Intravenous Urography

Intravenous excretory urography (IVU) has been a mainstay of urologic imaging for several years. The indications for performing an IVU are numerous. IVU allows imaging of the renal parenchyma, collecting system, and ureter. It can be used in the evaluation of urothelial abnormalities in evaluation of hematuria or in the evaluation of urolithiasis. As a parenchymal imaging technique, it may detect gross abnormalities, but it has been superseded by cross-sectional imaging methods ( Lang et al, 2003 ). IVU had been a core study in urologic imaging, but recently the number of examinations has declined, likely secondary to the increased use of CT ( Chen and Zagoria, 1999 ).
Patient Preparation.

Although a minor bowel preparation may allow for improved visualization of the collecting system, an emergent examination should not be delayed for a preparation. A pregnancy test may be indicated before the examination if clinical suspicion arises. Some institutions recommend a formal bowel preparation before examination, although routine use is controversial. A typical bowel preparation consists of clear liquids for 24 hours before examination and a cathartic agent or enema. Randomized studies have not shown a clear advantage in visualization of the urinary tract with bowel preparation, but prepared groups do have fewer feces in their colon, which may have a subjective impact on IVU efficacy ( Bailey et al, 1991 ; George et al, 1993 ). Bowel preparation should be considered in patients with chronic constipation, such as patients with neurologic deficits. Dehydration may improve imaging quality but has risks ( Dunbar et al, 1960 ). Similar to bowel preparation, the necessity of dehydration is controversial. Dehydration induces an increase in antidiuretic hormone, thus increasing tubular water resorption and subsequent concentration of the contrast medium ( Talner, 1972 ). Caution, however, is advised in patients with renal insufficiency, because dehydration may exacerbate nephrotoxicity. Overhydration should be avoided, because poor visualization of the collecting system may necessitate reexamination. In practice, withholding fluids after midnight before examination is sufficient to allow adequate imaging.
Technique.

First a scout radiograph is taken in the supine position. This radiograph, which encompasses the field from the renal outlines to the pubic symphysis, is essential in revealing renal outlines, calcifications, residual contrast media, and positioning. For larger patients, two films may be necessary to fully image the field. Oblique views may be taken if necessary to allow better distinction of calcifications from bony structures. Contrast medium injection may be given as a bolus or drip infusion, with bolus being the predominant technique. Fifty to 100 mL of contrast medium is given through an 18- or 19gauge needle. Immediately after injection and in the first few minutes after injection the nephrographic phase produces images of the renal parenchyma. Several tomograms may be taken to adequately document the parenchymal outlines. By 5 minutes the collecting system should opacify, and imaging of the pyelographic phase commences. A compression device

may be attached, which distends the collecting system and allows better visualization of the pelvis and ureters. After the 5-minute films, further imaging is individualized to the patient, and subsequent images should document the entire length of the ureter for filling abnormalities. Ureteral peristalsis may be viewed, and images may be taken after peristalsis for better visualization. A normal intravenous urogram is shown in Figure 4-4 .

Figure 4-4 Normal excretory urogram. A, A tomogram at 3 minutes shows distention of the collecting systems from ureteral compression. Visualization of the nephrograms is good. B, A 10-minute film with compression maintained shows excellent visualization of the collecting systems and proximal two thirds of the ureters above the area of compression. Note the symmetrically placed, fully inflated compression balloons overlying the pelvic portions of the ureters. C, A 30minute supine film. After release of compression, the calyces are slightly less dilated and the ureters not as well filled, which is indicative of satisfactory drainage. The bladder is fully distended. (Reprinted from Friedenberg RM, Harris RD: Excretory urography. In Pollack HM, McClennan BL, Dyer R, Kenney PJ [eds]: Clinical Urography, 2nd ed. Philadelphia, WB Saunders, 2000.)

Certain accessory radiographs may be taken to document special circumstances. Oblique views may better visualize the calyceal system or can allow clarification of filling defects that may overlap in the routine anteroposterior views. Prone images place the ureter in a dependent position and may be useful in distending and imaging the ureter ( Fig. 4-5 ). Upright films can document renal ptosis or layering of contrast media in severely hydronephrotic systems. The postvoid film may be useful in evaluating bladder outlet obstruction, diverticula, or filling defects within the bladder ( DeFilippo et al, 1984 ).

Figure 4-5 Value of the prone film. A, Supine 10-minute film from a urogram with poor visualization of the distal end of the right ureter. B, A prone film shows complete visualization of both ureters. (Reprinted from Friedenberg RM, Harris RD: Excretory urography. In Pollack HM, McClennan BL, Dyer R, Kenney PJ [eds]: Clinical Urography, 2nd ed. Philadelphia, WB

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