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Original Article

Magnetic Resonance Urography in the Evaluation of Obstructive

Uropathy
Irshad Ahmad, Mohd Ilyas1, Insha Khan2, Irfan Robbani1, Baldev S Wazir3
Departments of Surgery, Radiodiagnosis, Obstetrics and Gynecology and 3Urology, Sher‑I‑Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir,
1 2

India

Abstract
Purpose: The purpose of this study was to study the utility of magnetic resonance urography (MRU) in the evaluation of obstructive urological
diseases in comparison to intravenous urography (IVU). Materials and Methods: The study was carried out over a period of 2 years. A total
of 55 patients were included in this study with ages between 14 and 70 years (average age 37 years). The patients were selected on the basis
of ultrasonographic findings of hydronephrosis. The patients were subjected to IVU followed by static and dynamic MRU. The results
obtained were compared and the inferences drawn thereof. Results and Conclusions: MRU has high sensitivity in the diagnosis of urinary
tract obstruction, detecting the level of obstruction and acts as an aid in the diagnosis of obstructive uropathy, thus showing promising results.
MRU is safer than IVU due to avoidance of iodinated contrast material and could also be done without using contrast material so having less
contrast related events.

Keywords: Crossed fused ectopia, intravenous urography, magnetic resonance urography, obstructive uropathy, PUJ obstruction

Introduction treated early is a potentially curable disease of the kidney. The

Urinary tract obstruction is a relatively common problem. The
obstruction to urinary flow may be acute or chronic, partial or
complete, unilateral or bilateral and may occur at any site in the
urinary tract. Urinary obstruction is one of the few reversible
causes of renal failure. Early diagnosis and treatment is
important and can salvage the kidney. Temporary or permanent
obstruction of urinary tract can result from variety of causes
such as calculi, blood clots, prostate enlargement, stricture,
pelvi‑ureteric junction (PUJ) obstruction, vesicoureteric
reflux  (VUR), retroperitoneal fibrosis, compression from
outside like tumours of adjacent structures, pregnancy or rare
causes such as tubo‑ovarian masses, endometriosis, abdominal
aortic aneurysm, iliac artery aneurysm and circumcaval
ureter.[1] Hydronephrosis and obstructive uropathy are not
synonymous, and hence, it is important to differentiate
between obstructive and non‑obstructive hydronephrosis
and to know the level of obstruction for proper management
and to prevent its progression to obstructive nephropathy as
prolonged obstruction leads to worsening of renal functions and
unlike other renal diseases, obstructive nephropathy which if
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practicing urologist should be well versed with the diagnostic
imaging modalities currently available as well as their relative
advantages, limitations, and appropriate modifications.[2]
Ultrasonography (USG) is the mainstay in the evaluation of
suspected urinary tract obstruction. It is considered safe in
paediatric and pregnant patients due to no associated ionisation
risk, and there is no need of contrast injection; hence, USG can
be used in patients with azotemia or contrast allergy.[2] Being
inexpensive and widely available, USG is often used as a
first‑line investigation.[2] Although USG is an inexpensive and
rapid way of detecting a ureteric obstruction, however, the level
of obstruction is often difficult to determine due to overlying
bowel gas shadows and is unable to provide information on
Address for correspondence: Dr. Mohd Ilyas,
Department of Radiodiagnosis, Sher‑I‑Kashmir Institute of Medical
Sciences, Radiodiagnosis, Soura, Srinagar ‑ 190 011,
Jammu and Kashmir, India.
E‑mail: ilyasmir40@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Ahmad I, Ilyas M, Khan I, Robbani I, Wazir BS.
10.4103/AIHB.AIHB_61_17 Magnetic resonance urography in the evaluation of obstructive uropathy.
Adv Hum Biol 2018;8:91-101.

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Ahmad, et al.: MR urography
functional aspects and whether the obstruction is complete or
incomplete. [3‑5]
Although frequently used for the detection of a ureteral
obstruction, the usage of intravenous urography (IVU) is
limited by the nephrotoxicity of contrast material in patients
already having obstructive nephropathy with non‑excretion of
contrast in non‑functioning kidneys rendering it useless.[1‑3,6,7]
IVU may be contraindicated in pregnant and paediatric patients
because of radiation exposure and its subsequent side effects
and risk of contrast nephropathy.[2‑5,8] Conditions that arise
outside urinary tract can also result in urinary tract obstruction
and may go unnoticed with IVU. IVU has an inherited
disadvantage in providing limited information on mural
pathology and none on extramural pathology.[3] Therefore, it
is important to determine the cause and level of obstruction
by an effective protocol.
CT directly reveals calculi, classically considered radiolucent
when evaluated by plain radiography, including uric acid,
xanthine, dihydroxyadenine, and many drug‑induced calculi
except calculi composed of protease inhibitors.[2,8] Various
secondary features of obstruction on computed tomography (CT)
include hydroureter, perinephric stranding, hydronephrosis,
periureteral oedema and renal swelling.[1‑3,9,10] However an
non‑contrast CT does not indicate function of the kidneys,
cannot differentiate between acute and chronic obstruction,
has difficulty in differentiating distal calculi from pelvic
phleboliths,[1,2,10,11] has risk of radiation exposure which precludes
its application in pregnant and young patients and there is risk
of contrast allergy in case of contrast‑enhanced CT.[2,3,5,8,10,12,13]
Magnetic resonance urography (MRU) (as a technique
for the assessment of urinary tract was first described by
Henning et al. in 1987) is free of any radiation risk and can
be done both with or without using intravenous contrast as
the case may be, and is more suitable for examination of
paediatric, pregnant patients and patients with compromised
renal function. [1,2,4,12,13] The use of magnetic resonance
imaging (MRI) facilitates simultaneous examination of the
kidneys, ureters, renal vessels and inferior vena cava (IVC)
which is useful for assessing renal parenchymal, perinephric
and periureteric tumour extension in cases where tumour is the
cause of obstruction.[9,13] Sequential imaging of ureters with
MRU can be used to overcome problems with intermittent
lack of ureteral distension due to peristalsis, which can lead to
misdiagnosis of stricture and obstruction.[9] The combination
of static‑MRU (sMRU) and excretory‑MRU is useful in cases
of obstructive uropathy because T2‑weighted images can
show the extent of dilatation of the obstructed system and
excretory‑MRU can provide information on functional effects
of excretion.[4,5] Sequential imaging can also be used to map the
pattern of enhancement after contrast administration which can
be useful for characterising the lesions and quantifying renal
function.[4,5] The incorporation of intravenous administration
of gadopentetate‑DTPA has allowed a dynamic, functional
assessment of the collecting system that correlates well
92
with diuretic scintigraphy yet provides far greater anatomic
detail than nuclear studies.[5,6,14,15] Cost, availability, time for
acquisition of images and need for sedation in paediatric patients
have all been cited as possible limitations of this technique,
but the superior anatomical details, functional assessment,
elimination of risk of contrast‑induced nephropathy, and lack
of ionising radiation make this technique an attractive option
that is likely to continue to evolve.[2,4,9]
In view of fallacies and difficulties in the diagnosis of obstructive
uropathy despite the availability of multiple investigations
and shortcomings of above‑mentioned investigations such
as radiation exposure, invasiveness, non‑utility in pregnant,
paediatric and patients with compromised renal functions
there is still scope of improvement in the diagnostic workup
of obstructive uropathy. MRU being non‑invasive and
radiation‑free procedure might have an advantage in such
circumstances. This study was conducted focussing on MRU
as a diagnostic modality in patients with obstructive uropathy
and its advantages and limitations in comparison to IVU in
terms of safety, accuracy, reliability and adverse effect.
Aim and objectives
• To study patients with obstructive uropathy using MRU
as a diagnostic technique
• To analyse the statistical data obtained and draw
inferences thereto
• To assess the sensitivity, accuracy and safety of MRU in
comparison to that of IVU.
Material and Methods
This study was conducted at our Institution over a period of
2 years, on patients having symptoms such as abdominal/flank
pain, haematuria and dysuria. A total of 55 patients were
included in this study with ages between 14 and 70  years
(average age 37  years). Thorough clinical examination of
patients was done followed by few baseline investigations
including urea, creatinine and routine urinary examination
were done in all patients.
These patients first underwent screening USG using Aloka
Prosound ultrasound machine and patients showing dilated
pelvi‑calyceal system on screening USG, and normal serum
creatinine (<1.5 mg/dL) levels were subjected to IVU.
Informed consent was taken from patients before each
investigative procedure. After adequate bowel preparation,
IVUs were done using non‑iodinated contrast media, omnipaque
300 at a dose of 1–1.5 ml/kg body weight (approximately 50 ml
in adults). Patients were carefully observed for any adverse
contrast reaction in the meantime, and emergency drugs were
kept standby. Plain films followed by films at 5, 10, 15, 30 and
60  min, full bladder and post‑voiding films, and 24  h films
(if required) were taken. Patients in whom there was no contrast
excretion at 24 h, poor contrast excretion, persistent nephrogram
and/or diagnosis was not clear on IVU and those with contrast
reactions on IVU were subjected to MRU.
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Ahmad, et al.: MR urography

MRU was done using 1.5‑Tesla Magnetom Vision duration of symptoms in our study patients was 4 months
(Avanto Siemens Germany) using the standard circularly (range between 2 weeks and 15 months).
polarised body coil with use contrast material in the case of
A total number of kidney units was 110. Five patients had
dynamic MRU. The contrast material used was 0.1 mmol of
a bilateral obstruction, and 49 patients had a unilateral
Gadopentetate dimeglumine (Magnevist, Schering, Berlin,
obstruction, and one patient had no obstruction at final workup.
Germany) per kg body weight or Gadodiamide (Omniscan).
Hence, the total number of obstructed renal units was 59 and
Before starting the first breath‑hold MR sequence, the
number of non‑obstructed renal units was 51. Out of 55 patients,
patients lying inside the magnet were trained once or twice
28 patients (31 renal units) had no excretion of contrast on IVU,
to suspend their breath for 25–30 s to get familiar with this
diagnosis was not clear on IVU in 2 patients (1 renal unit) despite
special requirement of the examination. MRU sequences were
contrast excretion, 12 patients (14 renal units) had persistent
routinely repeated 5 and 15 min after the administration of
nephrogram, 9 had poor excretion of contrast material and 4
contrast material and delayed films were taken when necessary.
had contrast allergy [Tables 1 and 2]. Figures 1‑7 describe the
Subsequently, detailed MRUs and finally, the source images statistical data evaluated from the results.
were performed until completion of the examination after
usually 25–30 min of contrast material injection. The total
imaging time for complete MR urography was approximately Table 1: Reasons for inability of intravenous urography to
diagnose ureteral obstruction
35 min in the majority of patients. Maximum intensity
projection (MIP) images were post‑processed from the Causes of IVU Number of patients Number of obstructed
original source images of each three‑dimensional sequence failure to diagnose (n=55) (%) renal units (n=59)
dataset. Images were reviewed by senior radiologists both the No contrast excretion 28 (50.9) 31
original and MIP. Subsequently, the results were discussed Persistent nephrogram 12 (21.8) 14
and consensus reached. Poor excretion 9 (16.4) 9
Inconclusive diagnosis 2 (3.6) 1*
Diuretic‑enhanced excretory MRU was performed using a Contrast allergy 4 (7.3) 4
breath‑hold sequence in the coronal plane with an anteriorly *One patient who had inconclusive diagnosis on IVU had Grade I
located pre‑saturation slab. MRUs were obtained with a hydronephrosis on USG but was nonobstructed on final workup (MRU).
repetition time ms/echo of 7/2.8, a 30° flip angle, a 1.8–2.2 mm IVU: Intravenous urography, USG: Ultrasonography, MRU: Magnetic
resonance urography
section thickness and an overlap of 1 mm, two signals acquired,
a 128 × 210 matrix. Field of view was adjusted individually
to accommodate different patient sizes. Each MIP image Table 2: List of final diagnoses in our study patients
could be easily reconstructed without extra time while the (including few important non‑obstructive conditions
subsequent MR sequence was performed. Before contrast diagnosed in our study patients)
material injection, a heavily T‑2 weighted survey MR urogram Abnormality No. of
was obtained using a half‑Fourier acquisition single‑shot turbo Patients
spin echo (HASTE) sequence in coronal plane followed by Obstructive abnormalities (n=59)
conventional axial T2‑weighted tubro spin echo sequence of PUJ obstruction 46
the kidney or the pelvis. The HASTE sequence was applied in PUJ obstruction with secondary nephrolithiasis 3
the axial, sagittal and coronal planes. The data were compiled VUJ strictures 4
and computed for various results. The final diagnosis was Ureteric strictures 2
confirmed intraoperatively on open or endoscopic surgery and Circumcaval ureter 1
was considered the reference standard. Carcinoma cervix with BOO with left renal hypoplasia# 1
Bilateral double moiety with left ureterocele$ 1
Compression of lower ureter by crossing of iliac vessels 1
Results and Observations Non‑obstructive abnormalities (n=30)
This study was a prospective study conducted in the Subcentimetric cysts 13
Departments of Urology and Radiodiagnosis at our Institution Ectopic kidney 7
over a period of 2 years on patients of age group 14–70 years Renal hypoplasia 4
with an average age of 37  years. Out of 55  patients Duplex collecting system with single pelvis 3
19 (34.5%) were female and 36 (65.5%) were male. Majority VUR 2
of patients had unilateral symptoms, left side slightly more Crossed fused renal ectopia 1
#
On IVU there was no excretion of contrast from both kidneys. MRU
common (41.8%) than the right side (40%). The pain was most
showed cervical lesion indenting bladder neck causing BOO, with bilateral
common symptom present in 92.7% of our patients followed hydroureteronephrosis with left renal hypoplasia, $On IVU, there was right
by burning micturition in 27.2%, dysuria in 20% and increased duplex collecting system with dilatation in relation to lower end of left
frequency/urgency in 14.5%. One patient presented with the ureter? Ureterocele/bladder diverticulum/bowel loop. MRU clearly showed
bilateral double moiety with left ureterocele with HUN of left upper moiety.
only complaint of dyspepsia had no urological symptoms and IVU: Intravenous urography, BOO: Bladder outlet obstruction, VUR:
was found to have Grade‑IV hydronephrosis of right kidney Vesicoureteric reflux, PUJ: Pelvi‑ureteric junction, VUJ: Vesicoureteric
as an incidental finding on USG abdomen. The average junction, MRU: Magnetic resonance urography, HUN: Hydroureteronephrosis

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Ahmad, et al.: MR urography
b
Figure 1: (a) Pie chart showing the percentage of multiplicity of symptoms
in our patients. About 74.5% of patients had multiple symptoms. (b) Diagram
showing laterality of symptoms among two sexes in our study
patients (n = 55). Majority of patients had unilateral symptoms, left side
slightly more common (41.8%) than the right side (40%).
Majority of our study patients (78.1%) had contrast excretion
within 10 min of contrast media injection on d‑MRU, and all
patients had contrast excretion by 30 min. Urinary obstruction
was caused by PUJ narrowing in 49 renal units, ureteral
strictures in 6 (one stricture each in upper and mid‑ureter, 4
strictures at vesico‑ureteric junction [VUJ]), circumcaval ureter
in 1 unit, carcinoma cervix with bladder outlet obstruction
in 1 unit, ureterocele in 1 and compression of lower ureter
by crossing of iliac vessels in one patient. The cause of
ureteral strictures was urinary tuberculosis (1 renal unit) of
mid‑ureter, prior abdominal surgery/urological procedures in
2 renal units (upper ureter and VUJ), history of the passage
of documented VUJ stone in the past (1), primary VUJ
obstruction (2).
Level of obstruction was identified in 58 of 59 (98.3%) renal
units by sMRU and in 32 of 32 (100%) by dynamic MRU.
The sensitivity of MRU in detecting hydronephrosis was
100%. Intraoperatively, the majority of patients  (74.57%)
had mild or moderate hydronephrosis which was same as
the sum of Grade‑I, II and III on MRU. Intraoperatively,
mild hydronephrosis was consistent with Grade‑I and II
hydronephrosis on MRU, moderate hydronephrosis consistent
with Grade‑III and severe hydronephrosis with Grade‑IV.
MRU well delineated the pelvicalyceal anatomy in all
patients.
94
b
Figure 2: (a) Bar diagram showing age distribution among study patients:
Average age in our study patients was 37 years (range 14–70 years).
(b) Pie chart showing frequency of different symptoms in our study
patients. Majority of patients had more than one symptoms and pain was
the most common symptom present in 92.7% of patients.
Image quality was good in all patients and fluid‑filled bowel
was not a problem. There was no motion‑related artifacts.
MRU showed better anatomic details. Ectopic kidneys
were correctly identified on MRU in all patients. Average
creatinine was 0.82 mg/dL (range 0.4–1.4 mg/dL). No gross
change in serum creatinine was observed after d‑MRU
examination, and none of the patients developed any type
of contrast‑related event with MRU contrast injection.
MRU clearly visualised upper and mid ureter in all renal
units, and lower ureter was visualised in 108 of 110 renal
units (98.1%).
Out of 25 patients with excretion of contrast on MRU within
10  min period, only 9  (36%) patients had no excretion of
contrast material on IVU, whereas out of 7  patients with
excretion between 10  min and 30  min, 5  (71.4%) patients
had no excretion of contrast material on IVU. It signifies
that patients showing no contrast excretion on IVU had
more chances of delayed contrast excretion on MRU but the
difference is not statistically significant (P = 0.3).
Majority of patients had PUJ obstruction. Out of 31 renal
units showing no excretion of contrast on IVU, 27 (87.1%)
had PUJ obstruction. Similarly, 11 of 14 renal units having
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Ahmad, et al.: MR urography

a b

c
Figure 3: (a) Bar diagram showing levels of obstruction on magnetic resonance urography. Majority (83%) of patients in our study had pelvi‑ureteric
junction obstruction (total number of renal units n = 59). (b) Bar diagram showing comparison between fallacies of intravenous urography with level
of obstruction on magnetic resonance urography (n = number of obstructed units = 59). (c) Pie chart showing relative percentages of different
grades of hydronephrosis on magnetic resonance urography. Nunmber of obstructed units n = 59. It is noticed from the above chart that 67.6% of
patients had Grade‑III or IV hydronephrosis which could be the reason that majority (52.5%) of our patients had no excretion of contrast on intravenous
urography imaging.

persistent nephrogram on IVU had PUJ obstruction, and 8 of Discussion

9 renal units with poor excretion on IVU had PUJ obstruction.
It is concluded from the above figures that there was no
significant relationship between fallacies on IVU with the
level of obstruction on MRU and the difference is statistically
insignificant (P = 0.95).
In the present study, all the 11 renal units with Grade‑IV
hydronephrosis on MRU had no excretion of contrast on
IVU, whereas the majority of patients with Grade II‑III
hydronephrosis showed persistent nephrogram or poor contrast
excretion on IVU. So as the grade of hydronephrosis increases
the chances of getting no excretion on IVU increase or patients
showing no excretion of contrast material on IVU have a
more severe degree of hydronephrosis, and the difference is
statistically significant (P = 0.004).
All the 11 renal units showing no excretion of contrast
material on IVU were found to have severe hydronephrosis
intraoperatively whereas the majority of renal units with
persistent nephrogram or poor excretion on IVU had
mild‑to‑moderate hydronephrosis. This again signifies that
patients showing no contrast excretion on IVU had a higher
degree of hydronephrosis as confirmed intra‑operatively and
the difference is statistically significant (P = 0.001).
Figures 8‑15 describe the imaging correlation between IVU and
MRU, of various obstructive uropathic conditions encountered
in our study.
IVU has been used as the primary imaging technique for
diagnostic evaluation of urinary tract for years, especially in
determining the degree and level of ureteric obstruction,[2] and it
acts as an aid to identify the possible diagnosis. Unfortunately,
IVU has its own drawbacks such as contrast reactions,
radiation exposure[2] and non‑excretion of contrast material in
moderate‑to‑severe hydronephrosis (falsely labelling kidney
as non‑functional), precluding its use in a significant number
of cases such as patients of renal impairment, pregnant and
paediatric patients.[2] Although CT urography is promising
in evaluating hydronephrosis, it is also not without the
above‑mentioned hazards. In these cases, MRU offers the
possibility of evaluating the urinary system and showing
high‑quality images of the urinary tract without exposing the
patient to the main disadvantages of IVU or CT urography. MR
urography is a promising technique which affords equivalent
functional and additional anatomical information to isotope
renography.[13]
In obstructive uropathy, the main reason for the failure of IVU
to diagnose upper tract pathology is the absence of contrast
medium excretion.[14] Here, MRU scores over IVU. This is
of important significance in our study in which majority of
patients had no or very poor excretion of contrast material on
IVU. 50.9% of our patients had no excretion of contrast on
IVU. Shokeir et al.[16] also observed “no excretion of contrast”
as the most common reason (26%) for the failure of IVU to

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Ahmad, et al.: MR urography
a
b
Figure 4: (a) Bar diagram showing time period for excretion of contrast
material in magnetic resonance urography in our study patients. The
majority (78.1%) of patients had contrast excretion within 10 min of
contrast injection and all patients had contrast excretion within 30 min.
(b) Bar diagram showing the comparison between fallacies on intravenous
urography with the time period for excretion of contrast material on
dynamic magnetic resonance urography (n = 32).
diagnose obstruction, though it was not as common as in our
study. It could be because of the reason that 69.1% of our
patients had Grade III–IV hydronephrosis.
A total of 55 patients were included in this study with the age
range of 14–70 years with an average age of 37 years. Majority
of patients had unilateral symptoms, left side slightly more
common (41.8%) than the right side (40%) (reason not known).
The pain was most common symptom present in 92.7% of our
patients followed by burning micturition in 27.2%, dysuria
in 20% and increased frequency/urgency in 14.5%. Khanna
et  al.[14] observed a similar trend in the symptomatology of
patients in their study though pain and dysuria were slightly
more common in our patients and burning micturition, as well
as haematuria, were less common as compared to their study.
One patient presented with the only complaint of dyspepsia
and had no urological symptom, the patient visited a private
clinician and was found to have Grade‑IV hydronephrosis of the
right kidney on USG and was referred to our institute for further
management. The average duration of symptoms in our study
patients was 4 months (range between 2 weeks and 15 months).
One significant advantage of MR urography over IVU is
that during MR urography the level of obstruction is readily
96
a
b
Figure 5: (a) Bar diagram showing comparison between fallacies on
intravenous urography (obstructed units only) with intra‑operative grades
of hydronephrosis (n = 59). (b) Bar diagram showing comparison
between grades of hydronephrosis on magnetic resonance urography with
those of Intra‑operative grades. It shows that grades of hydronephrosis on
magnetic resonance urography are almost similar to those intra‑operativly
and the difference is statistically significant (P ≤ 0.00001).
apparent without the need for delayed films.[17] In our study,
level of obstruction was identified in 98.3% of renal units by
sMRU and in 100% by dynamic MRU. Comparable results
were obtained in a study conducted by Regan et al.[4] in which
HASTE imaging showed the level of obstruction within 13 s
coronal scan in all the obstructed kidneys (100% sensitivity).
Another study conducted by Sen et al.[3] showed that exact
level of obstruction was identified in 25 of 25 (100%) patients.
MRU correctly identified the grade of obstruction in all patients.
MRU showed Grade‑II hydronephrosis in 18 renal units and
Grade‑I in a single unit (total 19). Out of these, 17 units had
mild hydronephrosis intraoperatively (consistent with Grade‑I
and II HDN), and in two units hydronephrosis could not be
assessed intra‑operatively because of endoscopic approach.
Similarly, MRU showed Grade‑III HDN in 29 units, of which
27 were confirmed as moderate HDN intraoperatively and 2
could not be assessed because of an endoscopic procedure.
MRU showed Grade‑IV HDN in 11 units, all of which were
confirmed intraoperatively. Grades of hydronephrosis on MRU
are almost similar to those intraoperatively and the difference
is statistically significant (P ≤ 0.00001).
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Ahmad, et al.: MR urography
b three‑dimensional FLASH subtraction image of the same patient showing
Figure 6: (a) Bar diagram showing the comparison between fallacies
on intravenous urography (obstructed units only) with grades of
hydronephrosis on magnetic resonance urography (n = 59). (b) Bar
diagram showing percentages of intra‑operative grades of hydronephrosis
among study patients. In patients labeled as ‘not applicable’, grade of
hydronephrosis could not be assessed because of the endoscopic
approach of surgery.
a b
c d
Figure 8: (a) A 20 min intravenous urography image of 18‑year‑old
female showing right sided double moiety with normal contrast excretion
bilaterally. (b) A 2‑h intravenous urography image of the same patient
showing doubtful dilatation in relation to the lower end of the left ureter.
? ureterocele/bladder diverticulum/gut loop. (c) Coronal post‑contrast
three‑dimensional FLASH magnetic resonance urography image showing
bilateral double moiety with HUN (Hydroureteronephrosis) of the left upper
moiety. (d) Coronal HASTE magnetic resonance imaging sequence of same
patient showing left ureterocele.
MRU showed dilatation of urinary tract in 55 of 55 patients in
our study (sensitivity of 100% for detection of obstruction).
It was consistent with many studies done in the past. A study
Advances in Human Biology  ¦  Volume 8  ¦  Issue 2  ¦  May‑August 2018
a b
c
Figure 7: (a) Intravenous urography image of patient at 10 min showing
no excretion of contrast material from left kidney. There was no excretion
of contrast till 24 h on repeated films. (b) Coronal thick slab T2‑weighted
magnetic resonance urography image of the same patient showing
grossly hydronephrotic left kidney with visualization of normal caliber left
ureter s/o pelvi‑ureteric junction obstruction. (c) Coronal post‑contrast
uptake of contrast in right kidney and residual renal parenchyma of the
left kidney.
a b
Figure 9: (a) coronal T2-weighted thick slab magnetic resonance
urography image of the same patient as in figure 8 showing left
ureterocele with dilated left lower ureter. (b) Coronal T2‑weighted thick
slab magnetic resonance urography image of the same patient showing
HUN of left upper moiety with secondary to left ureterocele.
conducted by Zielonko et al.[15] in 2002 showed a sensitivity
as well as specificity of 100% to detect urinary tract dilatation
by sMRU. In a study by Karabacakoglu et  al.[6] in 2003,
the sensitivity of MRU to correctly identify dilated urinary
tracts was 100%. Sudah et al.[10] also showed that sensitivity,
specificity and accuracy of MRU to diagnose obstruction was
100%. Muthusami et al.[13] also found similar results in their
study in which they showed that the overall sensitivity and
specificity of MRU to detect hydronephrosis was 95% and
100%, respectively. O’Malley et al.[18] concluded in a study
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Ahmad, et al.: MR urography
a b
Figure 10: (a) Fifteen minutes prone intravenous urography image
showing normal contrast excretion from right kidney with no contrast
uptake or excretion from left kidney. (b) Coronal T2‑weighted magnetic
resonance urography (thick slab) of same patient showing Grade‑IV
HUN. Subsequent micturating cysto‑urethrogram showed Grade‑IV
vesicoureteric reflux.
a c
b
Figure 12: (a) A 10 min intravenous urography film showing
contrast excretion in right renal area with possible double collecting
system. No contrast uptake/excretion was seen on left side. (b)
Axial T2‑weighted static magnetic resonance urography image of the
same patient showing separate renal pelvis and ureter on right side
with non‑visualisation of kidney on left side. (c) Coronal T2W static
magnetic resonance urography image (thick slab) showing crossed
fused renal ectopia.
that MR urography was highly accurate, with a sensitivity
of 100% and a specificity of 96% in the detection of renal
pelvicalyceal and ureteric dilatation. Patients showing no
excretion of contrast material on IVU had a more severe
degree of hydronephrosis, and the difference is statistically
significant (P = 0.004).
The total imaging time for complete MR urography was
approximately 35 min in our study. Similar results were
obtained in a study conducted by Sudah et al.[10] in which
total imaging time for all MR sequences, if excretion was
not delayed, was approximately 25 min. Farres et al.[12] also
98
a b
c
Figure 11: (a) A 2 h intravenous urography film showing no excretion
of contrast bilaterally with radio‑opaque shadow in left renal area
s/o calculus. (b) Coronal T2‑weighted static magnetic resonance
urography thick slab image of same patient showing bilateral Grade‑IV
hydroureteronephrosis. MCU of the patient showed bilateral Grade‑IV
vesicoureteric reflux. (c) Axial HASTE image of same patient showing
bilateral hydronephrosis with 2 filling defects (calculi) in left renal
pelvis.
a
b c
Figure 13: (a) A 25 min intravenous urography image showing
nephrogram but no excretion of contrast from left kidney with normal
contrast excretion from right kidney. (b) Coronal post‑contrast
three‑dimensional FLASH magnetic resonance urography image showing
external compression of left ureter by crossing of left common iliac
vessels causing left HUN. Note the normal calibre ureter below the level
of obstruction. (c) Coronal post‑contrast three‑dimensional FLASH image
of same patient showing extrinsic ureteric compression caused by left
common iliac vessels.
showed similar results in their study in which total examination
time for dynamic, Gd enhanced MRU was usually 30  min.
Riccabona et al.[5] also obtained mean study time of 38 min
for MRU in their study.
MR urography was successful in making a diagnosis in
98.3% in our study patients. Similarly, results were obtained
in a study conducted by Farres et  al.[12] in which dynamic
MR urography was adequate in making diagnosis in 95%
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Ahmad, et al.: MR urography
a c
Figure 14: (a) A 6 h intravenous urography image showing no uptake
or excretion of contrast material from both kidneys. (b) Axial HASTE
magnetic resonance imaging image showing bilateral hydronephrosis
with hypoplastic left kidney. (c) Coronal TW Fat Sat image showing a
lesion indenting the bladder neck.
of patients. In another study, conducted by Aerts et al.[19]
demonstrated that MRU depicted all pathological conditions
in all patients (100%) including renal hypoplasia. One more
study (conducted by Zielonko et al.)[15] showed similar results;
in which the diagnosis of calculi group by MRU correlated
with other modalities in 85% of cases, whereas in group of PUJ
strictures, results of sMRU correlated with verification methods
in 100%. In another study, conducted by  Szopinski et al.,[20] the
diagnostic values of MRU were considered satisfactory in
98.9% of FLASH 2D studies. Extrinsic causes of obstruction
were better diagnosed by MRU because coronal and axial
sections could depict abdominal and pelvic pathologies causing
ureteric compression as we observed a case of circumcaval
ureter and also crossing of iliac vessels causing compression
of the lower ureter.[19,21‑24]
The final diagnosis in our patients included PUJ obstruction
in 49 renal units, VUJ strictures in 4, ureteric strictures in two
patients. Khanna et al.[14] obtained PUJ obstruction in 22.5%
of study patients. A study by Riccabona et al.[5] found PUJ
obstruction in 48% of pathological diagnosis followed by
VUR. Sen et al.[3] found PUJ obstruction in 12% of patients
followed by ureteric strictures in 8% and carcinoma cervix in
4%. All these studies obtained calculi as the most common
cause of obstructive uropathy, but in our study calculi were
not seen as the most common cause because calculi are almost
always detected on IVU and hence are excluded from the study
and it might be considered a limitation of our study.
In our study, prior abdominal surgery/urological procedures
were done in 2 out of 6 ureteric strictures (33.3%). Results
comparable to our study were observed in a study conducted
by Zielonko et al.[15] in which they revealed prior urological
procedure as the cause of stricture in 4 and prior surgery in
3 cases (total of 7 of 23 ureteric strictures) which comes out
to be 30.4%. The above‑mentioned figures in our study might
Advances in Human Biology  ¦  Volume 8  ¦  Issue 2  ¦  May‑August 2018
a b
Figure 15: (a) A 5‑min intravenous urography image showing
non‑excretion of contrast from right kidney with non‑visualisation of right
ureter. (b) Coronal T2‑weighted thick slab magnetic resonance urography
image of the same patient showing right hydroureteronephrosis with
possible right vesico‑ureteric junction stricture.
be falsely higher due to the very small number of patients with
ureteric strictures (small sample size) in our study.
MRU revealed overall better anatomy in the majority of urinary
systems, particularly concerning the renal parenchyma, ureter
and dilated collecting system, using T2‑weighted sequences.
Gadolinium‑enhanced dynamic MRU allowed accurate
anatomical assessment of the complete collecting system
and enabled a reliable estimate of pelvi‑ureteral drainage.
Diuretic‑enhanced excretory MRU seems to provide the best
possible non‑invasive performance in the pre‑operative and
post‑operative assessment of ureteral compression and partial
or complete displacement by extrinsic tumour diseases.[25] In
suspected strictures, particularly if malignant, one of the major
advantages of MR imaging is the capability to obtain additional
information as the extension of a pathologic process and the
presence of lymphadenopathy or distant metastases.[26]
T2‑weighted MRU is safe during pregnancy; therefore, it
can differentiate physiologic dilatation in pregnancy from
pathologic dilatation. [27] Another important advantage
of dynamic MRU is that it can give details regarding
functional (including split functions of two kidneys) as well
as anatomical aspects of urinary tract, so avoiding need for
multiple investigations like IVU followed by CT and/or renal
scan for functional and anatomical aspects separately when
a single investigation is not diagnostic. It becomes more
time‑consuming, adding patient discomfort and also less
cost‑effective than dynamic MRU alone. MRU could reveale
the pathology even in non‑functioning.[3]
A complete MRU protocol can be used for imaging all
components of the kidneys and the urinary collecting system in
a single imaging session.[28] MRU has better contrast resolution
than CT urography without exposure to ionising radiation and
can be done without contrast administration, making it more
suitable for examination of paediatric and pregnant patients
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Ahmad, et al.: MR urography
and patients with renal impairment.[29] MRI may have a role
in screening patients with inherited conditions affecting
the kidneys, such as Von Hippel Lindau disease, which is
characterised by haemangioblastomas of the CNS with a high
prevalence of renal cysts, angiomas, and renal cell carcinoma.
MRU is as effective as excretory urography, ultrasound and
nuclear medicine techniques for the investigation of most
paediatric uropathologic conditions and for the investigation
of congenital anomalies. MRU is better than IV urography
for the depiction of renal scarring in patients with spinal
dysraphism.[8,7,17,26,30‑32]
The option of performing either static‑fluid or excretory
MRU is useful in the context of renal obstruction, such as that
associated with an obstructed upper pole moiety in a duplicated
collecting system. In a duplex collecting system, the ureter
draining the upper pole principle moiety inserts ectopically
inferior and medial to the ureter draining the lower pole moiety
below the level of trigone and is prone to obstruction. The
lower pole and interpolar regions of the kidney are drained by
a separate ureter that has an orthotopic insertion but is prone
to VUR.[28] This principle is known as the Weigert‑Meyer rule.
The obstructed moiety is likely to excrete IV contrast material
slower than is the lower moiety, if at all. Static‑fluid MRU can
be used in such circumstances to visualise differential dilatation
of the upper pole moiety relative to that of the lower pole.[9]
The combination of static‑fluid and excretory MRU can be
useful in the evaluation of obstructive uropathy because
T2‑weighted images can show the extent of dilatation of the
obstructed system and excretory MRU can provide information
on the functional effects on excretion.[9] The use of MRI
facilitates simultaneous evaluation of the kidneys, ureters, renal
arteries, renal veins, and IVC, which is useful for assessing
renal parenchymal, perinephric, and periureteral tumour
extension. Sequential imaging of the ureters with MRU can be
used to overcome problems with intermittent lack of ureteral
distension due to peristalsis, which can lead to misdiagnosis
of stricture and obstruction at CT urography.[29] Sequential
imaging also can be used to map the pattern of renal and
lesional enhancement after contrast administration, which
can be useful for characterising lesions and quantifying
renal function.[9] In cases of compromised renal function
such as chronic renal failure, dynamic MRU is shown to be
effective because it is highly sensitive to even small amounts
of gadolinium in the collecting system.[12] Besides, Gd‑DTPA
complex is safe in such patients due to its hydrophilicity.
Although MRU has great potential for detection, localisation
and characterisation of renal and urothelial pathologic
conditions, it also has few limitations. Intravenous contrast
material (gadolinium) is routinely required for complete
evaluation. Contrast material has to be used judiciously,
especially in cases of patients with renal impairment due to
the risk of nephrogenic systemic fibrosis.[33] The optimal dose
of IV gadolinium for MRU has yet to be established. The
standard 0.1‑mmol/kg dose of gadolinium is reported to cause
100
T2 effects, and doses of 0.05 mmol/kg may impair contrast
resolution.
Conclusions
On MRU, it is the static fluid in a urinary system which
allows to us study the urinary tract without the use of contrast
material and provides images similar to those obtained
on IVU. An MRU study using a low‑dose contrast agent
coupled with a T2‑weighted study is an attractive alternative
to the conventional imaging of the kidneys and urinary tract,
especially in cases of renal tumours. MRU contributes critical
information regarding both morphological and functional
aspects of urinary tract avoiding exposure to radiation as well
as iodinated contrast and could be done without using contrast
material and is suitable for pregnant, paediatric patients and
patients of renal failure. HASTE‑MRU is a rapid, non‑invasive
technique for visualisation of urinary tract abnormalities.
MRU has high sensitivity in the diagnosis of urinary tract
obstruction, detecting the level of obstruction and as an aid in
the diagnosis of obstructive uropathy, thus showing promising
results. MRU is safer than IVU due to avoidance of iodinated
contrast material and could also be done without using contrast
material so having less contrast related events.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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