This document provides information about intravenous urography (IVU), including: - IVU involves injecting contrast media intravenously and imaging the urinary tract as it is excreted - It allows visualization of the kidneys, ureters, and bladder but has decreased in use due to alternatives like CT, US, and MRI - The procedure involves injecting contrast, then taking x-ray images over time to show contrast passing through the urinary system - Findings are evaluated for abnormalities, obstructions, or other issues by analyzing the appearance and timing of contrast in each part of the urinary tract.

1. Intravenous Urography
Anoopkrishnan

2. Definition
It is the radiographic examination of the
urinary tract including the renal parenchyma,
calyces and pelvis after the intravenous
injection of the contrast media.

3. Intravenous Urography
Use decreased significantly in recent years
CT, US, MR is replacing
Remains primary modality for visualization
of pelvicalyceal system and ureter

4. Introduction of excretory urograpy was done in 1929,
by American urologist Moses Swick.
He injected an organically-bound iodide
compound—later named Uroselectan—into a vein,
taking X-rays as the material cleared the body
through the urinary tract.
1937-Berger made several recommendations
•Routine tomography
•High dose of contrast agents
•Ureteral compression
Moses Swick

5. Terminology
 Urogram
Visualization of kidney
parenchyma,
calyces and pelvis resulting
from IV
injection of contrast.
 Pyelogram
Describes retrograde studies
visualizing
only the collecting system.
So, IVP is misnomer, should be
IVU

6. Cystography
Describes visualization of
the bladder
Urethrography
Visualization of urethra
Cystourethrography
Combined study to
visualize bladder and urethra.

7. One more word about terminology….
Contrast is what we give intravenously.
Dye is used on clothes and in cooking to
change the color of things—it is not given IV
to patients!

8. Indications
American College of Radiology (ACR) guidelines published
in 2010
To evaluate the presence or continuing presence
of suspected or known ureteral obstruction.
To assess the integrity of the urinary tract status
post trauma.
To assess the urinary tract for suspected
congenital anomalies.
To assess the urinary tract for lesions that may
explain hematuria or infection
Investigation of HTN in young adults not
controlled

9. contraindications
No absolute contraindication
Relative contraindications
Renal failure (raised serum creatinine level >1.5 mg/dL)
Hepatorenal syndrome
Previous allergy to the contrast agent/iodine
Generalized allergic conditions
 Multiple myeloma
Pregnancy
Infancy
Thyrotoxicosis
Diabetes

10. Advantages
Clear outline of the entire urinary system so can see
even mild hydronephrosis.

Easier to pick out obstructing stone when there are
multiple pelvic calcifications.
Can show non-opaque stones as filling defects.

Demonstrate renal function and allow for verification
that the opposite kidney is functioning normally.

11. Disadvantages
need for IV contrast material
may provoke an allergic response
multiple delayed films (Can take hours as contrast
passes quite slowly into the blocked renal unit and
ureter.)
May not have sufficient opacification to define the
anatomy and point of obstruction.
Requires a significant amount of radiation exposure
and may not be ideal for young children or pregnant
women

13. Internal structure
The parenchyma of the kidney is divided into two major
structures: superficial is the renal cortex and deep is the
renal medulla.
Grossly, these structures take the shape of 8 to 18 cone-shaped
renal lobes, each containing renal cortex
surrounding a portion of medulla called a renal pyramid
(of Malpighi).
 Between the renal pyramids are projections of cortex
called renal columns (of Bertin).

14. Nephrons, the urine-producing functional structures of
the kidney, span the cortex and medulla.
The tip, or papilla, of each pyramid empties urine into a
minor calyx
 minor calyces empty into major calyces, and major
calyces empty into the renal pelvis, which becomes the
ureter.

17. Relations of kidneys
Superiorly, the suprarenal (adrenal) glands sit adjacent to
the upper pole of each kidney
On the right side, the second part of the duodenum
(descending portion) abuts the medial aspect of the
kidney
On the left side, the greater curvature of the stomach
can drape over the superomedial aspect of the kidney,
and the tail of the pancreas may extend to overlie the
renal hilum

18. The spleen is located anterior to the upper pole of left kidney and is
connected by the splenorenal (lienorenal) ligaments
Inferiorly to these organs, the colon typically rests anteriorly to the
kidneys on both sides
Posteriorly, the diaphragm covers the upper third of each kidney,
with the 12th rib most commonly crossing the upper pole
The kidneys sit over the psoas (medially) and the quadratus
lumborum muscles (laterally)

34. Contrast
High osmolar contrast media
Low osmolar contrast media
Iso osmolar contrast media

35. All currently used IRCM are chemical modifications of a 2,4,6-tri-iodinated
benzene ring.
 They are classified on the basis of their physical and chemical
characteristics, including their chemical structure, osmolality,
iodine content, and ionization in solution.
 In clinical practice, categorization based on osmolality is widely
used.

37. 2,4,6 tri iodinated compound
i
i
i
Carboxl
HOCM
Organic sidechain
3 5 variation various brands
OH
LOCM
dissociates iodinated anion
CationNa,meglumine monomer/dimer

38. HOCM
High-osmolar contrast media (HOCM) are the oldest agents.
 They are relatively inexpensive, but their utility is limited.
They are monomers (single benzene ring)
that ionize in solution with a valence of -1.
 Their cation is either sodium or meglumine.

39. HOCM
Diatrizoate –Na10%,Meg66%-Hypaque76
Iothalmate-Na66.8—Conray400
Diatrizoate –Na35% meg34.3%—Renovist
Diatrizoate-Na10%meg66%--renografin76

40. LOCM
major advance was the development of non ionic
compounds.
They are monomers that dissolve in water but do not
dissociate.
 Hence, with fewer particles in solution,

41. LOCM
Hydrophilic
Non-ionise
Osmotic load<50%
<complications

42. Iso -osmolar contrast media
The most recent class of agents is dimers that consist of a
molecule with two benzene rings (again, each with 3 iodine
atoms) that does not dissociate in water(nonionic).

43. Dose of 200mg of iodine per pound body wt-dose of 20-30g.
Injection completed within 60 sec-rapidly injecting as bolus
with 50 ml syringes.
Slow injections decrease side effects but provides less dense
nephrogram
Another method –drip infusion technique,infusion kit with
40-50g iodine delivered in 250-400ml fluid.

44. DRIP infusion
Advantages
 Nephrogram prolonged
>diuresis—distends collecting
system & ureter
Collecting system—visualised
longer time-more flexibility in
filming
Ureter compression not
necessary
Administration easy
Disadvatages
Overloads with more iodine
Calyceal blunting
Pyelosinus extravasation—pain
 may produce CCF
 increased Diuresis- decrease
visualisation
Initial vascular nephrogram not
obtained

45. PREPARATION OF THE PATIENT
Complete urine and blood examination to assess the renal function.
The patient is given mild laxatives(1-2 oz castor oil) about twelve to
twenty four hours before the proposed x-ray examination. (A night
before the urographic examination) .Eliminates fecal material and
reduces amount of gas in bowel.
The patient is kept nil by mouth over night and is dehydrated by stopping
the fluid intake.
Most uroradiologist believe that with modern contrast media
overhydration should be avoided but dehydration is unnecessary.
In practice adviced omit fluids after 11pm,omit breakfast which
decreases chance of vomiting and produce slight dehydration.

46. The dehydration helps in better concentration of the contrast and
clearer x-ray pictures.
The patient should not be dehydrated if suffering from renal failure
as it may lead to severe fluid and electrolyte imbalance.
Sensitivity to the dye (Hypaque or Urographin)checked. Necessary
precautions are taken to avoid the allergic reactions.
Take informed consent.

49. Physiology of contrast excretion
Following bolus I.V. injection, very rapid plasma concentration is followed by rapid decline
Rapid mixing in vascular compartment
Diffusion into extravascular, extracellular space
Renal excretion
I.V. injection Contrast media
Anion(I2)
Osmotically inert &
non reabsorbable
Cation
Meglumine
Not reabsorbed
by renal tubules
Sodium
Freely reabsorbed
by renal tubules

51. Extrarenal routes for contrast
excretion:
Hepatic
Small bowel
Sweat
 saliva
Tears
Gastric juice

52. Procedure requirements

53. Equipments:
Medium powered X-Ray generator set-up,
typical 40-60 kW.
Basic tomography equipment.
Abdominal compression equipment.
Medium / Regular film screen
combination in a variety of sizes.

54. Pads and immobilisation aids.
Intravenous administration equipment:
50 ml syringe, filling needle, skin prep, sticky tape,
Selection of needles, straight/'Butterfly' 16, 19, 21,23 gauge.
Tourniquet or blood pressure cuff.
Emergency drugs and equipment.

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58. Technique
Venous access via the median antecubital vein is the preferred
injection site because flow is retarded in the cephalic vein as
it pierces the clavipectoral fascia.
The gauge of the cannula/needle should allow the injection
to be given rapidly as bolus to maximize the density of
nephrogram.
Upper arm or shoulder pain may be due to stasis of contrast
in vein which may be relieved by abduction of the arm.
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59. PROCEDURE
Plain film of the abdomen
(Scout film)
•State of bowel preparation
•Calcific density in the renal tract
•Soft tissue masses
•To observe the abdominal parities
•To check exposure factors
& positioning
Oblique views- optional
Contrast administration:
bolus/infusion
Dose: adults- 50ml of 350-370 strength water soluble contrast

60. Films Preliminary film:
 Supine, full length AP of
abdomen in inspiration.
 The lower border of cassette is
at the level of symphysis pubis
and the x-ray beam is centred
in the midline at the level of
iliac crests.
 To demonstrate bowel
preparation, check exposure
factor, and location of
radiopaque stones or any
radiopaque artifacts.
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61. If necessary the position of overlying opacities may be further
demonstrated by:
Supine AP of renal areas, in expiration. The x-ray beam is centred
in the mid-line at the level of lower costal margin
Or
35° posterior oblique views, or,
Tomography of the kidneys at the level of a third of the AP
diameter of the patient (app.8-11 cm). The optimal angle of
swing is 25-40°.
The examination should not proceed until these films are
reviewed by radiologist and claimed satisfactory.
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62. Contrast media:
Low osmolar contrast media (LOCM)- 300- 600mgI/ml
Adult dose : 50-100ml
Paediatric dose : 1ml/kg
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63. FILM SEQUENCE
1-3 minutes Antero-posterior- film coned to the renal area
5 minutes Antero-posterior-film coned to the renal area
Apply ureteral compression
10 minutes Antero-posterior
Release compression
“Flush”, “X” or “Release view”- - full length view at 20
minutes
Upright post void Antero-posterior

66. Scout film
Calculus
Skeletal abnormality
Intestinal gaspattern
Calcifications
Abdominal masses
Foreign bodies

74. Contraindications to ureteral
compression
Evidence of obstruction on the 5-minute image
Abdominal aortic aneurysm or other abdominal
mass
Severe abdominal pain
Recent abdominal surgery
Suspected urinary tract trauma
Presence of a urinary diversion
Presence of a renal transplant

75. WHAT TO LOOK FOR IN IVU
Size, shape, position and axis of kidneys
External cortex and inner medulla
Calyceal system
Renal pelvis and ureteropelvic junction
Ureter
Uretero-vesical junction
Urinary bladder
Relation of ureter to spine and psoas muscle
RADIATION DOSE FROM IVU
1,465 mR/projection for males
1,047 mR for females

96. The size of the kidneys should be assesed during
neprographic phase
The normal kidney may range from 9 to13 cm in
cephalocaudal length, with the left kidney inherently
larger than the right by 0.5 cm and the kidneys slightly
larger in men than in women
Significant discrepancies (right kidney 1.5 cm larger
than the left kidney,left kidney 2 cm larger than the
right kidney) require explanation.

97. Pyelogram
•In normally functioning kidneys, contrast is first seen in the calyces
at 2 mins following bolus injection.
Value of compression

98. On the 5-minute image, the nephrogram should be receding
as the collecting system becomes opacified.
On the 10-minute image, the pyelogram is the dominant
urographic element.
Alterations in this temporal sequence require explanation.

99. Visualization of the collecting system and renal pelvis can be
augmented with the use of abdominal compression,
Trendelenburg position, and other gravity maneuvers such
as placing the patient with the side of interest in the
ipsilateral posterior oblique position
The appearance of the calices and renal pelvis should be
examined closely

100. Early and mild obstruction is indicated by subtle rounding of
the forniceal margins
more severe and prolonged obstruction evidenced by
progressive loss of the papillary impression and eventual
clubbing of calices.

101. Ureters
Ureters begin to transport opacified urine about 3 mins post injection
Maximum ureteral filling occurs between 5-10 minutes.

103. At the release of compression, the bolus of contrast material–
laden urine entering the ureters provides optimal visualization
throughout their length
Persistence of a standing column of contrast material on
several images may indicate obstruction or ureteral ileus
(nonobstructive dilatation).
Medial deviation of the ureter should be considered when the
ureter overlies the ipsilateral lumbar pedicle.
lateral deviation should be considered when the ureter lies
more than 1.5 cm beyond the tip of the transverseprocess, but
comparison with the position of the contralateral ureter should
always be made

104. Urographic image
demonstrates acute medial
deviation of the right
ureter produced by an
aneurysm of the internal
iliac artery.

105. Ureteral filling defects may be single or multiple and can
usually be attributed to luminal, mural, or extrinsic causes.

106. Urographic image shows
multiple filling defects in
the left renal pelvis and
ureter.
 Multifocal transitional cell
carcinoma was confirmed
in this case.

107. An absolute ureteral diameter exceeding 8 mm
is considered a criterion for dilatation
Asymmetry of ureteral caliber is a more significant
finding.
Early in its course, high-grade ureteral obstruction may
be associated with only minimal ureteral dilatation.
More chronic forms of obstruction and other chronic
ureteral conditions are typically associated with greater
degrees of ureteral dilatation

108. Bladder

109. By 15–30 minutes after the injection of contrast material, the
bladder is often sufficiently filled, and the 15-minute KUB
radiograph may be adequate for evaluation.
 As the bladder distends with contrast the intraluminal
contrast material should be spheric and smoothly marginated
and the wall progressively less evident.

111. Bladder wall thickening and irregularity of the luminal
contrast material associated with a bladder base defect is
typical of changes of bladder outlet obstruction from
prostatic disease.
Contour abnormalities from cellule or diverticulum
formation.

113. Bladder transitional cell carcinoma.
 Bladder image shows a filling defect
with a papillary configuration along
the right bladder wall
 Note the irregular distribution of
contrast material
 associated with the filling defect
(“stipple sign”)

115. The postvoid image may also be helpful in evaluating patients
with upper urinary tract dilatation.
Persistence of the dilatation on the postvoid image suggests
fixed obstruction,
The postvoid image is most helpful in assessing residual
volume.

118. Extravasation of contrast medium
Local pain, erythema, swelling
Usually resolve with local therapy
Rarely, significant tissue necrosis and skin-sloughing
occur (even with small amounts)
 severe, may lead to compartment
syndrome
Severe edema, loss of pulses, necrosis
More common with injection in hand or foot

119. Initial recommended treatment of
extravasation

- Elevation of affected extremity above heart

- Ice packs (15-60min/3 times per day)
- Close observation for 2-4 hrs

120.  Immediate plastic surgery consultation
for the following indications
Extravasated volume exceeds 100 cc of nonionic contrast
Skin blistering
Altered tissue perfusion
Decreased capillary refill over or distal to injection site
Increasing pain after 2-4 hours
Change in sensation distal to site extravasation

123. Renal agenesis
U/L-Absent renal outline &
pelvicalyceal system, 99mTc
DMSA most sensitive test.
B/L-Uncommon & incompatible
with life

124. Renal Ectopia
Failure of complete ascent
of the kidney to its normal
position
IVU- abnormally placed
kidneys

126. Crossed fused renal ectopia
 Two complete pelvicalyceal
systems on one side usually one
above the other
 Ureter from the lower renal
pelvis crosses the midline and
enters bladder normally

128. Horseshoe kidney
Kidneys placed lower than
normal
Malrotation of pelvis
Lower pole calyces of both
sides deviated towards
midline
Ureters have characteristic
vaselike curve
Pelvicalyectasis
Renal calculi

129. Intravenous urogram (IVU) shows
an altered renal axis with medially
directed lower renal poles, which
suggests horseshoe kidney. Also
note the dilated collecting system
of the left kidney, resulting from a
uretero pelvic junction
obstruction; this is a frequently
associated finding

131. Duplex collecting
system
 Minor form – bifid renal pelvis
 Ureteral duplication
 Incomplete – ureters fuse in their
course
 Complete – 2 ureters open
seperately in bladder, lower moiety
inserted orthoptically & upper
moiety ectopically
 “Drooping lily” sign-obstructed
upper moiety ureter, in a
completely duplicated system, may
produce downward and lateral
displacement of the functional
lower moiety collecting system,

134. Horse shoe kidney
Duplex bilateral
134 09/06/14

135. Ureterocele
Contrast filled structure
with a thin smooth
radiolucent wall
surrounded by contrast
containing urine in the
bladder- “Cobra’s head’
appearence

137. Retrocaval ureter
The ureter may have a
sickle, S or reverse J
appearance before crossing
behind and medial to the
IVC.
The ureter descends medial
to right lumbar pedicle.
Proximal ureter is dilated.

139. Congenital Hydronephrosis
 Due to functional obstruction at the pelvi-ureteral junction
Aetiology- cong. Bands, adhesions, neuro muscular inco-ordination,
abberent vessels
Advanced cases
• large soft tissue mass replacing the renal parenchyma
• No opacification of collecting system
Lesser degrees of obstruction
• Nephrogram- thin rim of renal substance outlining
kidney
• Later films – crescent shaped opacities produced by
dilated stretched tubules surrounding the enlarged non
opacified calyx
• Delayed films – slow filling of calyces & renal pelvis
Mild forms
•“Wine glass appearance”
Mildest form- minimal deviation from the normal
appearance

140. Grading of hydronephrosis
Gr 1-dilatation of renal pelvis without dilatation of
calices,prominent reflex of renal sinus without signs of
parenchymal atrophy.
Gr2-dilatation of renal pelvis and calices ,pelvicalyceal
pattern is maintained,no signs of parenchymal atrophy
Gr3-moderate dilatation of renal pelvis and calyces ,blunting
of fornices and flattening of papillae,mild cortical thinning
may be seen
Gr4-gross dilatation of renal pelvis and calyces which appear
ballooned ,loss of borders between renal pelvis and
calyces,renal atrophy seen as cortical thinning.

144. The balloon on a string sign
This sign refers to the
appearance of a high and
somewhat eccentric exit
point of the ureter from a
dilated renal pelvis and is a
typical finding of
ureteropelvic junction
obstruction

146. PUJO

147. Polycystic kidneys
 Autosomal dominant
 Plain films- cyst calcification
 IVU- enlarged kidneys with
compression and displacement
of calyces by intrarenal cyst
 Autosomal recessive
B/L symmetrical enlargement of
kidneys
Streaky nephrogram
Calyces maybe distorted

152. Dromedary hump. Tomogram
from excretory urography
demonstrates a prominent cortical
hump in the interpolar region of the
left kidney.
 On a compression image
obtained in a later phase of the
sequence, the hump is subtended by
a normal collecting system element,
indicating that it represents normal
functioning tissue.

157. Bladder calculi
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162. Medullar y sponge kidney
 Brush like linear
striations in renal papillae
Enlargement of kidney
Renal calculi

163. Renal masses
Small SOL
 Localised bulge with increased
thickness of the renal substance
 Deforms or displaces or distends
a calyx

164. Medium sized lesions
Localized or generalized enlargement
of the kidneys
Displacement or distortion of renal
pelvis, ureter or adjacent structures
Malrotation
Very large lesions
Non functioning kidneys
Calycine spreading
Visceral displacement

170. Bladder transitional cell carcinoma
.
 Bladder image shows a filling defect
with a papillary configuration along
the right bladder wall
 Note the irregular distribution of
contrast material
 associated with the filling defect
(“stipple sign”)

183. GU Tb-plain KUB
Disparity in renal size on plain films may indicate early
increase in size of the affected kidney due to caseous lesions
or a shrunken fibrotic kidney of autonephrectomy.
Calcifications are seen in 30% to 50%
A characteristic diffuse, uniform,extensive parenchymal,
putty-like calcification, forming a lobar cast of the kidney is
seen with autonephrectomy
Calculi may also be seen in the collecting system or ureter
secondary to stricture formation.
 Ureteral calcifications are rare and are characteristically
intraluminal as opposed to the mural calcifications of
schistosomiasis

184. . Bladder wall calcifications seen in late cases of bladder
contraction.
 Calcifications of the prostate and seminal vesicles are seen in
10% of cases .
Plain film findings suggestive of tuberculosis may be seen in
surrounding tissues such as erosions of the vertebral bodies
or calcifications in a cold abscess of the psoas muscle.

187. GU Tb-IVU
The most common findings being
hydrocalycosis,hydronephrosis, or hydroureter due to
stricture formation .
 Early signs include the moth-eaten appearance of calyceal
erosion and papillary irregularity- signs are best seen on early
excretory films.

188. Cavitary lesions communicating with the collecting system
are characteristic of TB.
 These lesions eventually enlarge as parenchymal destruction
ensues.
Fibrotic distortion of the collecting system and ureter is also
seen.
Calyceal obliteration and amputation, hydrocalycosis,
segmental or total hydronephrosis, and a shriveled reduced
capacity renal pelvis may all be signs of renal tuberculosis

189. Scarring and angulation of the ureteropelvic junction (UPJ)
may also occur, the so-called “Kerr’s kink” .
Tuberculosis of the ureter is commonly seen as a rigid,
straightened “pipe-stem” ureter also beaded, corkscrew
appearance.
 Ureterovesical junction obstruction is caused by tuberculous
cystitis or strictures of the distal third of the ureter.
secondary stone formation on top of this stricture .
The cystogram films may show a small contracted bladder
due to excessive fibrosis

194. “A tailored urographic study allowing optimal visualization of
sequentially opacified portions of the urinary tract may provide
diagnostic detail in certain portions of the urinary system beyond the
current capabilities of other imaging modalities. This can be
accomplished only with good technique, an understanding of the
limitations of the procedure, and adherence to basic rules of
interpretation. The ability to correlate urographic findings with those
from other imaging modalities will remain an important skill until an
ideal "global" urinary tract imaging technique emerges.”

195. The professors of forensic medicine, Derobert and Dehouve
(who also was a radiologist), together with Wolfromm, an
allergologist, wrote in 1964: “More patients died from lack of an
IVU than patients died because they were submitted for an IVU”
However,urography now faced the challenge of the
alternative methods of US and CT, and the new generation of
uroradiologists needed to develop strategies for using them
optimally.

196. Thank
you