Genitourinary system

1
Genito-urinary system

• RAD220
• Jens Loberg

2
Genito-urinary system

• intravenous urography
• cysto-urethography
• retrograde pyelography
• hysterosalpingography
• antegrade pyelography

3
Intravenous urographyor IVP intravenous pyelogram

• Gross Anatomy
• Kidneys (2)
• Ureters (2)
• Urinary bladder
• Urethra
• Adrenal glands (2)
• Prostate (male)

4
Kidney

• Renal fascia
• Hilum
• Renal sinus
• Renal cortex
• Renal columns
• Renal medulla
• Renal pyramids
• Calyces
• Minor calyces
• Major calyces
• Renal pelvis

5
Kidney

• Anatomically
• Left upper pole at level of T11/12
• Right upper pole at T12
• Left lower pole at level L1/2
• Right lower pole at level L2/3

6
Ureter

• PUJ (proximal ureteric junction)
• VUJ (vesicoureteral junction)
• Proximal
• Middle
• Distal

7

• Anatomically
• Left PUJ is at L1
• Right PUJ is at L2
• Middle extends from PUJ to VUJ
• VUJ at level in 4-5cm above Pubis symphysis

8
Ureter

• Diseases and disorders
• cancer of the ureter
• Renal calculus
• ureterocele
• megaureter

9
Bladder

• Diseases of the bladder
• bladder sphincter dyssynergia cystitis
• cystolithiasis
• cancer of the urinary bladder bladder cancer
• hematuria, or presence of blood in the urine,
  interstitial cystitis
• ureterocele
• urinary bladder dysfunction
• urinary incontinence

10
IVU

• Also called IVP (intravenous pyelogram)
• Demonstrates both function and structure of the
  renal system
• Function
• filtration
• Structure
• Contrast filled filtration system

11
Indications for Intravenous urography

• Evaluation of abdominal masses
• Urolithiasis / calculus
• Pyelonephritis
• Polycystic kidney
• Hydronephrosis
• Trauma
• Tumour
• Vesicoureteral reflux
• Preoperative evaluation
• Renal hypertension
• Renal obstruction
• Renal colic
• Congenital abnormality
• Horseshoe kidney
• Pelvic kidney
• Duplicate collecting system

12
Contraindications for Intravenous urography

• Kidneys inability to filter contrast media
• Allergic history
• Lack of kidneys
• Patient History
• Asthma
• High creatinine
• Circulatory or cardiovascular disease
• Sickle cell disease
• Diabetes mellitus (metformin)
• Multiple myeloma

13
Equipment required

• X-ray table with tomographic capabilities
• Medical trolley
• Compression band (belt)
• 40-60mls of intravenous contrast
• Saline, alcohol swabs
• 22 gauge needle (or bigger) butterfly
• Extension tube (if using cannula)
• 60ml syringe
• Access to sharps container
• Arm board
• Kidney dish
• Emesis bag
• Micropore tape
• Radiographic
• Cassettes 35 x 43, 24 x 30 (30 x 40)
• Time marker
• Anatomical marker

14
Patient preparation

• Patient preparation
• Take two Bisacodyl 2 days before
• Take two more bisacodyl (or another type of
  laxative) the night before.
• Once in your department
• Explain procedure to patient
• Contrast
• Needle
• Bladder control
• compression

15
Patient preparation

• Patient to empty bladder
• Change into gown (removing all artifacts)
• obtain patient history
• Have you had on of these before?
• Allergies
• Asthma
• Diabetes
• Creatinine level (blood test required)

16
Patient position

• Patient in supine position
• Head on pillow
• Arm relaxed by sides
• One arm out to side for injection of contrast
• Support under patients knees
• Attach footboard to foot end of table.
• Attach shoulder support (where available)
• Ureteric compression ready for action

17
IVU

• Basic views for IVU studies
• These are local protocol variable
• Include
• Control (preliminary) AP abdomen
• Control Kidneys (AP kidneys)
• Immediate ( 1 minute) collimated around kidneys.
  (nephrogram)
• 5 minute (plain)
• 3 levels of tomography
• 10 minute
• Release image (post compression)
• Bladder
• Oblique bladder X 2
• Post micturition (post void)

18
IVU

• Preliminary x-ray (control)
• Time zero
• Projection
• Anteroposterior supine Abdomen
• Position of patient
• in supine position
• Anteroposterior
• Arms relaxed by patients side
• Suspended respiration on expiration.
• Shield gonads
• Compression at level of sacrum

19
cont.

• Central ray
• Perpendicular to image receptor
• Midsagittal plane
• At level of iliac crests
• Include
• From pubic symphysis to diaphragm
• Lateral borders of kidneys/ureters/bladder
• Time markers
• Use a 35 X 43 regular cassette lengthwise.

20
Control Kidneys

• Preliminary x-ray (control)
• Time zero
• Projection
• Anteroposterior supine Kidneys
• Position of patient
• in supine position
• Anteroposterior
• Arms relaxed by patients side
• Suspended respiration on expiration.
• Shield gonads
• Compression at level of sacrum
• Central ray
• Perpendicular to image receptor
• Midsagittal plane
• At level of lumbar vertebra 1 (midpoint between
  xiphoid process and iliac crests)
• Include
• Upper and lower poles of both kidneys
• Lateral borders of both kidneys
• Height in cms

21
Nephrogram

• After intravenous injection has taken place a
  nephrogram is a common starting point for IVUs
• Patient care (contrast administration will give
  warm flush sensation, strange taste in mouth, and
  may feel as though wetting self)
• Nephrogram is a designed to look at the kidneys
  parenchyma.
• This image is taken at 1 minute post injection.
• Tomography is utilised here

22
Nephrotomogram

• Time
• Immediate (1 minute)
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Central beam
• Perpendicular to image receptor
• Centred at L1
• In midsagittal plane
• At predetermined height (6-11cms)
• In tomographic mode
• Include
• Upper and lower poles of both kidneys
• Include lateral margins of kidneys
• Kidneys should be well demonstrated
• Surrounding anatomy should be blurred
• Time marker should be well visualised
• Anatomical marker should be well visualised
• Height markers should be well visualised

23
5 minute nephrogram

• Time
• 3-5 minutes
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Central beam
• Perpendicular to image receptor
• Centred at L1
• In midsagittal plane
• Plain film (no tomography)
• Include
• Upper and lower poles of both kidneys
• Include lateral margins of kidneys
• Kidneys should be well demonstrated
• Time marker should be well visualised
• Anatomical marker should be well visualised

24
5 minute nephrotomograms

• Time
• 3-5 minutes
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Central beam
• Perpendicular to image receptor
• Centred at L1
• In midsagittal plane
• At predetermined height (6-11cms)
• Tomography
• Include
• 3 x-rays at specified height then one above and
  one below
• Upper and lower poles of both kidneys
• Include lateral margins of kidneys
• Kidneys should be well demonstrated
• All surrounding anatomy should be blurred
• Time marker should be well visualised
• Anatomical marker should be well visualised

25
10 minute with compression

• Time
• 10 minutes
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Central beam
• Perpendicular to image receptor
• Centred at L1
• In midsagittal plane
• At predetermined height (6-11cms)
• Tomography
• Include
• 3 x-rays at specified height then one above and
  one below
• Upper and lower poles of both kidneys
• Include lateral margins of kidneys
• Kidneys should be well demonstrated
• Time marker should be well visualised
• Anatomical marker should be well visualised

26
10-15 minute full lengthRelease

• Time 10-15minutes
• Remove compression band
• Projection
• Anteroposterior supine Abdomen
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in supine position
• Anteroposterior
• Arms relaxed by patients side
• Suspended respiration on expiration.
• Compression at level of sacrum
• Central ray
• Perpendicular to image receptor
• Midsagittal plane
• At level of iliac crests
• Include
• From pubic symphysis to diaphragm

27
Bladder

• Time 45-60 minutes
• Remove compression band
• Projection
• Anteroposterior axial bladder
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in supine position
• Anteroposterior
• Arms relaxed by patients side
• Suspended respiration on expiration.
• Central ray
• Caudal angulation 15 degrees
• Midsagittal plane
• At level of Anterior superior iliac spine
• Collimated to include bladder
• Include
• Apex to base of bladder

28
Post micturition / post void

• Time 45-60 minutes
• Remove compression band
• Projection
• Anteroposterior axial bladder
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in supine position
• Anteroposterior
• Arms relaxed by patients side
• Suspended respiration on expiration.
• Central ray
• Caudal angulation 15 degrees
• Midsagittal plane
• At level of Anterior superior iliac spine
• Collimated to include bladder
• Include
• Apex to base of bladder

29
Additional views

• AP oblique projections
• Lateral projection
• AP Oblique bladder
• Prone release

30
AP oblique projections

• Projection
• Anteroposterior oblique
• RPO
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in supine position
• Left side raised 30 degrees
• Central ray
• Perpendicular to image receptor
• Approx 4-5cms lateral to midline
• At level of iliac crests
• Include
• From pubic symphysis to diaphragm
• Lateral borders of kidneys/ureters/bladder
• Kidneys and ureters projected away from spine
• Kidneys ureters and bladder should be well
  demonstrated
• Time markers

31
AP oblique projections

• Projection
• Anteroposterior oblique
• LPO
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in supine position
• Right side raised 30 degrees
• Central ray
• Perpendicular to image receptor
• Approx 4-5cms lateral to midline
• At level of iliac crests
• Include
• From pubic symphysis to diaphragm
• Lateral borders of kidneys/ureters/bladder
• Kidneys and ureters projected away from spine
• Kidneys ureters and bladder should be well
  demonstrated
• Time markers

32
Lateral projection

• Projection
• Lateral right or left
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in lateral recumbent position
• Knees flexed (with pillow in-between) for comfort
  
• Flex patients elbows with hands under head
• Central ray
• Perpendicular to image receptor
• Midcoronal plane
• At level of iliac crests
• Include
• A lateral projection of kidneys ureters and
  bladder should be well demonstrated filled with
  contrast
• Anatomical markers
• No rotation
• Use a 35 X 43 regular cassette.

33
AP Oblique bladder

• Projection
• Anteroposterior oblique bladder
• LPO or RPO
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in supine position
• Right / left side raised 40-60 degrees
• Pubic arch closest to image receptor aligned over
  midline of grid
• Abduct leg closest to table (for comfort and
  stability)
• Central ray
• Perpendicular to image receptor
• Approx 4-5cms above the upper border of pubic
  symphysis
• 4-5 cms medial to ASIS
• At level of ASIS
• Include
• Lateral border of indicated side
• Bladder and distal ureters filled with contrast

34
Prone release

• Time 10-15minutes
• Remove compression band
• Projection
• Posteroanterior prone Abdomen
• Anatomy position
• Midsagittal plane in the midline of image
  receptor
• With no rotation
• Position of patient
• in prone position
• Posteroanterior
• Arms relaxed by patients side
• Head turned to one side
• Suspended respiration on expiration.
• Central ray
• Perpendicular to image receptor
• Midsagittal plane
• At level of iliac crests
• Include
• From pubic symphysis to diaphragm

35
Patient aftercare

• Patient Aftercare
• General psychological reassurance.
• 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.