INTRAVENOUS UROGRAPHY

(IVU)

Moderator :
Mr. Ram Singh (Lecturer)
Deptt. Of Radio-Diagnosis &
Imaging, PGIMER, Chandigarh.
 INTRODUCTION
In diagnostic radiology, the imaging modalities
are growing very fastly since the x-rays had
been discovered by W.C. Roentgen in 1895. In
the beginning the urinary tract was examined
or diagnosed with the plain radiography. One
of the technique of diagnostic radiology have
developed. Previously it was called intravenous
pyelography (IVP). But it was limited to
pyelography.
As the introduction of the
urography, it is possible to study the
morphology of kidneys, ureters,
urinary bladder and urethra which
called intravenous urography.

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 Definition :

Intravenous urography is a radiological

examination of kidneys, ureters and urinary
bladder by injecting water soluble radiopaque
contrast medium intravenously through
antecubital vein. The term intravenous
pyelography (IVP) implies only visualization of
the calyceal system and pelvis so the term
intravenous urography or excretion urography is
broadly used to visualize the whole kidneys,
ureters and urinary bladders.

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The intravenous urography is done to
check or see the anatomy, physiology
and pathology of the urinary tract
kidneys ureters and urinary bladder.

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ANATOMY

The urinary system

comprises :
 A pair of kidney
 A pair of ureter
 A urinary
Bladder
 An urethra
 KIDNEY

 The kidney are bean shaped organs.

 It lies in the abdomen on each side
of the vertebral column behind the
peritoneum and below the
diaphragm.
 It extends at the level of T12 to L3
vertebra.
 The right kidney is usually slightly
lower than the left due to space
occupied by the liver.

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 The kidney has two borders (medial
and lateral).
 Medial border of each kidney being
concave and lateral border is convex.
 The medial border of each kidney has
hilum from transmission of a) renal
vein (B) renal artery (c) the renal pelvis.
The pelvis is the expanded upper end
of ureter.

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 It has two surface –
(i) anterior
(ii) posterior.

 It has two poles :

- upper
- lower.
 Size :
- 12cm long
- 6cm wide
- 3cm thick

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12
 RENAL PELVIS

 It is funnel shaped structure which acts

as a receptacle for the urine formation
by the kidney. It has a number of
branches called calyces at its upper end.
• Renal calculus is generally found in
renal pelvis.

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 URETER
 The ureters are a pair of narrow ,
thick walled muscular tubes that
convey urine from the kidney to
the urinary bladder.
 They are about 25cm long and
about 3mm diameter
 They lie deep to the peritoneum ,
closely applied to the posterior
abdominal wall in the upper part , and
to the lateral pelvic wall in the lower
part.

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 URINARY BLADDER

 The urinary bladder is the temporary

reservoir for urine.
 It lies in the anterior part of the
pelvic cavity and size and position
vary depending on the amount of
urine.
• Ureters enters the wall of bladder at the
lateral margins of the superior part of
the base and passes obliquely through
the wall of their respective internal
orifices.
• The mean capacity of the bladder in
adult is 500-600ml.

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19
 URETHRA
 The urethra extends from the
internal urethral orifice at the
neck of the urinary bladder to
the external urethral orifice.
• Female urethra is about 4cm long. It
opens at the external urethral orifice
just in front of the vagina.

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 EQUIPMENT
 High power x-ray unit i.e. three phase, 6 or
12 pulse is preferable.
 The kv range is usually 65-75kv and mA
ranges from 600 to 1000 mA which allows
an exposure of less than 0.1 second.
 Floating top type table for easier patient
positioning.
 Compression band

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*In this we use :
FLAT PANEL DETECTOR SYSTEMS:
This system uses x-ray detectors
of photoconductive materials such as
amorphous Se or Si for direct acquisition
of projection radiographs.
* Essentially, two methods have been
developed for direct capture radiographs:
Indirect method
Direct method

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 Indications for IVU
1. To check the anatomy and
physiology of urinary tract .
2. To diagnosed suspected urinary
tract pathology
a. Obstruction
b. Stenosis
c. Mass or tumour lesion
3. To check and diagnose the congenital
anomalies as
– Hypoplastic kidney : (small in size)
– Atrophic kidney: (Acquired)
– Horse shoe kidney: in which the kidneys are
united
– Duplex kidney: 2 kidneys on one side / 2
ureters from one side
– Low lying kidneys
– Floating kidneys.
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4. Polycystic kidneys: ( i.e. multiple cyst)
5. To diagnose the calculus disease in the
kidneys, ureters and urinary bladder.
6. Obstructive urpoathy:

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• In case of obstruction
• Stenosis
• Mass lesion
• PUJ/ Pyeloureteric junction obstruction.
7. Infection:
• (i) Urinary tract infection (UTI)
• (ii) Hematuria
• (iii) Nephritis
• (iv) Pyonephrosis (pus in the kidney )

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8.Tubercular infection (T.B.)
9. Sol (space occupying lesion) in the kidneys.
– Cystic lesion
– Tumour /mass
– Benign tumour
– Malignant tumour
– Renal cell carcinoma (RCC)
– Wilms tumour in children
– Neuroblastoma

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10. Traumatic kidneys
• Ruptured kidney
• Damage by trauma
11. Vesico-ureteric reflux in children
12. Miscellaneous
• Ca-cevix
• BEP (Benign enlargement of prostate
• BHP
• Bladder diverticula

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 CONTRA INDICATIONS FOR
IVU
1.Patients history of highly sensitive to
iodinated contrast medium
2.High fever
3.Dehydration is contra indicated
– In case of myelomytosis/ multiple mycloma.
– Cardiac patient
 – Asthmatic patient
– Severe hepatic and renal failure patient
– Diabetes mellitus
– Infant and children
– Very old patient
– Very ill patient
• Pregnancy

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 PREPARATION OF THE
PATIENT
 Usually 2 days preparation is
given.
 In case of emergency, infant and
children, very old, post trauma
patient there is no need for
preparation.
 Laxative two night prior to the
examination i.e.
 Dulcolax suppository / glycerin
suppository is given per rectum
on the day of examination for
pediatric patient, very old patient
and very ill patient.
 Some gas absorbing tablets.
 Charcoal tablet, 2 tab 3 time daily
for 2 days.
 Patient must be kept nil orally at
least 6 hours prior to examination.
 If patient is taking medicine which is
radiopaque i.e. Bismuth or iron one
must restrict the morning dose on the
day of examination.
 Patient must void the urinary bladder
prior to examination.

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Patients should be instructed to
bring following things :
 Contrast media.
 50cc disposable syringe.
 18G or 20G iv canula.
 Blood urea, or creatinine report.
 All the previous investigation e.g. US report, x-
ray film.
 CONTRAST MEDIA

 Contrast media are those substances

which is used to differentiate the body
tissue by introducing through various
route in the body for the urinary tract
are water soluble.
• Two types of water soluble contrast
media. Conventional one is the ionic,
HOCM and newer one is non ionic
LOCM which is safer as compared to
ionic or HOCM conventional ionic water
soluble contrast media.

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• Conventional ionic water soluble
contrast media are more acceptable for
the majority of the patient but non ionic
contrast media may be preferred for the
following patient:
• Infants and small children
• Renal and cardiac failure patient
• Poorly hydrated patient
• Diabetic patient
• Multiple myeloma patient
• Patient having history of allergic reaction to
ionic contrast media.
• Some list of low osmolar ionic
contrast media are:
• Injection of sodium and
meglumire diatrizoate.
Metrizoate or iothalamate which
are tri-iodinated benzoic acids.
They are ionic and have an
iodine to particle radio of 3:2.
• The ionic contrast media the sodium
salts produce slightly higher
concentrations of iodine and more
frequently cause arm pain and
vomiting.

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• Example of conventional ionic contrast
media
• 1. Urografin 76% - 20 ml ampoule contains
injection of sodium and meglumine diatrizoate
• Iodine content 370 mgI /ml
• Total iodine content in 20 ml = 7.4 gm
• There are various ionic contrast media
• Trazograf
• Trivideo
• Urovideo etc
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• Iothalamate containing ionic contrast
media are
• Conray 280
• Conray 420
• Sodium iothalamate are more preferable
for IVU since meglumine leads to a more
intensive diluting the pyelography.

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• 2. A new low osmolar contrast media are
ioxalate (Hexaboix) ionic and
• Niopalm - iopamidol
• Ultravist - iopromide
• Omnipaque - iohexol
• Which are non-ionic contrast media their iodine
to particle ratio is 3:1. They produce higher blood
and urinary concentrations of iodine but reduced
side effects osmotic diuresis compared with
triiodinated contrast media. Mild reactions are
less frequent and their drawback is high cost.

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 DOSAGE

• For normal renal function adult patient the dose

is 300 mgI/ml per kg body weight and 600 mgI/ml
per kg body weight (Sutton) for high dose study.
• Normally in practice for normal renal function,
adult patient 1 cc/kg body weight and renal failure
or high dose urography 2 cc/kg body weight.
• Simple dose – 40 cc i.e. 2 ampoules for
adult (normal)
• Double dose 80 cc i.e. 4 ampoules for
obese or any required patient
• Dose for the child is 1.5 cc/kg body weight
to 2 cc per kg body weight

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Contrast Media Reactions:

The incidence of reactions is considerably

higher the use of ionic contrast media
with a history of allergy or sensitivity of
any other drugs. Patients suffering from
ischaemic heart disease, asthma, having
history of previous severe reaction to
iodinated contrast media.

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Contrast media giving rise to
various reactions are:
1. Minor reaction
2. Intermediate reaction
3. Major reaction
• 1. Minor reactions :
It includes, urticaria, sneezing, flushing,
nausea and vomiting (mild), tinitus, violent
yawans; becomes restlessness usually no
treatment is required only to reassure the
patient is sufficient.

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• 2. Intermediate reactions:
• Development of patches all over the body,
nausea and vomiting is severe. Patient
urge to cough blood pressure raise up, a
down patient feeds drowsy, patient
sweating or feel cold and severing.
• Need treatment but no risk to the patient.

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• 3. Major reactions
• Bronchospasm, laryngeal oedema
patient pale, sweating, thready pulse
may loss consciousness, respiratory
failure as the patient can stop breathing
convulsion and coma, all these
required prompt and efficient treatment
if to survive the patient.

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• Treatment
• Note: Severe reactions are in emergency situation.
You must act quickly:
• 1. Reassure the patient
• 2. Inform and call the doctor
• 3. Tell the doctors where the emergency drugs are
kept
• 4. Kept the patient warm if cold
• 5. Release compression, it is applied, it is applied

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• 6. Give antihistamine or steroids intravenously
according to nature of reaction
• 7. Check BP, pulse. If BP is high or low, pulse
rapid or slow start quickly intravenous infusion
quickly, very fast rate.
• 8. If the pulse and BP low elevate the patients leg.
• 9. If breathing stopped, start quickly first aid
treatment i.e. mouth to mouth respiration.
• If cardiac arrest, call the cardiac team of doctors
start external cardiac message.

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 PROCEDURE/TECHNIQ
UE
 Before starting the procedure, the
pt. is explained about the
procedure & his consent is taken.
 Patient is asked to void the bladder.
 Filming sequence depends
institution to institution.
ROUTINE FILMS SEQUENCE
 Plain film (KUB)
 5 minutes film (Supine)
 10 minutes with compression
 11 minutes after releasing
compression
 15 minutes prone film if
indicated

 Oblique film if indicated
 Full bladder film
 Post void
 Different oblique if indicated
 Delayed film if indicated

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 PLAIN FILM (KUB)

Positioning :
• patient is made supine on
the center of the x-ray
table, hands and legs are
extended. Place 12”x15” or
14”x17” cassettes in the
bucky tray. Cover the area
from the xiphisternum to
symphysis pubis, light
beam aperture should be
proper collimate to cover
• Central ray is directly over the
umbilicus region. Exposure is made in
arrested expiration.

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 PURPOSE OF THE PLAIN FILM

 To check the exposure factor and

positioning
 To see the anatomical structure
 To see any abnormal calcifications
 To check the bowel preparation

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MODIFICATION OF PLAIN FILM

• If any radio opaque shadow or stones are

seen on plain film and we are doubtful
whether it is in the kidney region or outside
then take
• Oblique view of abdomen, to know the exact
position of stones with kidney boundaries
• Take lateral view of abdomen. The GB
stones can be seen anteriorly and kidney
stones can be seen posteriorly.
• Take inspiratory and expiratory phase
film further to confirm if it is stones or
gas. If it is stones it will be constant if it is
gas it will changes its position in each
phase.

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 5 MINUTES FILM
Positioning : (NEPHROGRAMS )
A coned down
view of kidney is
taken. The pt. is
allowed to lie down
in supine position
with the film
centered midway
b/w xiphisternum
& umbilicus.
• 10x12” cassette
is transversely
placed, upper
border of
cassette is
placed 1-1&1/2”
above the xiphoid
process.

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 Central: Ray is directed midway
between the xiphoid process and
umbilicusThe nephrogram phase to
assess the rate of urine formation.
 Rate of uncompressed calyces.
 After the 5min film. The uretric
compression is required

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 ADVANTAGE OF
COMPRESSION
 It acts as an immobilization device.
 It reduce the body thickness so
exposure is less.
 It is applied to collection of c/m in
the Pelvicalyceal system and
proximal ureter.
Contra indications of compression :

 Infant and children

 Very old
 Very ill patient
 Recent abdominal surgery
 Badly injured or trauma patient
 Abdominal mass

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 10 MINUTES
FILM
With compression band
as the previous renal
area film i.e. 5min film

Purpose :

 To ensure proper & well

distension of
pelvicalyceal system.
• To visualized
proximal / upper
2/3rd of ureter.

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 11 MINUTES
FILM
Taken immediately
after release of
compressor.
 Pt. position is same
as plain KUB film.
 12x15” or 14x17”
cassette used with
lower border of
cassette should just
below pubic
symphasis.
Purpose :

 To visualize ureter (esp. lower 1/3rd)

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 15 MINUTES PRONE
FILM
It is done to check
whole urinary tract,
Kidneys, ureters &
urinary bladder.

Positioning :
Patient is asked to lie
down in prone
position. Center the
film at the level of iliac
crest
• . Both posterior
superior iliac
spine are
equidistance from
the film.

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 Purpose :

 This film is required if the lower part of

the ureter is not visible in released film.
 As lower ureter are anteriorly in the
body, prone film show lower part of the
ureter.
 It is good view for lesion on the anterior
bladder wall & for showing bladder
hernias.
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 FULL BLADDER
FILM
 Ask the patient to
drink plenty of water
and wait for full
distension of urinary
bladder.
Positioning :
 A pt. is asked to lie
down in supine
position, with supine
of the pt. centered to
the x-ray table.
 A 10x12” film placed
longitudinally upper
border of iliac crest.
.
Central ray :
Is directed 2 inches above the
upper border of pubic symphasis with
a 5° angulation towards feet.

Modification in full Bladder :

 Lateral film is taken in case of vesico
vaginal fistula.

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 Purpose :

 To detect the abnormality in bladder

filling & a filling defect with in bladder.
 The film shows the amount of urine
formed during examination

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 POST VOID
FILMS
 It is taken either a
full length film or
coned view of
bladder film.
 Full film is taken to
check the vesico
uretric junction
and returned the
contrast in the
ureters.
 A cone view of bladder is taken to check
the residual volume of urine retained in the
bladder and bladder abnormalities.

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 MODIFICATION OF IVU
• Renovascular hypertension
• Film sequence for renovascular hypertension
(RVH). It is also called rapid sequence film.
• Rapid sequence
• 1 minutes of renal area
• 2 minutes of renal area
• 3 minutes of renal area
• 5 minutes of renal area
• Purpose of rapid sequence film
– To diagnose the renal vascular hypertension
– To check the renal artery stenosis if the renal
artery is blocked or stenosis or partially
caliber of artery is small ti will cause high
blood pressure i.e. cause of RVH.
• So to compare the rate at which the
kidney commence excretion reveal films
are taken within five minus.

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• Hydronephrosis: Delayed film upto 24 hours.
Dilatation of renal calyces cause overfilled calyces
seen on one side or both can be due to narrowing
or growth or some obstruction. So to find the site
of obstruction has to modify the technique. Prone
view of kidney region is done because after 5
minute film or 10 minutes film show
hydronephrotic changes. It is done to see the
pelvic ureteric junction and kidneys lies anteriorly
and contrast media pools in it when the patient
lies prone.
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• Technique: Patient is made prone position
one 12”x15” film is placed lengthwise
showing whole-length of ureters and
kidneys much greater volume of CM
needed to outline filling of enlarged renal
pelvis and ureters.
• Delayed film, after 10 min = 30 min film, -45
min film, 1 hour film, 2 hour film, 4 hour
film, 8 hour film, 24 hour film
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1. Congenital abnormalities. For the
congenital abnormalities or displaced
the kidneys and ureters by the
tumours to other sides then bigger
size film is done in 10 minutes film, as
the large size film 12”x15” or 14”x17”
film covering whole KUB region.

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 Renal failure: If there is no contrast
creation in one kidney or both kidneys,
the delayed films are taken after 10
minutes film 30 minutes film, 1 hour film,
2 hour film, 4 hour film, 6 hours film, 24
hours film if required.
• Floating kidneys
• After 10 minutes film take one 12x15 film
in erect position to prove whether the
kidney is moving with the change in
position.

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• BEP benign enlargement of prostate. If is
done in filled bladder with tube angled
25° caudal. This will show impression of
prostate over bladder. Now a days it is
seen by USG.

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• Bladder tumour
• To check the bladder tumour both
oblique views of bladder are taken to see
the bladder tumour.

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• Infants and children
• Film sequence for infants and children are
difference to reduce the exposure:
• a) 2 minute film of renal area
• b) 5 minutes film of renal area
• c) 15 minutes film the full-length
abdominal film. Other films are as
required.
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• Other Method of doing IVU
• High dose IVU (DLD double dose): It is
done in renal failure when blood urea is
high, 600 mg iodine or 2 ml per kg body
weight or 80 ml of water soluble iodinated
contrast media is injected rapid bolus.
Different film sequences are taken as
routinely check the one film and follow the
other.
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• Drip infusion pyelography: It is done in
case of trauma when no preparation is
required or IVU is done without bowel
preparation. A good nephrogram is
required; a nephrotomography is done
can different a cyst and a tumour.

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• 150 cc contrast diluted with equal amount
of 5 percent dextrose glucose solution.
Contrast media has to be injected by drip
infusion method within a period of 15-20
minutes normally 16 gm is injected is
found IVU then 40 to 50 gm of iodine not
as bolus but in diluted form technique.

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• 1st film is taken immediately after the
completion of contrast i.e. at the end of
injection which will show nephrogram
phase. If tomography has to be done in
this stage do difference between cyst and
tumour rest film done as normal IVU i.e. 5
minutes, 10 minutes and 15 minutes.

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• Retrograde pyelography (RGP) –
Retrograde pyelography or instrumental
pyelography done under GA in main OT
(MOT). It is a radiological investigation of
findings, ureters by retrograde injection of
contrast medium through catheter perform
the gross anatomical study and not
functioning detail. Modern high dose
technique has made this study less common.

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 RADIATION PROTECTIONS :

 The radiation dose can be

minimized by applying appropriate
collimation, lead shielding for vital
organ and gonads.
 Where it is possible, 10 days rule
followed in case of women bearing
child.
 Use the high speed film and I/S.
 ALARA Principle keep in mind.
 In CT we use low mAs technique when
evaluating the renal calculi .

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 ALTERNATE MODALITIES &
PROCEDURES :
Ultrasound :
 It provides a means to evaluate the Kidneys
& Bladder in a non invasive manner.
 The ureters are normally not visualised
except when dilated. Colour flow doppler
can be used to demonstrate the renal blood
flow and may be used to assess renal artery
stenosis.
• The patient may be fasted to reduce bowel
gas, and is given half litre water to drink
one hour prior to examination to allow
visualisation of bladder.

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 Indications
KIDNEYS
1.Renal failure
2.Hypertension
3.Abdominal pain
4.Suspected renal obstruction
5.Hydronephrosis

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BLADDER
1.Tumors
2.Diverticula
3.Bladder wall thickness
4.Ureteroceles
5.Calculi and Intra-vesicle filling defects

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105
CT
• Allow to visualize stone in the urinary
system without the use of c/m.
• It continues to be an ideal imaging
modalities for evaluation of tumor &
obstruction.

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• Bilateral Renal
Pelvis Calculi

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 MRI

 Where routine radiography doesn't

give required information , MRI
(MR-Imaging & MR-Urography)
gives dilated imaging of KUB,
collecting system & parenchyma.
 Gadolinium contrast is given
Intravenously to assess the renal
abnormality.
Limitation
:
 Little functional information available.
 It is difficult to distinguished b/w obstructive
& non-obstructive urinary dilatation.

Can’t detect urinary calculi very clearly.

Major Limitation :
It is an alternative technique to IVP & CT-
Urography for: children & pregnant women &
Advantages
for pt. with history of allergy to c/m.

109
 Fig. 4 : T2 weighted post-contrast MR
Urogram depicting a dilated right pelvicalyceal
system and ureter, the lower third of
which was compressed by the pelvic lesions

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 RADIO-NUCLIDE
IMAGING
• Radio-nuclide imaging is used to
study the renal vascular supply,
function and drainage as well as
providing a means of observing
gross anatomical details.
• By selecting the appropriate
combination of radio-nuclide and
pharmaceuticals,quantitive
Analysis of renal function can be obtained
from a processed time activity curve. This
is normally referred to as Renogram and is
a graphical representation of amount of
radioactivity in kidneys over a period of
time.

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INDICATIONS
• Renal/ureteric calculi for complete or
partial obstruction and relative functions.
• Pelvi-ureteric obstructions
• Hypertension
• Investigation of renal artery stenosis
• Trauma
• Renal failure
• Assessment of bladder function

113
IMAGING AND RADIO-
PHARMACEUTICALS PARAMETERS
TYPE ACTIVITY ENERGY
99m

Tc DTPA 100-300MBq 140keV

(DiethyleneTriamine
PentaAcetic acid)
99m

Tc MAG-3 40-400MBq 140keV

(Mercapto
AcetyltriGlycine)
123

I Hippuran 20MBq 159keV

114
CONCLUSION

Now a days this examination is less

often used because of development of
alternative modalities as Ultrasound,
Helical CT, Multislice CT, MRI & Nuclear
Scan. But to check the functional
status of the kidneys, IVU is better
diagnostic modality

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Intravenous urography demonstrating crossed renal ectopy.
The "left" kidney is located below the right kidney.

116
A horseshoe kidney is easily demonstrated at intravenous urography.
The renal axes intersect inferiorly.
 

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Kidney Stone

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119