RADIOLOGY IMAGING

Semi Cluster Bedah (RSST-FK UGM)

URINARY TRACT IMAGING

• INTRA VENOUS PYELOGRAPHY• ULTRASONOGRAPHY• ANTEGRAGE PYELOGRAPHY• RETROGRADE PYELOGRAPHY• MCU, URETHROGRAPHY• COMPUTED TOMOGRAPHY • MAGNETIC RESONANCE IMAGING• RENOGRAPHY

DEFINITION IVP

A type of x-ray examination specifically designed to study the kidneys, ureters and bladder, using contrast material (x-ray dye).

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INDICATION AND CONTRA INDICATION

Suspected of urologic disease:

infections acute genitourinary pain hematuria (microscopic

or gross) trauma suspected neoplasm renal transplantation neurogenic bladder congenital anomalies investigation of

complications following a surgical procedure

• combined renal and liver failure

• multiple myeloma • pregnancy • previous reactions to

contrast media • history of allergy • infancy • thyroid disease • renal failure• diabetes mellitus

THE CONTRAST

• Consists of iodine atoms. • Following injection, their distribution in the body and

routes of excretion are identical, and their visualization in the kidneys is equal. Assuming normal renal function, their route of excretion is greater than 99% by glomerular filtration.

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INTERPRETATION

• Abnormalities in the appearance of the kidneys or ureters, distribution of contrast within a kidney, asymmetry in the amount of contrast in each kidney, or defects in the collecting systems can be identified and are suggestive of particular diseases and conditions.

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PATIENT PREPARATION

Dehydration INCREASE OF UROGRAPHIC IMAGING AND AVOID EMESIS

Bladder voiding Bowel preparation ELIMINATING GAS AND FECES Psychological preparation – Anxiety appears to be a factor in the so-called idiosyncratic

reactions (nausea and vomiting, urticaria) following contrast injection.

Informed consent previous alergic reaction, sensation during and following contrast injection

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PROCEDURES

• Plain film of the abdomen• • Contrast administration

• Film sequencing

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Urinary tract, KUB (kidneys, ureters and bladder),

Sequencing IVP

plain 5’

15’ 30’

45’ PV

Normal bolus injection urographic nephrogram

A. One minute after contrast injection. the cortex and cortical columns are opacified; the medullary pyramids remain relatively lucent.

B. Four minutes later, the cortex and medulla are equally opacified. Note excellent filling of the collecting system and ureter.

(Newhouse JH, Pfister RC: The nephrogram. Radiol Clin North Am, 17:213, 1979)

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Obstructive nephrogramContrast material had been administered intravenously 45 minutes before this radiograph was obtained in a patient with acute unilateral ureteral obstruction. The kidney is enlarged; the nephrogram was slow to develop, but the kidney is now much denser than normal and contains faint radial striations

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Normal excretory urogram.

An anterior calyx points laterally (large arrow); the paired posterior calyx (small arrow) directly posterior, mimicking a filling defect.

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Ten-minute film from urogram with compression cuff in place.

The upper ureters and collecting system are well distended, allowing confident diagnostic evaluation. Note that the balloons are well inflated and the upper margin parallel the illiac crest.

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Minimal right ureteral obstruction

The fornices of the left kidney appear normal. Those on the right are slightly but definitely blunted

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Moderate ureteral obstruction

There is partial effacement of the fornices and generalized caliceal dilatation.

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Proximal right ureteral obstruction

The collecting system is dilated and there is diminished concentration of contrast within it.

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Distal right ureteral obstruction

The right ureter is filled as a continuous column; serial radiographs revealed no change in its configuration.

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Bilateral chronic ureteral obstruction.

On the right, the nephrogram of the remaining parenchyma surrounds the dilated nonopacified calices, producing a "negative pyelogram." On the left, the obstruction is less severe: the dilated proximal ureter and collecting system are faintly opacified.

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Uric acid calculus

Intravenous urogram (IVU) shows an extensive branched filling defect in the lower pole collecting system.

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Partially obstructing distal ureteral calculusAn opaque calculus just distal to the inferior aspect of the left sacroiliac joint is producing several of the urographic changes associated with an obstructing ureteral calculus: ureteropyelocaliectasis, a continuous column of contrast-laden urine from the renal pelvis to the calculus, and narrowing of the ureter (arrow) just distal to the stone. These were persistent findings on several films whereas the contrast-filled left juxtavesical ureter appeared collapsed on other films. The right collecting system has partially emptied of contrast at the time of this 1-hour film.

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Ultrasound of the urinary tract :

• USG of kidney and bladder• USG of the male genitalia• USG of the prostat

Fig.29.8 Normal renal; note the relatively hypoechoic pyramids and markedlyHyperechoic fat containing sinus (centrally) compared to the cortex.

Mild and Moderate Hydronephrosis

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Severe Hydronephrosis

• This ultrasound image demonstrates dilated renal calyces indicative of hydronephrosis. Chronic reflux uropathy can lead to hydronephrosis which can result in renal dysfunction as the calyces dilate and compress the renal parenchyma.

Black arrow = renal capsule Black arrowhead = sinus fat White arrow = dilated calyx White arrowhead = renal cortex

Fig. 29.9 Normal bladder ultrasound; note the thin smooth wall and the shapeApproximating to rounded-off square in the transverse view (A) and a rounded-off triangle in the sagital view (B)

Antegrad pyelography

• Simple procedure• Evaluate the cause and level of ureteric obstr• First step : Nephrostomy or Whitaker procedur• The patient is positioned approximately 45°

semiprone and the pelvicalyceal system cannulated with a fine (22 gauge) needle

Antegrad pyelography

• Directed through the parenchyme renal calyx pelvis ren

• Confirmation of cannulation of the collecting system is obtained by aspirating urine

150 strength contrast is infused into the system

a series of spot films of the ureter down tothe level of the obstruction is taken

Antegrade pyelography.The dilated pelvicalyceal system has been cannulated with a 22 gauge needle and opacified with 150 strength contrast (A). The ureter is dilated, shows marked medial displacement distally and tapers to a complete occlusion (B)

Sample

Pic. A partial obstruction in the distal ureter is caused by a small calculus (seen as a filling defect) followed by a stricture.

MCU

male - oblique Female - supine

Verumontanum ( filling defect in the posterior urethra