INTRODUCTION- Intravenous
Urography/Intravenous Pyelography (IVU/IVP) is a useful technique used for the
evaluation of pathology of the urinary tract. It uses ionizing radiation and
contrast media for visualization of the urinary tract. It includes a
control/scout film of the abdomen with kidney and urinary bladder and
post-contrast films at serial intervals [1].
Anatomy-
The urinary system, also known as the
renal system or urinary tract. This consists of kidneys, ureters, bladder, and
urethra. The main purpose of the urinary tract is to remove waste from the
body. Pair of kidneys are located between the dorsal body wall and parietal
peritoneum on both sides (left and right sides). The formation of urine begins
in the functional unit of the kidney that is called the nephrons. Urine then
flows through a system of conversing tubules called collecting ducts. From
there urine continues its flow into the ureter, transporting urine into the
urinary bladder. Urine exits through the external urethral meatus [1].
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Fig. 1: Picture
depicting anatomy of urinary tract
Intravenous
Urography- The IVU procedure is performed
under fluoroscopy to evaluate the urinary tract and for the procedure, the
patient should void before the examination. If there is any calcification in
the urinary tract, the location will assess before the injection of contrast
medium, because contrast obscure calcification. For the position and
nature of calcification, oblique conventional radiographs can be helpful [1,2].
Plain films are obtained first and radio-opaque calculi are identified.
Urographyprograms are produced by
filteration of contrast material by the nephrons, with the images of
renal parenchyma 13 minutes after contrast medium injection. When the obstruction
is the issue, a standard radiograph is collimated to the kidney, it may be
sufficient in young patients. Oblique radiographs may be of added benefit
if findings allow lateralization [2]. If we talk about the
size of the kidney, it should be assessed on every radiograph, and best
visualization during the nephrographic phase. An image is collimated to the
kidneys to detect renal calculus and visualization of collecting systems which
are obtained in 5 minutes after the compression device is applied. Oblique
images are helpful for optimal evaluation of the ureters and
pelvicalycealsystems. When compression is released, it allows the delivery of
contrast material into the ureters [3].
KUB radiograph is obtained immediately after
compression release, which is 15 minutes after administration of the contrast
medium. Imaging with the patient in the prone assists with visualization of
radiopaque parts of the ureters, especially, when there is an obstruction. In
such cases, delayed images must be an important tool and must take, until
opacification results to the level of obstruction are not defined. 1530
minutes after the administration of contrast media, the bladder is fully-filled,
and the 15-minute KUB radiograph may be adequate for evaluation. Visualization
of filling defects, oblique images may also be useful. Filling defects that are
not related to enteric gas, which may project over the bladder on images
obtained only in the anteroposterior projection [4-7].
If there is specific attention is
required to bladder disease, delayed images can be helpful and must be obtained
to improve bladder distention, and oblique, prone, or post-void images may be
obtained to evaluate filling defects. Delayed images of the bladder may
be necessary if distention is incomplete [8]. The bladder position
should be evaluated within the anatomy of the pelvis. Because the bladder is
situated at the lower aspect of the anatomic pelvis, its position and
appearance may be distorted by masses and other pathologic processes [9].
Bladder wall thickening and irregularity of the luminal contrast material
associated with bladder defect. Early filling images followed by a
post-void examination may help in the evaluation of filling defects.
The post maturation image is helpful in the
diagnosis of patients with upper urinary tract dilatation and assessing
residual volume when it is obtained immediately after voiding and demonstrates
complete emptying of the bladder [10-12].
Need of
the study- IVU is usually not preferred
over ultrasound and CT Urography due to many drawbacks. On USG, ureteric
evaluation is often limited due to overlying bowel gases. CT Urography has its
disadvantages like high radiation dose and high cost of the examination. Hence
in a rural setting with the majority of patients belonging to low socioeconomic
groups, IVU is still a preferred, relatively cheaper and valuable technique.
METHODS AND MATERIALS- This quantitative prospective study was carried out to assess the
role of intravenous urography in renal abnormalities on the patients who visit
the radiology department of SGT Hospital and Research Institute, Gurugram,
Haryana. This study was conducted over 6 months from 1st October
2019 to 1st April 2020. A total of 40 patients were selected
pre-decided according to the inclusion criteria and exclusion criteria of this
study. The consent form of each patient was acquired. History and symptoms were
obtained from the patient before the investigation. IVU was performed under
fluoroscopy using intravenous contrast media.
Exclusion criteria- Patients
with a kidney transplant, Postoperative patients, patients with malignancies,
patients with ongoing chemo/radiotherapy are excluded from the study to avoid
putting any patient at risk of delayed urgent care.
Inclusion criteria- Patients
with the following findings in ultrasonography were included in this study:
Hydronephrotic patients, Renal Calculi, Congenital abnormalities, Horseshoe
kidney, absent kidney.
Ethical approval- Ethical approval was taken from the
central institutional committee of SGT University; Hospital & Research
Institute. Informed consent was obtained from all the participants.
Statistical
analysis- Statistical
analysis for this article like frequency and average
was calculated through MS Office 2009.
RESULTS- A total of 70 patients were added to this study out of which 65
patients were found with positive findings and 5were reported under normal
study (Fig. 2). Out of a total (65), 44 patients were found normal functioning
right kidney and 21 have delayed functioning (Fig. 3). And out of total (65) 46
normal functioning of left kidney, 14 delayed and 5 non-functioning left
kidneys (Fig. 4). Pathological finding through Intravenous urography was Right
renal calculus in 25 patients, right hydronephrosis in 35 patients, left renal
calculus in 15 patients and left hydronephrosis in 27 patients (Fig. 5). Left
PUJ calculus is shown in 7 patients, Left VUJ calculus is in 9 patients and
left ureteric calculi are seen in 12 patients.
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The result of this study
shows intravenous urography is the gold standard evaluation of physiological
functioning of the kidney means rather the kidney's excretion function is
normal or delayed or not functioning. Clean means is intravenous urography can
be used how well kidney, ureters and bladder are in good functioning.
Anatomical and physiological details are well evaluated in the urography procedure.
The evaluation of hydronephrosis is easy and rapid evaluation in intravenous
urography. Calculus in PUJ (pelvic ureteric junction) and ureterovesical
junction (VUJ) with contrast hold-up are well diagnosed in the intravenous
urography that may replace the need for CT urography and can be used after the
limitations of ultrasonography. Because PUJ and UVJ are cannot easily diagnose
in ultrasonography where IVU are choice of imaging modality. In concern to ionizing radiation dose risk
versus benefits, the ratio must be calculated. An IVU also will be helpful for
diagnosis difference between urinary tract obstruction and calculus it may also
help the physician to choose rather go for medication only or further invasive
procedure.
DISCUSSION- This study suggested that a non-ionizing procedure Intravenous Urography
is found the gold standard investigation to know the physiological functioning
of kidneys for kidneys and it is the most common choice of procedure in
tertiary health care centres, rather studies have proven role of sonography is
more a primary diagnostic of renal diseases [9]. Also, it is important the selection of choice of
the procedure according to the clinical or previous medical history of each
patient. For each pathology imaging modality varies like in nephrolithiasis
condition computed tomography is choice of selection versus ultrasonography [13] and for different pathology patient
consideration changes and management of patient must be done as per guidelines
for the particular disease those may also vary from patient to patients [11].
In a comparison of computed tomography versus ultrasound versus intravenous
urography, ultrasonography considers as a fast-imaging technique with a rapid
result. Also, after sonography clinicians can make the easy call for the next
choice imaging modality [12]. Sonography equipment has a mobile
facility that is easy to use in emergencies department, Intensive care units,
operation theatres; those are addon in the benefits of fast imaging and rapid
result [14,15]. Studies do not suggest that
Intravenous Urography should be the first choice of selection procedure but it
play an important role right after the sonography limitations.
The
study of upper urinary tract obstruction studies shows different appearances of
ureters in different imaging modality could give a better diagnosis to patient
bit simultaneously it also increases the time and cost effects for the
patients. Hereby intra-venous urography has the advantage for the primary
selection of procedure after the limitations of conventional X-Ray Kidney
ureter and bladder [16-19]. Congenital diseases like horseshoe
kidney, one kidney or congenital hydronephrosis are difficult to diagnose and
treat in early phases also studies have proven urinary monocyte chemotactic
protein-1 osteopontin and regulated upon activation, normal T-cell and secreted
are useful in early diagnosis of congenital diseases. Whereas these markers are
also shown dangerous effects to renal and lead to nephropathy too, hereby
laparoscopy shows promising result by Taranta-Janusz
et. al [20]; Bartoli
et. al [21]; Ross
and Kay, [22]; Yurkanin et. al [23].
Hereby study suggests intravenous urography can lead to a minimally invasive
procedure. That can also help to better management of the patient and to plan a
line of treatment. So that physicians can show promising healthcare to patients
[24,25].
CONCLUSIONS- The study concludes
uses of IVU should not perform as a primary investigation to all patients.
Ultrasonography must be performed as a primary investigation. Duration of
symptoms must be taken into the account. A patient with long-standing symptoms
is more likely to diagnose with pathologies in IVU. For the radiolucent
calculus, IVU found a gold standard procedure as compared to sonography. IVU
also shows the functioning of the kidneys and any obstruction in the tract.
The study shows the uses or
importance of IVU in diagnostic radiology as it visualizes any pathologies or
obstruction, which leads to more difficulties for the patient in future.
ACKNOWLEDGEMENT- We are
thankful to Dr. Abhivind Bhutani (PG Resident), Ankit Kumar and Dhiraj M.Sc.
fellows for data collection.
CONTRIBUTION OF AUTHORS
Research concept- Mr. Mohit Deswal, Mr. Nitish Virmani
Design & Materials- Mr. Mohit Deswal, Mr. Nitish Virmani
Supervision- Mr. NitishVirmani
Data collection- Mr. PrashantJha
Data analysis and
Interpretation- Ms Aarzoo, Ms. Veenu
Literature search &
Critical review- Mr. Arshad Alam Khan
Writing article- Mr. MohitDeswal
Article editing- Ms. Ashita Jain
Final approval- Dr. BB Sharma, Dr. Mir Rizwan
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