PPT about radiography of RGU and MCU techniques

1. Retrograde Urethrography (RGU)
AND
Micturating Cystourethrography
(MCU)
By:- Dr. Shubham Singhal

2. Urethrography
• Urethrography refers to the radiographic study of the urethra using
iodinated contrast media.
• Types of Urethrography :-
• Retrograde urethrography (RGU) - Contrast is retrogradely injected
with the urethral orifice occluded to prevent reflux of contrast.
• Antegrade (VCUG) - Bladder is filled with contrast via suprapubic or
retrograde catheterization and the urethra is assessed during
voiding.
• For both, static images can be obtained, but preferably assessed
dynamically under fluoroscopy.
• The male urethra is best seen in the oblique position.
• Female urethra is best seen in lateral or anteroposterior position.
• Voiding cystourethrogram is mostly used to visualize and evaluate :-
prostatic urethra and changes in the bladder neck.
• Retrograde urethrogram is mostly used to evaluate :- membranous and
anterior urethra , inflammatory lesions and diverticula.
• Some patients are assessed with both techniques, usually the RGU is
performed first, followed by the VCUG.

3. Retrograde/Ascending Urethrography (RGU)
INDICATIONS:-
• Stricture
• Urethral Trauma
• Fistulae or false passages
• Congenital abnormalities
• Periurethral / prostatic abscess
CONTRAINDICATIONS:-
• Acute UTI
• Recent instrumentation
CONTRAST MEDIUM :-
• Iopamidol (LOCM)
EQUIPMENT :-
• Tilting radiography table.
• Fluoroscopy/spot film device.
• Foley’s catheter, Syringe, Gloves
PREPARATION :-
• Patient is asked to micturate prior to the procedure

4. TECHINIQUE :-
• Preliminary film – coned supine PA
view of bladder base and urethra
• Patient is made to lie in supine
position and slightly tilted with legs
position as shown in the image.
• Using aseptic conditions, the tip of
the Foley’s catheter is inserted in the
urethra after applying lignocaine
jelly for 2 to 4 cm length. Pressure is
applied over the glans penis to avoid
expulsion of the catheter and also to
straighten the penis over the
ipsilateral leg and prevent urethral
overlap.
• Contrast medium is injected slowly
under fluoroscopic control.

5. COMPLICATIONS :-
• Contrast reaction (due to absorption through bladder
mucosa)
• UTI
• Urethral trauma.
• Intravasation of contrast – due to use of excessive
pressure in stricture.
IMAGING:-
• Supine PA before injecting contrast medium.
• 30º left anterior oblique
• 30º right anterior oblique

6. Radiographic anatomy on RGU

7. IMAGING IN RGU
Pre-contrast AP Film Right-anterior Oblique Left-anterior Oblique

8. Micturating cystourethrogram
(MCU)/Anterior Urethrography

9. Micturating cystourethrogram (MCU)/Anterior
UretherographyINDICATIONS :-
CHILDREN
- UTI
- Voiding difficulties.
- Vesico-ureteric reflux.
- Baseline study prior to urinary tract
surgery.
- Post operative evaluation of ureteric
abnormalities.
- Trauma.
- Suspected anatomic abnormalities of
bladder neck & urethra. (posterior
urethral valve)
ADULTS
- Functional disorders of bladder &
urethra.
- Suspected vesicovaginal / vesicocolic
fistula.
- Suspected bladder / urethral trauma.
- Urethral diverticula
NORMAL MCU

10. CONTRAINDICATION :-
• Acute urinary tract infection
CONTRAST MEDIUM :-
• Low osmolar contrast medium such as Iopamidol; or
• High osmolar contrast medium such as Urovideo 76%, 50 cc
EQUIPMENT :-
• Fluoroscopy unit with spot film device and tilting table
• Foley’s catheter (10 F) or infant feeding tube (No. 6)
• Syringe, gloves
PATIENT PREPARATION :-
• Patient is asked to micturate prior to the examination.

11. PROCEDURE :-
• Under aseptic conditions, catheterize the urinary bladder with
patient in supine position.
• Push the diluted contrast medium slowly under fluoroscopic guidance
• Ask the patient to inform you when he has urge to micturate.
• Ask the patient to micturate in a urine receiver in an erect oblique
position.
• Spot images are taken during micturition in right and left oblique
projections and any reflux is recorded.
• Finally, a full-length view of the abdomen is taken to demonstrate any
undetected reflux of the contrast medium that might have occurred
in the kidneys and to record the post micturition residue.

12. COMPLICATIONS :-
• Contrast reaction
• Contrast induced cystitis
• UTI
• Catheter trauma
• Bladder perforation – due to overfilling of contrast
• Retention of Foley’s catheter
AFTER CARE :-
• Patient should be warned of rare dysuria and
retention of urine.
• In case of reflux – antibiotics are to be prescribed.

13. Radiographic anatomy on MCU

14. IMAGING in MCU
Full Bladder in supine position
(Filling phase)
Left Anterior Oblique
(Voiding phase)
Right Anterior Oblique
(Voiding phase)
A case of stricture urethra

15. A case of posterior urethral valves
Thick walled trabeculated bladder Bullet nosed dilatation of posterior urethra

16. Vesicoureteric reflux (VUR)
Refers to retrograde passage of urine from the bladder into the
ureter and often into the calyces.
Most significant risk factor for childhood renal scarring and its
sequelae.
VUR in most cases is the result of a primary maturation
abnormality of the vesicoureteral junction resulting in a short distal
ureteric submucosal tunnel.
Imaging of VUR:
•VCUG
•Radionuclide cystography
•MR voiding cystography
Primary diagnostic procedure for evaluation of VUR is VCUG.
However radionuclide cystography is better as a screening tool as
the radiation dose is lower.

17. Grades of VUR
Grade I Grade II Grade III

18. Grades of VUR (contd.)
Grade IV Grade V

19. THANK YOU