IVU – INTRAVENOUS URETHROGRAPHY

TABLE OF CONTENT

INTRODUCTION

It is a radiographic examination of urinary tract including renal parenchyma, calyces and pelvis after intravenous injection of contrast media or dye into the bloodstream.

Intravenous urography (IVU) also referred as intravenous pyelography (IVP) as it implies the visualisation of the pelvis and calyces without the parenchyma.

The term “pyelogram” is reserved for the retrograde studies visualising only the collecting system.

ANATOMY OF THE URINARY SYSTEM

Urinary system refers to the structures that produce and conduct urine to the point of excretion.

COMPONENTS OF THE URINARY SYSTEM

1.Two kidneys

2.Two ureters

3.Urinary bladder

4.Urethra

After filter the blood, the remaining water (urine), passes through the ureters and then stored in the urinary bladder.

GROSS ANATOMY OF THE KIDNEY

The functional unit of the kidney is nephron.

It has two parts: renal parenchyma and renal sinus.

The renal parenchyma of the kidney is divided into two major structures:  superficially renal cortex and deep is the renal medulla.

The medulla consists of 6-18 renal pyramids.

Between the renal pyramids are projection of cortex called renal columns.

The papilla or tip, of each pyramid empties urine into a minor calyx.

minor calyces empty into major calyces empty into the renal pelvis, which becomes the ureter.

FUNCTION OF THE URINARY SYSTEM

The kidneys are bean-shaped organs. They filter blood to remove extra water and waste in urine (wee). Most of us have two kidneys. They are on either side of our spine (backbone), near the bottom edge of our ribs at the back.

The two ureters are long tubes that carry urine from the kidneys to the bladder.

The bladder is a bag that stores urine until we are ready to urinate. It sits low down in the pelvis.

The urethra is a tube that carries urine from the bladder to the outside of the body.

INDICATIONS

1.haematuria

2.To evaluate the ureteral obstruction.

3.Abnormalities of the ureter.

4.Differentiation of function of both kidney.

5.Suspected renal injury.

6.Renal colic or flank pain.

7.Urinary tract infection (UTI).

8.Calculus disease

CONTRAINDICATION

Iodine sensitivity

Pregnancy

Previous allergy to contrast agent.

Cardiac and renal failure.

Raised serum creatinine level.

PATIENT PREPARATION

  1. BOWEL PREPARATION

Laxatives is recommended to eliminate faecal matter from the colon and to reduce amount of gas in the bowel.

Dulcolax (biscodyl) is given 2-4 tablets at bedtime for 2 days prior to the IVU.

Castor oil is an effective laxative given about 80ml the night before IVU. Castor oil is contraindicated in case of abdominal pain of unknown cause, old and debilitated patients.

Medication required for old age patient and fatty patient.

Low residue diet and plenty of oral fluid is required.

2. Ask for any history of diabetes, renal disease, allergy to drugs and any specific food.

    Blood creatinine level should be in its normal range (Males- 0.6 to 1.5mg/dl, Females- 0.5-1.5mg/dl)

     Blood urea level should range between 9 to 42mg/dl.

3. Fasting for 4 hours.

4. Do not dehydrate the patients if patient suffering from renal failure as it may lead to severe fluid and electrolyte imbalance.

5. Sensitivity to the dye checked. Necessary precautions are taken to avoid the allergic reactions.

6. Take informed consent.  

Extra renal routes for contrast excretion:

¢Hepatic

¢Saliva

¢Sweat

¢Tears

¢Gastric juice

PROCEDURE REQUIREMENTS

Compression band is applied over distal ends of ureters to retard flow of opacified urine into bladder and to ensure adequate filling of renal pelvis and calyces, so it is required for the procedure.

IV cannula or butterfly needle(20-24G).

Fixing tape

Syringe- 50ml,10ml

Medical Gloves

Tourniquet

Cotton swap

Dry cotton

Emergency drugs

CONTRAST MEDIA

Adult dose – 50-100ml (w/v)

Paediatric dose – 1ml/kg

MODE OF INJECTION

Contrast material is injected intravenously into a prominent vein in the arm within 30-60 seconds.

STANDARD PROCEDURE

Patient is placed in supine position.

A support is placed under patient’s knees to reduce  curvature of lumbosacral spine and provide comfort.

A scout film is taken including the kidneys, ureters, bladder and urethral regions on a large size film.

Test injection of 1ml of contrast is given and patient is observed for 1 min to look for any contrast reactions. Then rest of the contrast is rapidly injected within 30-60 seconds.

Nephrographic images (obtained 1-3 min after contrast material administration).

KUB radiograph (obtained 5 min after contrast administration).

Abdominal compression (applied immediately after review of 5min radiograph).

Phylographic image collimated to kidney (5min after compression, 10min after contrast administration).

Ureter bladder images (obtained 15min after contrast material and immediately after release of compression).

Complete overview of urinary tract. (obtained 35min after administration).

Post void.

FILM TECHNIQUE

Low KV: 65-75.

High mA: 600-1000. Short exposure should be used to get optimum image contrast

FILM SEQUENCE

1.Plain X-ray/ scout film-

it provides valuable information and useful in assessing:

Calculus

Intestinal abnormalities

Intestinal gas pattern

Abdominal mass

Foreign body

2. NEPHROGRAM PHASE (Immediate film)

It shows nephrogram.

This radiograph is often omitted as a renal outline are usually adequately visualised on 5 min film.

3. SECRETORY PHASE (5 minutes film)

It shows nephrogram, renal pelvis, upper part of ureter.

Compression band is applied.

CONTRAINDICATED IN:

  • Renal trauma
  • Large abdominal mass
  • Abdominal aneurysm
  • After abdominal surgery

4. URETEROGRAM PHASE (15 minutes film)

Visualisation of ureter is better in prone position as they fill better.

5. CYSTOGRAM PHASE (35 minutes film)

It gives complete overview of the urinary tract- kidney, ureter, bladder.

6. POST VOID FILM

Take immediately after voiding. It is used to assess for-

  1. Residual urine
  2. Bladder mucosal lesion
  3. Bladder tumour
  4. Outlet obstruction
  5. VUR (vesicoureteral reflux)

SPECIAL FILM/VIEWS

  1. Oblique view- to project the ureter away from spine and to separate overlying radio opaque shadows mimicking calculi. It is also used for visualisation of posterolateral aspects of bladder.
  2.  Erect view- Used to provoke emptying of urinary tract. Detect urinary tract gas not seen in other films.
  3. Delayed films – taken 1-24 hours after injection. It should always be instructed to void prior to delayed films so calculus in distal ureter is seen well. it is used in Cases of obstruction where early nephrogram is seen but collecting system not seen.

COMPLICATIONS

1.Minor reactions- nausea, vomiting, mild rash, light headache,.

2.Intermediate reactions- facial oedema, hypotension, bronchospasm.

3.Severe reactions- severe angina, myocardial infarction, coma, cardiac or respiratory arrest.

AFTER CARE

¢Observation for 6 hours.

¢Watch for late contract reactions.

¢Prevention of dehydration.

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