Pyelogram

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Pyelogram
ICD-9 87.73, 87.74, 87.75
MeSH D014567
OPS-301 code 3-13d

Pyelogram (or pyelography or urography) is a form of imaging of the renal pelvis and ureter. [1]

Contents

Types include:

Intravenous pyelogram

Intravenous pyelogram
Ivu 1.jpg
An Example of an IVU radiograph
Specialty Radiology
ICD-9-CM 87.73
OPS-301 code 3-13d.0

An intravenous pyelogram (IVP), also called an intravenous urogram (IVU), is a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys, ureters, and bladder. Unlike a kidneys, ureters, and bladder x-ray (KUB), which is a plain (that is, noncontrast) radiograph, an IVP uses contrast to highlight the urinary tract.

In IVP, the contrast agent is given through a vein (intravenously), allowed to be cleared by the kidneys and excreted through the urinary tract as part of the urine. [5] If this is contraindicated for some reason, a retrograde pyelogram, with the contrast flowing upstream, can be done instead.

Uses

An intravenous pyelogram is used to look for problems relating to the urinary tract. [5] These may include blockages or narrowing, such as due to kidney stones, cancer (such as renal cell carcinoma or transitional cell carcinoma), enlarged prostate glands, and anatomical variations, [5] such as a medullary sponge kidney. [6] They may also be able to show evidence of chronic scarring due to recurrent urinary tract infections, [5] and to assess for cysts [6] associated with polycystic kidney disease.

Procedure

An injection of X-ray contrast medium is given to a patient via a needle or cannula into the vein, [7] typically in the antecubital fossa of arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the contrast media becomes visible on X-rays almost immediately after injection. X-rays are taken at specific time intervals to capture the contrast as it travels through the different parts of the urinary system. [7] At the end of the test, a person is asked to pass urine and a final X-ray is taken. [7]

Before the test, a person is asked to pass urine so that their bladder is emptied. [5] They are asked to lie flat during the procedure. [7]

Normal appearances

Immediately after the contrast is administered, it appears on an X-ray as a 'renal blush'. This is the contrast being filtered through the cortex. At an interval of 3 minutes, the renal blush is still evident (to a lesser extent) but the calyces and renal pelvis are now visible. At 9 to 13 minutes the contrast begins to empty into the ureters and travel to the bladder which has now begun to fill. To visualize the bladder correctly, a post micturition X-ray is taken, so that the bulk of the contrast (which can mask a pathology) is emptied.

An IVP can be performed in either emergency or routine circumstances.

Emergency IVP

This procedure is carried out on patients who present to an Emergency department, usually with severe renal colic and a positive hematuria test. In this circumstance the attending physician requires to know whether a patient has a kidney stone and if it is causing any obstruction in the urinary system.

Patients with a positive find for kidney stones but with no obstruction are sometimes discharged based on the size of the stone with a follow-up appointment with a urologist.

Patients with a kidney stone and obstruction are usually required to stay in hospital for monitoring or further treatment.

An Emergency IVP is carried out roughly as follows:

If no obstruction is evident on this film a post-micturition film is taken and the patient is sent back to the Emergency department. If an obstruction is visible, a post-micturition film is still taken, but is followed up with a series of radiographs taken at a "double time" interval. For example, at 30 minutes post-injection, 1 hour, 2 hours, 4 hours, and so forth, until the obstruction is seen to resolve.This is useful because this time delay can give important information to the urologist on where and how severe the obstruction is.

Routine IVP

This procedure is most common for patients who have unexplained microscopic or macroscopic hematuria. It is used to ascertain the presence of a tumour or similar anatomy-altering disorders. The sequence of images is roughly as follows:

  • plain or Control KUB image;
  • immediate X-ray of just the renal area;
  • 5 minute X-ray of just the renal area.
  • 15 minute X-ray of just the renal area.

At this point, compression may or may not be applied (this is contraindicated in cases of obstruction).

In pyelography, compression involves pressing on the lower abdominal area, which results in distension of the upper urinary tract. [8]

  • If compression is applied: a 10 minutes post-injection X-ray of the renal area is taken, followed by a KUB on release of the compression.
  • If compression is not given: a standard KUB is taken to show the ureters emptying. This may sometimes be done with the patient lying in a prone position.
  • A post-micturition X-ray is taken afterwards. This is usually a coned bladder view.

Image assessment

The kidneys are assessed and compared for:

  • Regular appearance, smooth outlines, size, position, equal filtration and flow.

The ureters are assessed and compared for:

  • Size, a smooth regular and symmetrical appearance. A 'standing column' is suggestive of a partial obstruction.

The bladder is assessed for:

  • Regular smooth appearance and complete voiding.

Risks

Intravenous pyelograms use ionizing radiation, which involves risk to healthy tissues (potentially encouraging cancer or risking birth defects). [5] Therefore, they are often now replaced by ultrasonography and magnetic resonance imaging (MRI). Also, the iodinated contrast medium used in contrast CT and contrast radiography can cause allergic reactions, including severe ones. [5] The contrast dye may also be toxic to the kidneys. [7] Because a cannula is inserted, there is also a risk of a cannula site infection, that may cause fevers or redness of the cannula area. [7]

Contraindications

Anterograde pyelogram

Antegrade pyelography, anterograde pyelography
Antegrade pyelogram of grade III hydronephrosis with obstruction at the ureterovesical junction.jpg
Antegrade pyelogram of grade III hydronephrosis with obstruction at the ureterovesical junction due to bladder endometriosis in a 29 year old female. The tip of the nephrostomy is located in an inferior calyx.
Purposevisualize the upper collecting system of the urinary tract

Antegrade pyelography is the procedure used to visualize the upper collecting system of the urinary tract, i.e., kidney and ureter. It is done in cases where excretory or retrograde pyelography has failed or contraindicated, or when a nephrostomy tube is in place or delineation of upper tract is desired. It is commonly used to diagnose upper tract obstruction, hydronephrosis, and ureteropelvic junction obstruction. In this, radiocontrast dye is injected into the renal pelvis and X-rays are taken. It provides detailed anatomy of the upper collecting system. As it is an invasive procedure, it is chosen when other non-invasive tests are non confirmatory or contraindicated and patient monitoring is required prior and after the procedure. [11] [12]

Retrograde pyelogram

Retrograde pyelogram
ICD-9 87.74
OPS-301 code 3-13d.5

A retrograde pyelogram is a medical imaging procedure in which a radiocontrast agent is injected into the ureter in order to visualize the ureter, bladder, and kidneys with fluoroscopy or radiography, using plain X-rays. [13] The flow of contrast (up from the bladder to the kidney) is opposite the usual outbound flow of urine, hence the retrograde ("moving backwards") name.

A retrograde pyelogram may be performed to find the cause of blood in the urine, or to locate the position of a stone or narrowing, tumour or clot, as an adjunct during the placement of ureteral stents. [13] It can also be used ureteroscopy, or to delineate renal anatomy in preparation for surgery. Retrograde pyelography is generally done when an intravenous excretory study (intravenous pyelogram or contrast CT scan) cannot be done because of renal disease or allergy to intravenous contrast.

Relative contraindications include the presence of infected urine, pregnancy (because of radiation), or allergy to the contrast. [13] Because a pyelogram involves cystoscopy, it may cause sepsis, infection or bleeding, [13] and may also cause nausea and vomiting. [13] The dye may also be toxic to the kidneys. [13]

Before the procedure, a person is usually asked to complete a safety check assessing for potential risks, such as pregnancy or allergy. [13] They may be asked to take an enema, and not to eat for some hours. [13] An intravenous drip is inserted and a person is given some sedation before a cystoscope, which is a flexible tube, is inserted into the bladder via the urethra. [5] 10 ml of contrast [14] is usually injected during cystoscopy, which is where a flexible tube is inserted into the bladder and to the lower part of the ureter. [5] Fluoroscopy, or dynamic X-rays, is typically used for visualization. The procedure is usually done under general or regional anesthesia. [13]

Risks of complications of the procedure includes: pyelosinus extravasation (contrast going into renal sinus) and pyelotubular (contrast going into collecting duct) reflux of contrast due to overfilling of the urinary system. It can cause pain, fever and chills. Infection may be accidentally introduced into the urinary tract. There can be also damage or perforation of renal pelvis or ureter. [14] Rarely, acute renal failure can occur. [15]

Treatment

Depending on the outcome and diagnosis following an IVP, treatment may be required for the patient. These include surgery, lithotripsy, ureteric stent insertion and radiofrequency ablation. Sometimes no treatment is necessary as stones <5mm can be passed without any intervention.

Future

IVP is an affordable and useful imaging modality and continues to be relevant in many parts of the world. In the developed world, however, it has increasingly been replaced by contrast computed tomography of the urinary tract (CT urography), which gives greater detail of anatomy and function. [5]

History

The technique of IVP was originally developed by Leonard Rowntree of the Mayo Clinic in the 1920s. [16] IVP was previously the test of choice for diagnosing ureter obstruction secondary to urolithiasis but in the late 1990s non-contrast computerized tomography of the abdomen and pelvis replaced it because of its increased specificity regarding etiologies of obstruction. [17] Because of increased accuracy, computed tomography and ultrasounds of the renal tract are now used; ultrasounds additionally do not involve radiation. [6]

Etymologically, urography is contrast radiography of the urinary tract ( uro- + -graphy ), and pyelography is contrast radiography of the renal pelvis ( pyelo- + -graphy ), but in present-day standard medical usage, they are synonymous.

See also

Related Research Articles

<span class="mw-page-title-main">Kidney stone disease</span> Formation of mineral stones in the urinary tract

Kidney stone disease, also known as renal calculus disease, nephrolithiasis or urolithiasis, is a crystallopathy where a solid piece of material develops in the urinary tract. Renal calculi typically form in the kidney and leave the body in the urine stream. A small calculus may pass without causing symptoms. If a stone grows to more than 5 millimeters, it can cause blockage of the ureter, resulting in sharp and severe pain in the lower back or abdomen. A calculus may also result in blood in the urine, vomiting, or painful urination. About half of people who have had a renal calculus are likely to have another within ten years.

<span class="mw-page-title-main">Urinary system</span> Human anatomical system consisting of the kidneys, ureters, urinary bladder, and the urethra

The urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, control levels of electrolytes and metabolites, and regulate blood pH. The urinary tract is the body's drainage system for the eventual removal of urine. The kidneys have an extensive blood supply via the renal arteries which leave the kidneys via the renal vein. Each kidney consists of functional units called nephrons. Following filtration of blood and further processing, wastes exit the kidney via the ureters, tubes made of smooth muscle fibres that propel urine towards the urinary bladder, where it is stored and subsequently expelled from the body by urination (voiding). The female and male urinary system are very similar, differing only in the length of the urethra.

<span class="mw-page-title-main">Ureter</span> Tubes used in the urinary system in most animals

The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually 20–30 cm (8–12 in) long and around 3–4 mm (0.12–0.16 in) in diameter. The ureter is lined by urothelial cells, a type of transitional epithelium, and has an additional smooth muscle layer that assists with peristalsis in its lowest third.

<span class="mw-page-title-main">Bladder stone</span> Concretion of material in the urinary bladder

A bladder stone is a stone found in the urinary bladder.

<span class="mw-page-title-main">Pyelonephritis</span> Medical condition

Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness. Other symptoms may include nausea, burning with urination, and frequent urination. Complications may include pus around the kidney, sepsis, or kidney failure.

<span class="mw-page-title-main">Hydronephrosis</span> Medical condition

Hydronephrosis describes hydrostatic dilation of the renal pelvis and calyces as a result of obstruction to urine flow downstream. Alternatively, hydroureter describes the dilation of the ureter, and hydronephroureter describes the dilation of the entire upper urinary tract.

Horseshoe kidney, also known as ren arcuatus, renal fusion or super kidney, is a congenital disorder affecting about 1 in 500 people that is more common in men, often asymptomatic, and usually diagnosed incidentally. In this disorder, the patient's kidneys fuse to form a horseshoe-shape during development in the womb. The fused part is the isthmus of the horseshoe kidney. The abnormal anatomy can affect kidney drainage resulting in increased frequency of kidney stones and urinary tract infections as well as increase risk of certain renal cancers.

<span class="mw-page-title-main">Diatrizoate</span> Chemical compound

Diatrizoate, also known as amidotrizoate, Gastrografin, is a contrast agent used during X-ray imaging. This includes visualizing veins, the urinary system, spleen, and joints, as well as computer tomography. It is given by mouth, injection into a vein, injection into the bladder, through a nasogastric tube, or rectally.

<span class="mw-page-title-main">Nephrostomy</span> Surgical procedure that creates a long-term opening between the kidney and the skin

A nephrostomy or percutaneous nephrostomy is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system. It is an interventional radiology/surgical procedure in which the renal pelvis is punctured whilst using imaging as guidance. Images are obtained once an antegrade pyelogram, with a fine needle, has been performed. A nephrostomy tube may then be placed to allow drainage.

<span class="mw-page-title-main">Vesicoureteral reflux</span> Medical condition

Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one direction from the kidneys to the bladder via the ureters, with a one-way valve at the vesicoureteral (ureteral-bladder) junction preventing backflow. The valve is formed by oblique tunneling of the distal ureter through the wall of the bladder, creating a short length of ureter (1–2 cm) that can be compressed as the bladder fills. Reflux occurs if the ureter enters the bladder without sufficient tunneling, i.e., too "end-on".

In urology, voiding cystourethrography (VCUG) is a frequently performed technique for visualizing a person's urethra and urinary bladder while the person urinates (voids). It is used in the diagnosis of vesicoureteral reflux, among other disorders. The technique consists of catheterizing the person in order to fill the bladder with a radiocontrast agent, typically diatrizoic acid. Under fluoroscopy the radiologist watches the contrast enter the bladder and looks at the anatomy of the patient. If the contrast moves into the ureters and back into the kidneys, the radiologist makes the diagnosis of vesicoureteral reflux, and gives the degree of severity a score. The exam ends when the person voids while the radiologist is watching under fluoroscopy. Consumption of fluid promotes excretion of contrast media after the procedure. It is important to watch the contrast during voiding, because this is when the bladder has the most pressure, and it is most likely this is when reflux will occur. Despite this detailed description of the procedure, at least as of 2016 the technique had not been standardized across practices.

<span class="mw-page-title-main">Ureteric stent</span>

A ureteral stent, or ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 and 30 cm. Additionally, stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place; this is called a JJ stent, double J stent or pig-tail stent.

<span class="mw-page-title-main">Ureterostomy</span>

A ureterostomy is the creation of a stoma for a ureter or kidney.

<span class="mw-page-title-main">Abdominal x-ray</span>

An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB.

Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region. It is usually done under general anesthesia or spinal anesthesia.

<span class="mw-page-title-main">Ovarian vein syndrome</span> Medical condition

Ovarian vein syndrome is a rare condition in which a dilated ovarian vein compresses the ureter. This causes chronic or colicky abdominal pain, back pain and/or pelvic pain. The pain can worsen on lying down or between ovulation and menstruation. There can also be an increased tendency towards urinary tract infection or pyelonephritis. The right ovarian vein is most commonly involved, although the disease can be left-sided or affect both sides. It is currently classified as a form of pelvic congestion syndrome.

Urologic diseases or conditions include urinary tract infections, kidney stones, bladder control problems, and prostate problems, among others. Some urologic conditions do not affect a person for that long and some are lifetime conditions. Kidney diseases are normally investigated and treated by nephrologists, while the specialty of urology deals with problems in the other organs. Gynecologists may deal with problems of incontinence in women.

Bladder outlet obstruction occurs when urine is unable to flow from the kidneys through the ureters and out of the bladder through the urethra. Decreased flow of urine leads to swelling of the urinary tract, called hydronephrosis. This process of decreased flow of urine through the urinary tract can begin as early as during intrauterine life and it prevents normal development of fetal kidneys and fetal urine. Low levels of fetal urine leads to low amniotic fluid levels and incomplete lung maturation. Older children and adults can also experience bladder outlet obstruction; however, this process is usually reversible and isn't associated with as many poor outcomes as in infants with congenital bladder outlet obstruction.

<span class="mw-page-title-main">Ureteral cancer</span> Medical condition

Ureteral cancer is cancer of the ureters, muscular tubes that propel urine from the kidneys to the urinary bladder. It is also known as ureter cancer, renal pelvic cancer, and rarely ureteric cancer or uretal cancer. Cancer in this location is rare. Ureteral cancer becomes more likely in older adults, usually ages 70–80, who have previously been diagnosed with bladder cancer.

A computed tomography urography is a computed tomography scan that examines the urinary tract after contrast dye is injected into a vein.

References

  1. ↑ " pyelography " at Dorland's Medical Dictionary
  2. ↑ Resnick MI, Novick AC (1999). "Evaluation of Hydronephrosis in Children". Urology secrets. Philadelphia: Hanley & Belfus. ISBN   1-56053-320-X. OCLC   41137551.
  3. ↑ Marley J (2007). Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA (eds.). "Campbell-Walsh Urology, 9th Edition (E-dition)". International Journal of Urological Nursing. Wiley. 1 (2): 94–95. doi: 10.1111/j.1749-771x.2007.00017.x . ISSN   1749-7701.
  4. ↑ Tanagho EA, McAninch JW (2008). Smith's general urology. New York: McGraw-Hill Medical. ISBN   978-0-07-159331-1. OCLC   190760280.
  5. 1 2 3 4 5 6 7 8 9 10 "What is an Intravenous Pyelogram (IVP)? - Urology Care Foundation". www.urologyhealth.org. Retrieved 2020-07-04.
  6. 1 2 3 "Intravenous pyelogram - Mayo Clinic". www.mayoclinic.org. Retrieved 2020-07-04.
  7. 1 2 3 4 5 6 "Intravenous Pyelogram". www.hopkinsmedicine.org. 14 August 2019. Retrieved 2020-07-04.
  8. ↑ Rubin GD, Kalra M, Saini S, eds. (2008). MDCT: From Protocols to Practice. Berlin: Springer. p. 159. ISBN   978-88-470-0831-1.
  9. ↑ Thomsen HS, Morcos SK (1999). "Contrast media and metformin: guidelines to diminish the risk of lactic acidosis in non-insulin-dependent diabetics after administration of contrast media. ESUR Contrast Media Safety Committee". Eur Radiol. 9 (4): 738–40. doi:10.1007/s003300050746. PMID   10354898.
  10. ↑ Caro JJ, Trindade E, McGregor M (April 1991). "The risks of death and of severe nonfatal reactions with high- vs low-osmolality contrast media: a meta-analysis". AJR Am J Roentgenol. 156 (4): 825–32. doi:10.2214/ajr.156.4.1825900. PMID   1825900.
  11. ↑ "Antegrade Pyelogram" . Retrieved 17 January 2015.
  12. ↑ "Antegrade Pyelography". Urology Care Foundation. Retrieved 4 March 2015.
  13. 1 2 3 4 5 6 7 8 9 "Retrograde Pyelogram". www.hopkinsmedicine.org. 19 November 2019. Retrieved 2020-07-04.
  14. 1 2 Watson N, Jones H (2018). Chapman and Nakielny's Guide to Radiological Procedures. Elsevier. pp. 141–142. ISBN   9780702071669.
  15. ↑ Chiu YS, Chiang HW, Huang CY, Tsai TJ (August 2003). "ARF after retrograde pyelography: a case report and literature review". American Journal of Kidney Diseases. 42 (2): E13–6. doi:10.1016/s0272-6386(03)00668-1. PMID   12900846.
  16. ↑ Osborne ED, Sutherland CG, Scholl AJ, Rowntree LG (November 1983). "Landmark article Feb 10, 1923: Roentgenography of urinary tract during excretion of sodium iodid. By Earl D. Osborne, Charles G. Sutherland, Albert J. Scholl, Jr. and Leonard G. Rowntree". JAMA. 250 (20): 2848–53. doi:10.1001/jama.250.20.2848. PMID   6358545.
  17. ↑ Smith RC, Rosenfield AT, Choe KA, Essenmacher KR, Verga M, Glickman MG, Lange RC (March 1995). "Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography". Radiology. 194 (3): 789–94. doi:10.1148/radiology.194.3.7862980. ISSN   0033-8419. PMID   7862980.
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