Intravenous Urography (IVU)

Dr.Abdalla Mutwakil Gamal

Radiology Department
Sebha Medical Center
Contents

Introduction

The procedure

Examples for abnormal findings

IVU vs KUB & USG vs NCCT

Introduction
Definition

- X-Ray + Contrast

- Other names
Indications

1 – Hematuria

2 – Renal Colic

3 – Recurrent urinary tract infection

4 – Suspected urinary tract pathology

Contraindications

They are the general contraindications to

water soluble agents :

- Contrast allergy
- Hepatorenal syndrome
- Thyrotoxicosis
- Pregnancy
- Raised serum creatinine
Advantages of IVU

- Detailed anatomy of the collecting systems

- Demonstration of major calcification

- Sensitive for acute obstruction

- Low cost
Limitations of IVU

- It depends on kidney function

- Do not differentiate solid or cystic lesion

- Requires contrast medium and radiation.

- Missing small stones.

- Quality of study may be limited by

inadequate bowel preparation, bowel ileus,
swallowed air and technician variability.

- Inconvenience of a long filming sequence.

The procedure
Equipments
Contrast

LOCM 370 (LOCM = Low osmolar contrast material)

Adult dose = 50 – 100 ml , Pediatric dose = 1ml for each kg

Patient preparation

- Eating and drinking

- Moving around

- Bowel preparation

- Metformin
Preliminary film (control film)
Technique

- Dye injection

- Precautions during dye injection

- Taking x-rays
Films

Immediate 5-15 min film 30-min film 45-min film Postvoiding

film (Nephrogram (Ureterogram (Cystogram film
phase) phase) phase)
Immediate film (Nephrogram phase)

A.P. of the renal areas to show the

nephrogram, i.e. the renal parenchyma
opacified by the contrast medium in the
renal tubules.

(taking it after injection equals about 10 to

14 seconds which is the approximate arm-
to-kidney time).
5-15 minutes film (Secretory phase)
inspect :

- Both Kidney contour

- Contrast is filling both the Pyelum or not,

- is there any delayed filling?

30 minutes film (Ureterogram phase)

inspect:

Is there any collecting systems and ureters

dilatation or filling defect? (normal ureter
filling is rarely demonstrate the whole
ureter from proximal to distal as there is a
peristaltic wave )
45 minutes film (Cystogram phase)

inspect :

- Bladder size and shape

- Contrast is filling the bladder or not

- Bladder surface is smooth or rough

- Is there any diverticlula, filling defect or

prostate indentation?
Postvoiding film

look for:

- Residual urine

- Contrast left on upper tract? (normally

there is no contrast left on upper urinary
tract on postvoiding film)
Patient Aftercare

- Needle wound site dressed and

checked for extravasation.

- Check patient understands how to receive

the results.

- Ensure patient understands any

preparation instructions are finished

- Escort to changing rooms and bid

good-bye.
Sample Report

- Clinical Information:

- Description:

- Impression:
Description

- A supine view of the abdomen demonstrates a normal bowel gas pattern, with no evidence
of free intraperitoneal air, pathologic calcification, or soft tissue mass. The bony structures
are unremarkable.

- Following the administration of intravenous contrast, prompt and symmetric bilateral

nephrograms are identified.

- The kidneys are normal in size, contour, axis, and position.

- Prompt excretion is noted bilaterally into normal renal collecting systems and ureters, with
no evidence of intraluminal filling defect or mucosal irregularity.

- The bladder is smooth-walled, with no evidence of intraluminal filling defect or mucosal

abnormality.

- There is no significant post void residual.

Examples for abnormal findings
Example for Findings – Before dye injection

Stone in the left ureter

Example for Findings – Before dye injection

classic lobar pattern of calcification,

which is pathognomonic of end-stage
renal tuberculosis. Ureteral
calcification is also noted, which is
fainter in upper parts (arrowheads)
Example for Findings – Kidneys

Horseshoe Kidney - Tissue Bridge Across

Midline Causes Abnormal Orientation of Renal
Axis
Example for Findings – Kidneys

Extravasation of Contrast from Left Kidney

Secondary to High Grade Obstruction
Example for Findings – renal collecting system and ureters

Pyelo-ureteric Junction Obstruction Shows as

Dilation of Right Renal Pelvis and Calyces.
Example for Findings – renal collecting system and ureters

Dilation of Left Renal Pelvis and Calyces

Above the Obstructing Calculus
Example for Findings – renal collecting system and ureters

Stab wound of right ureter shows

extravasation (at arrow) on intravenous
urogram.
Example for Findings – renal collecting system and ureters

Crossed Renal Ectopia on the Left Kidney and

Absent Right Kidney.
Example for Findings – Urinary Bladder

Round shadow on right side of bladder later

shown to be a bladder cancer.
Example for Findings – Urinary Bladder

Nodular squamous cell carcinoma of the

bladder. Dilated left lower ureter probably
secondary to obstruction by tumor.
Nonvisualization of the right ureter caused
by complete occlusion
Example for Findings – Urinary Bladder

Intravenous urography showed no

obstructive uropathy, but symmetric
diverticula could be seen near both ureteral
orifices (arrows). These lesions, known as
Hutch diverticula, are usually congenital
rather than occurring as a result of a
neurogenic bladder or an infection or
obstruction.
Benign prostatic hyperplasia. White = bladder.
Dark = benign enlargement of prostate,
pushing down on inferior bladder
IVU vs KUB & USG vs NCCT
USG & KUB vs IVU

S J Andrews, P T Brooks, D C Hanbury, et al. Ultrasonography and abdominal radiography versus

intravenous urography in investigation of urinary tract infection in men: prospective incident
cohort study. BMJ 2002;324:454. http://www.bmj.com/content/324/7335/454. Accessed April 5,
2014.

Participants: Consecutive series of men (n=114) referred to the department of urology for investigation
of proved urinary tract infection.

Results: Important abnormalities were seen in 53 of 100 fully evaluated patients, the most common being
a poorly emptying bladder (34). The combination of plain radiographs of kidneys, ureter, and bladder
and ultrasonography detected more abnormalities than intravenous urography alone. No important
abnormality was missed by this combination (sensitivity 100% and specificity 93%).

Conclusions: Ultrasonography with abdominal radiography is as accurate as intravenous urography in

detecting important urological abnormalities in men presenting with urinary tract infection. This
combination is safer than intravenous urography and should be the initial investigation for such
patients. Additional determination of urinary flow rate is useful for the assessment of an incompletely
emptying bladder.
USG & KUB vs IVU
Zafar Amin, Abdul Salam. ROLE OF ULTRASOUND AND INTRAVENOUS UROGRAPHY IN PATIENTS
WITH RENAL COLIC. Pakistan Armed Forces Medical Journal. 2011; 7(4).
http://www.pafmj.org/showdetails.php?id=529&t=o . Accessed April 5, 2014.

Materials and Methods: One hundred and eleven consecutive patients with clinically suspected urinary
tract calculi were selected for study. At first they underwent sonography along with x-ray KUB and then
IVU. We evaluated the sensitivity, specificity, negative /positive predictive values and accuracy of US X-
ray KUB combination and IVU for detecting renal / ureteric calculi while final diagnosis (gold standard)
obtained from the results of clinical course/urological procedures.

Results: Out of 111 consecutive patients 46 (41 %) were normal and 65 (59 %) patients had KUB calculi.
US along with x-ray KUB detected 59 patients and missed 6 patients and likewise IVU detected 61
patients out of 65 patients. Sensitivity, specificity, and accuracy of both these modalities are almost
similar with IVU having slightly upper edge.

Conclusion: IVU remains an important investigation in the assessment of calculus and other causes of
urinary tract obstruction. Ultrasound in combination with x-ray KUB is an excellent modality having almost
similar diagnostic capability as IVU in detecting KUB calculi along with many more significant
advantages, as it has less radiation dose, relatively inexpensive, universally available, easily applicable
and high diagnostic efficacy.
NCCT vs IVU
N Khan, Z Anwar, AM Zafar, F Ahmed, et al. A comparison of non-contrast CT and intravenous
urography in the diagnosis of urolithiasis and obstruction. African Journal of Urology .
2012; 18(3). http://www.ajol.info/index.php/aju/article/view/84103 . Accessed April 5, 2014.

Subjects and methods: This is a retrospective review of radiological and clinical data of patients with
suspected urolithiasis or ureteric obstruction who had both NCCT and IVU performed within 30 days of
each other. The data were analyzed using the statistical packages Epidata™ and SPSS™. The number
of calculi, presence of hydronephrosis and hydroureter, cysts and ureteric wall thickening were
evaluated in both NCCT and IVU. Additionally, perinephric stranding in NCCT and delayed excretion in
IVU were also evaluated.

Results: Of the 139 patients (87 male and 52 female), 102 patients (73.4%) had positive findings on
NCCT and 71 (51.1%) on IVU. On NCCT 133 stones were detected in 80 patients (57.6%), 67 (48.2%) in
the kidney, 63 (45.2%) in the ureter and 3 (2.2%) in the bladder. The findings on NCCT were
hydronephrosis in 43 (31%), hydroureter in 34 (24.5%), perinephric stranding in 7 (5%), ureteric wall
thickening in 4 (2.8%), renal mass and renal cyst in 1 (0.7%) each. On IVU 86 stones were detected in
46 patients (33.1%), 53 (38.1%) in the kidney, 31 (22.3%) in the ureter and 1 (1.4%) in the bladder. The
findings on IVU were hydronephrosis in 31 (22.3%), hydroureter in 18 (13%), delayed excretion in 5
(3.6%), renal cyst and ureteric wall thickening in 1 (0.7%) each. Incidental findings were more common
on NCCT (23/139, 16.6%) than IVU (2/139, 1.4%).
Conclusions: NCCT compared with IVU had a higher detection rate for ureterolithiasis,
especially for stones in the distal ureter. An added benefit of NCCT was the detection of significant additional findings.