, and MRI are being used with increasing frequency. The declining use of urography in clinical practice presents a challenge for instruction in urographic technique and interpretation. In addition, alternative modalities also have their limitations, and despite their increasing use, the ideal global urinary tract examination remains controversial. Nevertheless, urography may still be important in the diagnosis of some urinary tract disease processes.Two methods:1. Excretory Urography (Intravenous Urography/ Functional Method/ Descending Urography) most frequently employed in which contrast is routinely administered intravenously or to the normal flow of blood stream.Examples: Intravenous Pyelography, Hypertensive IVP, Drip Infusion IVP)

2. Instrumental Method (Ascending Method/Non-functional Method) contrast is introduced directly into the canal by means of catheterization or instrumentation or against the natural flow of blood stream.Examples: Ureteral Catheterization, Urethral Catheterization, Cystoscopy, Percutaneous Antegrade Urography/Retrograde

Anatomy Kidneys a pair of gland like organ that function to remove waste materials from the blood and eliminate waste in the urine that they excrete to the extent of about 1-2 liters per day.(Kidneys are somewhat higher in individual with hypersthenic habitus and somewhat lower for asthenic habitus. Right kidney is lower than the left because of the large space occupies by the liver. The kidneys are approximately located between the level of T12-L3. Kidneys have a respiratory excursion of approximately 1 and normally drop no more than 2 in the change of supine to erect. The kidneys are bean-shaped bodies. The lateral border of each organ is convex, and the medial border is concave. They have slightly convex anterior and posterior surfaces, and they are arbitrarily divided into upper and lower poles. The kidneys measure approximately 4.5 inches (11.5 cm) in length, 2 to 3 inches (5 to 7.6 cm) in width, and about 1.25 inches (3 cm) in thickness. The left kidney usually is slightly longer and narrower than the right kidney.

Excretory ducts transport urine to the exterior through:a. Calyces beginning stem of variable number.b. Renal Pelvis expanded portion of the ureter at the union of major calyces.Together, these are known as the Pelvicalyceal System.The calyces are cup-shaped stems aris ing at the sides of the papilla of each renal pyramid. Each calyx encloses one or more papillae, so that there are usually fewer ca lyces than pyramids. The beginning branches are called the minor calyces (numbering from 4 to 13), and they unite to form two or three larger tubes called the major calyces. The major calyces unite to form the expanded, funnel-shaped renal pelvis. The wide, upper portion of the re nal pelvis lies within the hilum, and its ta pering lower part passes through the hilum to become continuous with the ureter

*note: The essential microscopic components of the parenchyma of the kidney are called nephrons. Each kidney contains approximately 1 million of these tubular structures.

Ureters pair of long tubes one extending from the pelvis of each kidney, which is 10-12 inches in length.It descends behind the peritoneum and in front of the psoas muscle and the transverse processes of the lumbar vertebrae, passes inferiorly and posteriorly in front of the sacral wing, and then curves anteriorly and medially to enter the posterolateral surface of the urinary bladder at approximately the level of the ischial spine. The ureters convey the urine from the renal pelves to the bladder by slow, rhythmic peristaltic contractions.3 Constricted Points:1. Ureteropelvic Junction (UPJ) where the renal pelvis funnels down into the small ureter.2. Brim of the Pelvis where the iliac blood vessels cross over the ureters.3. Ureterovesical Junction (UVJ) (bladder inlet) where the ureter joins the bladder.Most kidney stones that pass down the ureter tend to hang up at the third site, and once the stone passes this point and moves into the bladder, it generally has little trouble passing from the bladder and through the urethra to the exterior. Urinary Bladder musculo-membranous sac which receives the distal portion of the ureter and serves as reservoir for urine.The bladder is situated immediately posterior and superior to the pubic symphysis and is directly anterior to the rectum in the male and anterior to the vaginal canal in the female. The most fixed part of the bladder is the neck, which rests on the prostate in the male and on the pelvic diaphragm in the female.When empty, it is pyramidal in shape and presents an apex behind the symphysis pubis, a base anteriorly and a superior and two inferolateral surfaces. The bladder varies in size, shape, and position according to its content. It is freely movable and is held in position by folds of the peritoneum. When empty, the bladder is located in the pelvic cavity. As the blad der fills, it gradually assumes an oval shape while expanding superiorly and anteriorly into the abdominal cavity. The adult blad der can hold approximately 500 ml of fluid when completely full. The desire for mic turition (urination) occurs when about 250 ml of urine is in the bladder. Urethra serves to convey urine to the exterior, a narrow musculomembraneous canal with sphincter type of muscle at the base of the bladder.a. Female Urethra passes along the thick anterior wall of the vagina to the external urethral orifice.b. Male Urethra extends from the bladder to the end of the penis.The urethra arises at the internal urethral orifice in the urinary bladder and extends about I Y'2 inches (3.8 cm) in the female and 7 to 8 inches (17.8 to 20 cm) in the male.

Pathologic Conditions: Benign Prostatic Hyperplasia (BPH) - Enlargement of the prostate. Calculus Abnormal concentration of mineral salts, often called a stone Carcinoma malignant new growth of epithelial cells.1. Bladder carcinoma located in the bladder2. Renal Cell Carcinoma located in the kidney Congenital Anomaly abnormality present at birth:1. Duplicate Collecting System two renal pelvi and/or ureters from the same kidney.2. Horseshoe Kidney Fusion of the kidneys, usually at the lower poles.3. Pelvic Kidney kidney that fails to ascend and remains in the pelvis. Cystitis inflammation of the bladder. Fistula abnormal connection between two internal organs or between an organ and the body surface. Glomerulonephritis Inflammation of the capillary loops in the glomeruli of the kidney. Hydronephrosis distention of the renal pelvis and calyces with urine. Polycystic Kidney massive enlargement of the kidney with the formation of many cysts. Pyelonephritis inflammation of the kidney and the renal pelvis. Renal Hypertension increased blood pressure to the kidneys. Renal Obstruction Condition preventing the normal flow of urine through the urinary system. Stenosis narrowing of contraction of passage. Tumor new tissue growth where cell proliferation is uncontrolled.a. Wilms most common childhood abdominal neoplasm affecting the kidney. Ureterocele ballooning of the lower end of the ureter into the bladder. Vesicoureteral Reflux backward flow of urine from the bladder into the ureters.

Indications of Urography:1. Hydronephrosis abnormal dilation of the renal pelvis and the calyces of one or both kidneys. It is caused by an obstruction of urine flow in the genitor-urinary tract.2. Achalasia abnormal constriction of the urinary system which leads to renal failure.3. Abdominal/Pelvic Tumor any abnormal mass resulting from excessive multiplication of cells swelling.4. Renal/Uteral Calculi very common insoluble stones formed from crystal salts found in urine due to excessive intake of mineral salts and insufficient intake of water. To remove the obstruction, a surgery or invasive procedure may be done.5. Hematuria presence of blood in the urine.6. Hypertension persistently high arterial blood pressure.7. Urinary Tract Infection caused by bacteria that entered the body in retrograde fashion.

Internal defects of the Renal system:a. Ptotic Kidney abnormal depression of the kidney. Falling down of the Kidney.b. Uremia complex biochemical abnormality occurring in the kidney, failure causing build up of nitrogenous wastes in the blood.

Contraindications:1. Hypersensitivity to contrast media.2. Extravasation leakage of contrast media out of the vein into the surrounding tissue.3. Vasovagal Response response to fear.4. Multiple Myeloma malignant condition of plasma cells of bone marrow.5. Diabetes Mellitus6. Renal Failure7. Pregnant Patient8. Unprepared Patient

Materials Used: 1/3/5 cc syringe 50cc syringe Catapres (For high BP) Hydrocort Micropore Hypodermic needle for aspiration Butterfly or IV Cannula

Contrast MediaThe urinary system blends in with the other soft tissue structures of the abdominal cavity, thus requiring contrast media to radiographically visualize the internal, fluid filled portion of the urinary system. Types of Contrast Media:1. Ionic2. Non-ionicIonic ContrastIt contains Iodine as the opacifying element and other chemical components that create a complex molecule. Ionic iodinated contrast media contain a positively charged side chain element called CATION. The cation is a SALT, usually consisting of sodium or meglumine, or acombination of both. These salts increase the solubility of the contrast media. The cation is combined with a negatively charged component called the anion. It helps to stabilize the contrast media compound.The cation and anion attach to the parent benzoic acid ring, along with three iodine atoms (Tri-iodinated contrast media). (THREE IODINE ATOMS PER TWO ION RELATIONSHIP)

Higher Osmolality and Greater chance of Reaction:Once injected, the cation dissociates from the anion, creating two separate ions in the blood. This action creates a hypertonic condition, or an increase in the blood plasma OSMOLALITY. Increase is osmolality can cause vein spasm, pain at the injection site, and fluid retention. Ionic Contrast agents ay increase the probability that a patient will experience a contrast media reaction. There might be a disruption in the physiologic balance (homeostasis) which may lead to an adverse reaction. Most likely to experience adverse contrast reactions to ionic contrast media are those with a history of previous CM reaction, asthma, hematologic disorders, kidney/heart/liver disease, and/or diabetes.

Low Osmolality Organic IodideIt is ionic I nature but holds the nondissociating characteristics of a non-ionic CM. It has SIX iodine atoms per two particles. It remains as two particles when introduced into the bloodstream and has twice the iodine concentration as other ionic contrast agents. Approxiamtely half the dose is needed to maintain opacification of the area of interest. This causes fewer adverse contrast reactions than ionic CM. Commercial names:1. Visipaque 2. Ultravist 3. Hexabrix

Blood Chemistry:The technologist must check the patients chart to determine the creatinine and BUN (blood urea nitrogen) levels. Creatinine and BUN are diagnostic indicators of kidney function. Elevated creatinine or BUN levels may indicate acute or chronic renal failure, tumor or other conditions of the urinary system. Metformin Metformin hydrochloride is a drug that is given for the management of non-insulin dependent diabetes mellitus. Patients whoa re currently taking metformin can be given iodinated CM ONLY if their kidney function levels are within normal limits. Combination of iodinated contrast media and metformin may increase the risk for contrast media induced acute renal failure and lactic acidosis.AcidosisWhen your body fluids contain too much acid, this is known as acidosis.The acidity of your blood is measured by determining its pH. A lower pH means that your blood is more acidic. A higher pH means that your blood is more basic. The pH of your blood should be around 7.4. Lactic AcidosisLactic acidosisoccurs when there is too much lactic acid in your body. Many things can cause a buildup of lactic acid. EpinephrineA common emergency drug.To reduce severity of Cm reactions, some patients may be premedicated before an iodinated CM procedure is performed. Example: Benadryl Contrast Media Reactions:1. MildThis does not require drug intervention/assistance. This type of reaction may be based on anxiety and/or fear. Symptoms: Axiety, Light headedness, nausea, vomiting. 2. ModerateThis reaction is a TRUE ALLERGIC REACTION (Anaphylactic reaction) that results from iodinated CM. May lead to life threatening condition. It often involves drug intervention to counter effects of reaction.Symptoms: urticaria (moderate to severe hives), possible laryngeal swelling, bronchospasm, hypotesion, tachycardia/bradycardia 3. SevereAlso known as vasovagal reaction is a LIFE THREATHENING CONDITION. Introduction of iodinated contrast agents stimulates the VAGUS NERVE, which may cause the heart rate to drop and the blood pressure to fall dangerously low. Fast and prompt response from medical team is required. Symptoms: Hypotension, bradycardia, cardiac arryhtmias, laryngeal swelling, possible convulsions, loss of conciousness, cardiac/respiratory arrest*hospitalizatoin for patient is eminent. 4. Organ SpecificSpecific organs are affected by the contrast media injection.a. Cardiac system pulseless electrical activityb. Respiratory system pulmonary edemac. Vascular system venous thrombosisd. Nervous system seizure inductione. Renal system temporary failure or complete shutdownf. Extravasation leakage of ICM outside of the vessel into surrounding soft tissue

Patient Preparation:1. Low residue diet, 1-2 days prior to examination to prevent gas formation.2. A light evening meal the night before the examination.3. When indicated, by costive bowel action, non-gas forming laxative is given the night before the examination.4. NPO (Nothing per Orem) after midnight. However, the patient should not be dehydrated. The patients who have multiple myelomas, high uric acid, and diabetes must be well hydrated before urography because there is an increased risk of contrast media that can induce renal failure.5. No breakfast and no smoking on waking up.6. Report to x-ray department for examination.

Urograms should have the same contrast and density and the same degree of soft tissue as the abdominal radiographs. It must show a sharply defined outline of the kidneys, lower border of the lvier and the lateral margin of the psoas muscles. The technologist must check the patients chart to determine the creatinine and BUN (blood urea nitrogen) levels. Creatinine and BUN are diagnostic indicators of kidney function. Elevated creatinine or BUN levels may indicate acute or chronic renal failure, tumor or other conditions of the urinary system. Patients with elevated blood levels have a greater chance of experiencing an adverse contrast media reaction. Normal creatinine levels for the adult are 0.6-1.5mg/dl. BUN levels should range between 8-25mg/100ml.

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.

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.

Sensitivity Test: 15-30 minutesThe patient is instructed to completely empty the bladder. The bladder should be emptied to prevent dilution of the opacified urine when contrast enters the urinary bladder. 1-2cc of contrast is injected to determine if the patient is sensitive or allergic to contrast or to determine any untoward reaction.

ProcedureScout Film (Preliminary film)The scout radiograph is taken to (1) verify patient position, (2) determine whether exposure factors are acceptable, (3) very positioning, and (4) detect any abnormal calcifications. These scout radiograhs should be shown to the radiologist before injection. If the patient has a catheter in place, it should be clamped before injection. Position: KUB1. Patient in supine2. MSP of the body center to the midline of the table.3. A support should be placed under the patients knees to reduce lordotic curvature of the lumbar spine.4. If the head of the table is to be lowered further to enhance pelvicalyceal system filling, shoulder support must be attached and adjusted to the patients height.5. When ureteric compression is to be used, it should be placed so that it is ready for immediate application at specified time. Compression is sometimes applied over the distal ends of the ureters. This is done to retard the flow of the opacified urine into the bladder and ensures adequate filling of the renal pelves and calyces.6. RP iliac crest.7. CR perpendicular to RP.8. Respiration suspended at the end of exhalation.

Contrast Dosage: Average patient: 3100 ml (depends on body habitus and physician)Children and Infants: dosage will depend upon the patients body weight and age.

When the injection is made, the exact start time and the length of injection should be noted. Timing for the entire series is based on the start of the injection, not the end of it. The injection usually takes between 30 seconds and 1 minute to complete. As the examination proceeds, the patient should be observed carefully for any signs or symptoms indicating a reaction to the contrast media. Most contrast media reactions will occur within the first 5 minutes following injection. Delayed reactions may also occur. The chart should note the amount and type of contrast media given to the patient.After the full injection of contrast media, radiographs are taken at specific time intervals. Each image must be marked with a lead number that indicates the time interval when the radiograph was taken.

Image quality and exposure technique Urograms should have the same contrast, density, and degree of soft tissue density as do abdominal radiographs. The radiographs must show a sharply defined outline of the kidneys, lower border of the liver, and lateral margin of the psoas muscles. The amount of bone detail visible in these studies varies according to the thickness of the abdomen.

Ureteral compression In excretory urography, compression is sometimes applied over the distal ends of the ureters. This is done to retard flow of the opacified urine into the bladder and thus ensure adequate filling of the renal pelves and calyces. If compression is used, it must be placed so that the pressure over the distal ends of the ureters is centered at the level of ASIS. As much pressure as the patient can comfortably tolerate is then applied with the immobilization band. The pressure should be released slowly when the compression device is removed to avoid the possibility of visceral rupture. Compression is generally contraindicated if a patient has urinary stones, an abdominal mass or aneurysm, a colostomy, a suprapubic catheter, or traumatic injury. As a result of improvements in contrast agents, ureteral compression is not routinely used in most health care facilities. With the increased doses of contrast medium now employed, most of the ureteral area is usually demonstrated over a series of radiographs.

IV Urography Contrast Opacification after full dose:1-8 minutes: contrast appears in the pelvicalyceal system.15-20 minutes: greatest concentration of contrast occurs.

Basic Imaging Routine (Sample IVU Protocol)A common basic routine for an IVU is as follows:1. Nephrogram or nephrotomogram is taken immediately after completion of injection (or 1 minute after start of injection) to capture the early stages of entry of the contrast media into the collecting system.2. 5 Minute Image requires a full KUB to include the entire urinary system. The supine position (AP) is the preferred position.3. 10 to 15 minute image requires a full KUB to include the entire urinary system. Once again, the supine position (AP) is required most commonly.4. 20 minute Obliques should use LPO and RPO positions to provide a different perspective of the kidneys and project the uereters away from the spine.5. Postvoid radiograph is taken after the patient has voided. The positions of choice may include a prone (PA) or erect AP. The bladder should be included on this final radiograph. *note: Ensure that time markers are placed on the IR prior to exposure to record the tome of exposure.

Frequent recommended positions: AP Urograms at different time intervals ranging from 3-20 mins. LPO and RPO at 5-10 or 5-15 time intervals with 30 body rotation.Each kidney lies in an oblique plane and is rotated about 30 degrees anteriorly toward the aorta, which lies on top of the vertebral body. When the body is rotated 30 degrees for the AP oblique projection (LPO or RPO position), the lower kidney lies perpendicular and the up per kidney lies parallel to the IR Prone demonstrate ureteropelvic region and filling of the obstructed ureter in the presence of hydronephrosis. The ureters fill well in prone because it reverses the curve of their inferior course. Kidneys obliquely, slanting anteriorly so the urine tends to collect in and distend in the dependent part of the pelvicalyceal system. Posteriorly place upper calyces fill more readily in supine while anterior and inferior parts of calyces and renal pelvis fill more in prone. Erect or Semi Erect demonstrate opacified bladder and mobility of the kidneys.

Post Voiding or Post Micturation: Upright to detect ptotic kidneys.

Patient is aked to void or urinate to detect:1. Presence of residual urine.2. Such condition as small tumor or masses.3. Prostate enlargement for male.4. Mobility of the kidneys.

Optional Positions: Cross Table Lateral to determine or demonsrate:1. Ureteropelvic junction in presence of hydronephrosis.2. Whether an extra renal mass in the flank is intraperitoneal or extraperitoneal.3. Screen both kidneys and ureters for any abnormal anterior displacement. Oblique and Lateral 1. To demonstrate conditions as rotation or pressure displacement of the kidneys.2. To localize calcareous shadows and tumor masses. AP Trendelenburg 15-20 table elevation demonstrate lower end of the ureters. Weight of contained fluid stretches the bladder fundus superiorly, giving an unobstructed projection of the lower ureters and vesicoureteral orifice areas.

Films:a. Preliminary Film: Supine, full length AP of abdomen in inspiration. The lower border of cassette is at level of symphysis pubis and the CR in midline at level of iliac crest/umbilicus. To demonstrate bowel preparation, check exposure factor, and location of radiopaque stones or any radiopaque artifacts.*note: If necessary, the position of overlying opacities may be further demonstrated by:1. Supine AP of renal areas, in expiration. The CR is centered in the midline at the level of lower costal margin.2. Or 35 posterior oblique views3. Or Tomography of the kidneys at the level of a third of the AP diameter of th patient (25-40).b. 5 Minute Film:* AP of renal mass* To determine if excretion is symmetrical and is invaluable for assessing the need to modify the technique.c. 15 Minute Film:* Supine full length AP* There is usally adequate distension of the pelvicalyceal systems with opaque urine by this time.d. Full Bladder* taken to show the bladder. If the film is satisfactory, the pt. is asked to void.

e. Post Void Film:* to assess the bladder after emptying.* residual volume of urine

Additional Films: Posterior Obliques of kidneys/ureters/bladder to determine whether the radiopaque shadow is in the ureter or ourside (Patient is rotated 30-35 in rpo/lpo depending on pathology side). Prone Film to investigate pelviureteric and ureteric obstruction as the heavy contrast laden with urine will more readily gravitate to the side of the obstruction; to displace the overlying bowel gas toward the periphery. (Patient lies prone after doing 15 min film and after 5 mins of lying prone) Tomography when there are confusing overlying gas shadows in renal areas. AP with caudal angulation to separate the over shadows by stomach on the left kidney (AP position, film of kidney area with 25 caudal tube angulation). Erect Film to determine whether or not there is small ureteric calculus, erect oblique film of area of ureter. To demonsrate layering of calculi in cysts and abscesses. Delayed Film may be necessary for up to 24 hrs. after injection to demonstrate the actual site of ureteric obstruction. Children films are taken in 3min, 15min and post void after CM injection and further depending upon pathology.

Modification in case of Pathology: In case of suspicious shadows in renal area:Take lateral film of renal area. Take inspiratory and expiratory film of renal area to demonstrate the relationship of opacities and filling defects of renal tract. In case of Hypertension:Take fast sequences (1min, 3min and 5min film) Ectopic KidneyFull film KUB region from immediate to last film. Renal AgenesisFull film KUB from immediate to alst film. Delayed films up to 24hrs. Bladder DiverticulumAbnormal pouch formed within the bladder. Lateral film of bladder area. Vesicovaginal FistulaLateral film of bladder area.

Hypertensive IVP Used for hypertensive patient or infant to determine if the kidneys are causing hypertensive condition.Preparation: same as IV UrogramsScout Film: same as IV Urograms Time intervals:1. Take 1,2,3 mins, after completion of injection using (10x12) centered to kidney area.2. 5 minutes take exposure of the entire urinary system centered to the iliac crest.3. 15 minutes (PA)4. 30 minutes (AP)5. Post voiding film. Note: time interval exposures will depend upon the discretion of the radiologist.

Drip Infusion IVPPreparation: same as IV UrogramScout Film: same as IV UrogramSensitivity test: same as IV UrogramProcedure: 2-3 vials or ampoules of contrast is being incorporated with a 200cc of 5% dextrose in water connected to a veno-set or rubber tubing. Prepare the IV set and an IV stand, adjust the height of the dextrose in such a way that the fluid will flow as fast possible. After the amount has been consumed, take time interval exposures.Time intervals:1. 5, 15, 30, 45, 1hr, 2hrs or even up to 2hrs. depending upon the discretion of the radiologist.2. All exposures are taken in AP position.3. RP umbilicus or iliac crest. This method provides opacification of the renal parenchyma as well as of the renal drainage canals and thus embraces both nephrography and urography. Note: after 2hrs. film, patient may be allowed to eat.