RDSC 233 Unit 7Cystography & Retrograde Urography Bontrager pp. 563-574

Positioning of:

AP cone down bladderOblique cone down bladder Lateral cone down bladderVoiding cystourethrogram (VCUG) female male Injection urethrogramRetrograde pyelogram

Radiographic anatomyFilm Critique

Radiographic Pathology

Exposure Factors

What in the World?Miscellaneous, but significant, odds and ends

Routine IVU PositioningPreparation

1. Evaluate the order

2. Greet the patient 3. Take History

What is pertinent Hx?

4. Remove jewelry, check attire, snaps, pins, NG tubes, etc.

5. Explain the exam in layman’s terms

6. Questions?

Bladder diverticula, rupture, CA,incontinence, bladder infections,outlet obstructions, vesicoureteralreflux, postoperative anastomoses.

7. Set technique before positioning

Cystograms are obtained in two basic ways. 1. As part of an excretory IVU. The three “cone down” views may be incorporated in an IVU routine, or may be done on request.

* When a patient having an IVU has a foley catheter in place, drain the bladder before the injection, then clamp it.

* When working with a catheterized patient, do not raise the bag above the level of the bladder.

2. As a retrograde cystogram. Contrast is instilled via a urinary catheter. Unless there is reflux into the ureters, no other urinary structures are seen.

Cystography

* Patients arrive with a urinary (urethral) catheter in place, or it is inserted in radiography room, under aseptic conditions.

* The bladder is drained of urine and contrast is dipped under gravity, never injected, or the bladder could be ruptured.

* The contrast is an iodine preparation of approximately 18-30%. Common brands include: Cystografin, Cysto-Conray, Hypaque-Cysto.

* Filling may be monitored under fluoroscopy, or films may be taken at intervals during filling, such as 100, 200, 250, 300cc, etc. The amount of filling is determined by patient comfort.

Retrograde cystography

Routine AP bladder positioning

AP position

1. Supine2. 100-150 caudad angle3. CR 2” superior to pubic symphysis, midline

40” SID, 12:1 or 16:1 grid,70-75 kVp for iodine, expose onexpiration.

Film size: 11”x14” lengthwisefor distal ureters (reflux on a cystogram).

It is not unusual for 10”x12” or 8”x10s” to be used crosswiseinstead, especially in consideration of the centering.

Setup for all cystograms

Critique criteria for AP bladder

The purpose of the caudad angle is to project the pubicbones beneath the floor of the bladder.

All of the bladder is included.

If using an 11” x 14”, abouthalf of the ureters will visualize should there be reflux.

Routine oblique bladder positioning

Oblique positions

1. RPO & LPO: 450-600

2. CR perpendicular3. CR 2” superior to pubic symphysis, and 2” medial to the ASIS of the side up

Routine oblique bladder positioning

1. AP – Obturator foramen are symmetrical, symphysis pubis is midline.

Phleboliths – Stones in veins.Common in large division of the iliacs around the pelvic floor.

Characteristics of the obliquepelvis (1-3).

3. Also an RPO: the left SI joint isdemonstrated, andthe left ala isforeshortened

2. In this RPO position the rami on the right are superimposed, while the obturator on the left is seen in profile.

Suprapubiccatheter –Used whena urethral cathetercannot be inserted.

Critique criteria for oblique of bladder

The most shallow angled cystogram is taken with a 14”x17” oblique of the kidneys (IVU). The film shown here is a 300 RPO, as evidenced by the excellent demonstration of the left SI joint

When the bladder is filmed alone,45 to 600 is used. Notice the position of the ASIS relative to the obliquity.

ASIS

Distance to bladderis much greater than2” in a shallow oblique

No specific structures are demonstrated on the 450 oblique. All of the bladder is included.

Critique criteria for oblique of bladderThe 600 oblique is designed to demonstratethe ureterovesicle (UV)junction of the side up.

All of the bladder is included, and the thigh ofthe independent leg is notsuperimposed on the bladder

The above obliquesshow diverticula at the UV junctions. The APfilm is seen on the left

In a steep oblique position the ASIS is close to the center of the bladder

Lateral bladder positioning (not routine)

Lateral position

1. True lateral position2. CR perpendicular3. CR 2” superior and 2” posterior to pubic symphysis.

Critique criteria for lateral bladder

The lateral demonstrates the anterior and posterior walls of the bladder, and parts of the superior and inferior aspects not as well seen on the frontal views.

All of the bladder is included.

kVp will be above the optimal range, and may need to be 90 or more in larger patients. Quality will be compromised.

Increased scatter also lessens the value of this view, and the gonadal dose is higher.

For these reasons the lateral is most often done on special request.

Voiding Cystourethrograms (VCUG) female & male

In addition to being a cystogram, the VCUG s is a functional study to examine the urethra for strictures, obstructions, diverticula, and reflux into the ureters.

The patient may be recumbent or upright.

Filming may be done using a spot film camera, or overhead tube.

The bladder is filled retrograde via a urinary catheter (Foley). After filling the bladder the retention balloon is deflated, and the catheter is removed. The patient is instructed to begin urination into a radiolucent receptacle or absorbent padding (chux) while filming.

Foley urinary catheter. Retention balloon is inflated with sterile water or NS.

Deflationport

Female Voiding Cystourethrogram (VCUG)

AP position

1. Supine2. CR perpendicular3. CR to pubic symphysis

All of the bladder is included.The entire urethra is seen during micturition (micturate)

RPO

1. 300 RPO2. CR perpendicular3. CR to pubic symphysis 4. Superimpose urethra on thigh to act as filter

All of the bladder is included.The entire urethra is seen during micturition (micturate)

Male Voiding Cystourethrogram (VCUG)

Injection (retrograde) Urethrogram male only

Injection urethrography is done when an obstruction hinders the insertion of a catheter, or trauma prevents urination.

Brodney Clamp,(or catheter)

Extravasation of contrast from ruptured bladder.

Extravasate = escape out of, vs.Infiltrate = passing, or forced into.

Retrograde Pyelography: female & male

Retrograde pyelograms are minor surgical procedures that are performedis a “cysto room” that is often in the surgical suite.

Patients are sedated, or given general anesthesia.

A cystoscope is inserted by the urologist, and the visible interior of the bladder is visually examined.

Ureteral catheters are advanced through the cystoscope, and the ureteralorifice is catheterized unilaterally, or bilaterally, as indicated.

The lithotomy position

Used for urological procedures.

In the stirrups

Retrograde Pyelography: the filming sequence

A scout film is taken tocheck the technique,position, and placementof the ureteral catheters.

3 to 5 cc of contrast is injected by the urologist. A film demonstrating the renal pelvis and calycesis taken

The urologist withdrawsthe catheters and filmof the contrast filled ureters it taken.

These three films are a typical routine, though more may be taken at the urologist’sdiscretion. All films must be marked by the technologist: order and time.

cystoscope

ureteral catheter

Scout0900 #1

0907#20912

Exposure Factors

75 kVp for optimal visualization of iodine contrast

All other technique computations are the same asfor the abdomen

1. 40-60% increase for oblique positions2. 2x kVp (15% rule) and 2x mAs for lateral.3. 25% increase of mAs when using 10”x12” for cone down views

Calcified prostate

Bladder stones

Cystocele

Significant Pathologiesof the kidneys and bladder

and their

Radiographic Appearances

Renal calculi

Hydronephrosis

Calcified Prostrate Gland

With age the prostrate glandatrophies (atrophy), and sometimes calcifies.

Both conditions lead to a narrowing of the prostatic urethra and the inability to completely emptythe bladder.

The surgical remedy is a transurethralresection of the prostate (TURP)

Seen on these films is a severelycalcified prostate. Though rare, bladder stones may look similar on a plane film. On a cystogram the calcifications areseen to be in the prostate.

Bladder Stones

Once prevalent, stones in thebladder are rarely seen today,unless they pass from the kidneys.

Stones that form in the bladderare typically large and numerous.

Prior to the 20th century, bladder stones were a common malady that were so painful, due to obstructions, people subjected themselves toa procedure called “cutting for stones,” that was performed withoutanesthesia, antibiotics, or aseptic techniques.

Cystocele

A hernia of the bladder, intothe vagina, caused by a weakening of the vesicovaginalfascia during delivery.

Causes urinary frequency, urgency, and dysuria.

The cystocele on this upright postvoid is completely below the superior rim of the pelvic bones,and would have been missed with routine centering.

Renal calculi

Kidney stones are formed in the parenchyma, calyces, pelvis of the kidneys. They may remain in place and be asymptomatic, or they come loose and travel down the ureter. Though often small, renal calculi are sharp and jagged. They cut the inside of the ureters which are rich in sensory nerves, causing intense pain. Hematuria may be a sign of passing stones.

Lithotripsy is an alternative to surgery that pulverizes stonesby using shock waves.

An obstructed ureter caused by a kidneystone shows dilation of the ureter abovethe obstruction, tapering to the lodgedcalculus.

Renal calculi

A thin stream of contrast isslipping by, seen to the UV junction. If thepressure were not relieved the ureter wouldcontinue to dilate.

A similar example is seen on this postvoid upright of the bladder. This delayed film shows that excretion of contrast is complete on the left, but a column of contrast remains in the right ureter.

Caculi filling largeparts of the calycesare called staghorncalculi

Calculi in parenchyma

Hydronephrosis

When a ureter is obstucted from calculi or other causes, urine (orcontrast) causes the renal pelvisand calyces to dilate as long as thekidney is functioning.

A build up of fluid in the collectingsystem is hydronephrosis.

What in the World?

Miscellaneous, but significant, odds and ends

What in the World?

What was this?

Review

And these?

What in the World?

Guess what this is

What in the World? A stent is a device that holds tissue in place, or holds open a hollow organ or vessels.

These ureteral stents create an open channel from the renal pelvis to the bladder, to bypass and obstruction.

What in the World?

A percutaneous renal puncture is performed under fluoroscopy. Aneedle is inserted intoa calyx, or the renal pelvis.

A catheter is insertedinto the collecting systemfor access to the kidney.

This procedure is called a nephrostomy.

What in the World?

An ectopic kidney is one that is in an abnormal position.

In this case it is a transplanted kidney.

Transplants are turned backwards,and placed in the pelvic cavity. The renal artery and vein are sutured tothe iliac vessels.

Adding a kidney, rather than replacingone, often results in a damaged kidney regenerating its function.

What in the World?

A pelvic mass, seen by displacement of the bladder.

38. Excretory urograms are antegrade studies of the kidneys, ureters, and bladder. Cystograms (not IV injection) are studies of the bladder.

39. When urine (or contrast) from the bladder, flows back into the ureters, this condition is called .

40. What is the angle and direction of the CR for an AP cone down view of the bladder?

41. What is the range of obliquity for the RPO and LPO of the bladder?

42. What specific anatomy will a steeper oblique demonstrate?

38. Excretory urograms are antegrade studies of the kidneys, ureters, and bladder. Cystograms (not IV injection) are retrograde studies of the bladder.

39. When urine (or contrast) from the bladder, flows back into the ureters, this condition is called reflux.

40. What is the angle and direction of the CR for an AP cone down view of the bladder? 10-150 caudad

41. What is the range of obliquity for the RPO and LPO of the bladder? 45-600

42. What specific anatomy will a steeper oblique demonstrate? The ureterovesicle, or, ureterocystic junction.

43. What is the name, and acronym, for a functional study of the bladder and urethra?

44. What is the term that describes contrast media that has escaped from (out of) the bladder, due to a leakage or rupture?

45. What physician (

Oblique position degree of obliquity what is demonstrated

RAO stomach 40 asthenic -70 hyper profile view “GI”