Urinary System New PDF

12/9/24 URINARY SYSTEM 1 At the end of the session, the students should be able to: Describe the anatomy & physiology of the urinary system. Describe the common procedures in urinary system which covers the technical factors, contrast media, procedure-...

12/9/24 URINARY SYSTEM 1 At the end of the session, the students should be able to: Describe the anatomy & physiology of the urinary system. Describe the common procedures in urinary system which covers the technical factors, contrast media, procedure- related drugs & any special considerations in urinary system. Demonstrate ethics & professionalism skills via role-play while performing radiographic positioning & special consideration in urinary system. Demonstrate teamwork skills through radiographic positioning, technical parameters & special consideration in urinary system. 2 1  12/9/24 Content: Intravenous (Descending) Urography Ascending Urography/ Retrograde Pyeloureterography Ascending Urethrography Micturating Cystourethography(mcug) 3 INTRODUCTIONS The examination cover the kidney, ureter, urinary bladder and urethera as general. Contrast must be used to visualize the urinary tract adequately Iodinated, water-soluble contrast is administered intravenously to examine this system This is known as antegrade filling – This provides a physiologic study Retrograde filling introduces contrast through the urethra or selectively into the bladder or the ureter via catheter or sound – This does not provide a physiologic study – This must be done using sterile technique 4 2  12/9/24 Methods of demonstrating the urinary system Plain films Ultrasound Intravenous Urography Radioisotopes (IVU) CT Micturating cystogram MRI (MCU) / urethrography Ascending Urethrography Retrograde pyelography Percutaneous renal puncture Arteriography venography 5 Indications For Contraindications For Urography Urography Demonstrates the Inability to filter contrast physiologic function and medium from blood structure of the urinary system Allergy to contrast Evaluate abdomen Abnormal BUN and masses, renal cysts and Creatinine tumors Urolithiasis – Normal values are 8 - Pyelonephritis 25mg/100ml and 0.6- Hydronephrosis 1.5mg/100ml Effects of trauma Pre-op evaluation Renal hypertension 6 3  12/9/24 General Preparation Of Patient The patient should follow a low residue diet for 1-2 days prior to exam A laxative should be taken the day prior to clean out the bowel NPO after midnight Patients with multiple myeloma, high uric acid levels, or diabetes should be well hydrated before an IVU exam – Dehydration leads to increased risk of renal failure 7 DESCENDING UROGRAPHY / INTRAVENOUS UROGRAPHY(IVU) 8 4  12/9/24 RELATED ANATOMY 9 Plain film radiography Preliminary film of KUB taken prior to IVU – why? Abdominal view to demonstrate calculi (usually involves inspiration & expiration film) Post trauma – e.g: knife injury, to demonstrate kidneys Technical factors: o Supine, full length of the abdomen, in inspiration o Use 35x43cm film, should include upper pole of kidneys & symphysis pubis o Center at the level of iliac crest o FFD 100cm 10 5  12/9/24 Indications Urinary tract pathology Renal stone Obstructions Hydronephrosis Contraindications Allergy to contrast media Renal failure due to dehydration Myeloma due to dehydration Infancy due to dehydration 11 CONTRAST MEDIA HOCM/LOCM 370 Most hospital use LOCM nowadays LOCM is prefer in: – Infant, small children & elderly – Renal and cardiac failure – Poor hydrated patient – Patients with diabetes, myeloma and sickle cell anemia – History of strong allergic reaction to CM Standard dose: – Adult= 50ml(2 syringes with 25ml) – Paeds= 1ml per kg 12 6  12/9/24 EQUIPMENT X-Ray system/machine with angulated table and foot pad and imaging device Abdominal compression device Pads / immobilization aids IV administration equipment o Contrast media o 50ml syringe, filling needle, sticky tape o Selection of needle, butterfly o Tourniquet Emergency drugs 13 14 7  12/9/24 PATIENT PREPARATION Basic abdominal preparation (NPO 4-6 hours prior to examination) Light evening meal (2 days) before procedure Ambulant 2hours prior to procedure Bowel cleansing laxative & enema on the morning of examination. If patient has allergy to CM, give methyle prednisolone 12H & 2H prior to examination Before the procedure: – Ensure patient remove metalic area at the abdomen region and change into gown – Ask to go to toilet first (WHY?) – Ask the location of pain area – Confirm ID, allergy and bowel preps before the procedure. – Current drug therapy – why? – Obtain previous films / examinations – Patients notes 15 IVU – Film sequence Control film (35x43cm) – KUB o Include lower border of symphysis pubis & diaphragm Immediate film (24x30cm) o AP of renal areas – nephrogram (usually taken under 1 minute) 5 minutes film (35x43cm) o purpose? o Compression? – why? 16 8  12/9/24 PRELIMINARY FILMS AP Abdomen supine is taken as preliminary film/control film Purpose of control film: – Exposure – Positioning – Bowel prep/condition – Initial stone localizing – Machine status – Comparison for contrast study 17 TECHNIQUE Set up IV line. – Prefer at antecubital vein. – Apply swab – Use tourniquet to ensure vessel visibility – Needle inserted at remove tourniquet Needle from 19G is chosen. Drain the CM into syringe Place tape at the needle side to ensure it is maintain not moving Hand(bolus) injection is chosen 18 9  12/9/24 Veins of the antecubital fossa (inner elbow) 19 PROCEDURE STEPS 1. Timing set up. Once CM administered, start the time. 2. Immediate film: ¢ 10-14s after the injection. Use to visualize the nephrogram@nephrotomogram. The renal area will be enhanced by contrast. 3. 5min film: ¢ evaluate the excretion both kidneys side. – KUB radiograph ¢ Compression is applied after the image taken(after reach 5 minutes) ¢ No comporession if: After abd surgery Renal trauma Abd mass If 5min show distended calyces 20 10  12/9/24 PROCEDURE STEPS 4. 15min film: ¢ Demonstrate the adequate pelvicalyceal systems. ¢ Release compression if satisfactory 5. Release film: ¢ Show the whole urinary tract ¢ Proceed for bladder empty if satisfactory achieved 6. Post Micturation film: ¢ Used to visualized the bladder emptying and show as it return to normal dilated tract condition 21 FILM SEQUENCES 1. Preliminary 2. Immediate 3. 5 minutes 4. 15 minutes 5. Release 6. Post-Micturation 22 11  12/9/24 Image PRELIMINARY / CONTROL (AXR) IMMEDIATE FILM 23 5 minutes film 24 12  12/9/24 15 minutes Release (20 minutes) Post Micturition 25 ADDITIONAL FILMS AP oblique projections – Right or Left Posterior oblique positions (35x43cm) o To determine whether the radiopaque shadow is in the ureter or outside. Prone (35x43cm) o To investigate pelviureteric & ureteric obstruction as the heavy contrast laden urine will more readily gravitate to the site of obstruction o To displace bowel gas towards periphery Delayed films (35x43cm) o May be necessary for up to 24hrs after injection to demonstrate the actual site of ureteric obstruction 26 13  12/9/24 IVU SERIES FOR INFANTS Need to reduce radiation dose Consist of: 1. 2min film of renal area 2. 5 min film of the renal area 3. 15min film of the abdominal region. No compression used The drainage is faster after 1 month age compare with adult. So, if the 2 series show no CM drainage, the image taken the next 1-2H time should be useful. 27 RELATED PATHOLOGY A post-micturition film performed in an IVU series in a patient with right renal colic. This demonstrates mild right-sided pelvicalyceal dilatation with calyceal clubbing (large white arrows) and dilatation of the right ureter also down to the level of the vesico-ureteric junction (small white arrow). This was secondary to a radiolucent calculus. 28 14  12/9/24 AXR demonstrates bilateral renal calculi. The left-sided staghorn calculus has a configuration similar to the pelvicalyceal system that it fills. On the right side there is a large calculus lying in the renal pelvis and upper right ureter, with smaller calculi seen in the lower pole of the right kidney (arrows) 29 30 15  12/9/24 RELATED PATHOLOGY Ureteral obstruction secondary to orthotopic ureterocele. Urographic image demonstrates the typical “cobra head” configuration of an orthotopic ureterocele in the bladder (arrow). In this case, marked ureteral dilatation, columnization, and associated fullness of the collecting system. 31 Collecting system dilatation. Fifteenminute urographic image demonstrates a standing column of contrast material from the ureteropelvic junction to the ureterovesical junction on the right, a finding that is associated with mild collecting system dilatation. A stone is impacted at the ureterovesical junction. Note also the edema in the right side of the interureteric ridge (arrow), which is normally less than 3 mm in thickness. 32 16  12/9/24 COMPLICATIONS Due to CM: mild, moderate, severe Due to technique: Incorrectly applied abdominal compression Swelling & pain during injection Extravasation of CM 33 AFTERCARE 1. Advice to drink plenty of water 2. Check for any allergy reactions 3. Take off the needle and ensure the injection site is secured 34 17  12/9/24 ASCENDING UROGRAPHY/ RETROGRADE PYELOURETEROGRAPHY 35 DEFINITION ¢ Radiologic examination use CM to study the KUB by introducing the catheter into the ureter via bladder using the cystoscopee ¢ The CM and catheter is retrograde(oppose the normal route direction) ¢ Only evaluate the structure, not the functionality. ¢ CM inserted up to the Pelvic ureteric junction (PUJ) level. 36 18  12/9/24 anatomy 37 Indications Demonstrate site (area), length, lower limit & nature of obstruction lesion Demonstrate pelvicalyceal system after unsatisfactory IVU (equivocal IVU) Calculi present Filling defect in IVU Strictures Urethral tears Congenital abnormalities Periurethral / prostatic abscess Fistulae / false passage Contraindication Allergy to CM, but rare Acute urinary tract infection Recent instrumentation 38 19  12/9/24 EQUIPMENT Conventional fluoroscopy with spot film unit General X-ray system in conjunction with cystoscopy table. Leg stirrups Sterile tray/set – Galley pot – Gauze – Catheters – Cystoscope Normal saline, lubrication gel and alcohol swab Sterile glove and clothing available LOCM, 150-200: – not too dense to obscure small lesions Water soluble Non-ionic Amount: ±10ml 39 40 20  12/9/24 GALLEY POT AND ASEPTIC DRESSING 41 PATIENT PREPARATION As for surgery and contrast study Blood test: PT,PTT, platelet count Fasting at least 4-6hrs prior and on the day of examination 42 21  12/9/24 FILMS Preliminary : During – Full length supine AP – Supine PA ureter abdomen (if the – R & L 35° anterior examination is oblique ureter performed in xray department) Catheter may be left in the pelvis to drain a pelviureteric obstruction* 43 TECHNIQUE Operating theater (OT) – Surgeon catheterizes ureter via cystoscope (endoscope of urinary bladder via urethra) – Uretheric catheter is advanced to the desired lavel – CM is injected with help of I.I system(fluroscopy unit) – Spot films are taken 44 22  12/9/24 TECHNIQUE Radiology department – Ureteric catheter is inserted (done in OT), pt is transferred to x-ray department then. – With ureteric catheter in situ, urine is aspirated – Under fluoroscopy control, CM (3-5ml) is injected *3-5ml are enough to fill the pelvis BUT the injection must be terminated if pt complains pain or fullness in the loin** 45 If there is PUJ obstruction, CM is aspirated Films are taken - satisfied :- catheter is withdrawn Withdrawn catheter:- 2ml CM is injectedat each of – 1st: 10cm below the renal pelvis those levels and films taken – 2nd: just di bawah ureteric orifice 46 23  12/9/24 A sterile flexible cystoscope in an operating theatre 47 FILMS Films from a right retrograde pyelogram study. Contrast has been injected into a catheter lying in the right ureter (large white arrow) introduced cystoscopically. Note extensive irregular filling defects (small white arrows) within the pelvicalyceal system and ureter consistent with diffuse transitional cell carcinoma. 48 24  12/9/24 COMPLICATIONS Due to anesthetic: GA Due to technique Due to CM: – Infection – Cm can be absorbed from the – Mucosa damage to the ureter intact renal pelvis & induce – Perforation of ureter / pelvis adverse reaction by the catheter – Chemical pyelitis (inflammation of renal pelvis due to stasis chemical;CM) – Extravasation due to overdistension of pelvis 49 AFTER CARE Post anaesthetic observation Prophylactic antibiotics may be used Ask to inform urologist if any prolong blood urine after the procedure 50 25  12/9/24 ASCENDING URETHROGRAPHY 51 DEFINITION ¢ Radiologic examination use CM to study the Urethra by introducing the catheter into the bladder. ¢ CM will use to evaluate the entire urethra to diagnose any pathological condition. 52 26  12/9/24 Indications Stricture Anterior urethra disease/tear Trauma Congenital abnormalities Prostatic abscess Fistulae/false passage CONTRAINDICATIONS Acute Urinary Tract Infection (UTI) Recent instrumentations 53 EQUIPMENT X-Ray system/machine with angulated table, foot pad and imaging device(spot film) Fine Folley catheter/penile clamp(Knuttson) Lubricating gel LOCM contrast media 20ml Pre warming CM – help reduce the incidence of spasm of external sphincter Normal saline Galley pot 54 27  12/9/24 55 FILM Preliminary – Coned PA supine of bladder base & urethra During – 30 LAO with R leg abducted & knee flexed – Supine PA – 30 RAO with L leg abducted & knee flexed 56 28  12/9/24 PROCEDURAL TECHNIQUE 1. No specific patient preparation 2. Patient in supine position on the table 3. Put some gel at the tip of the catheter and insert into the urethra. 4. The balloon is place at the fossa navicularis of the penis. 5. Inflate the balloon using 1-2ml normal saline 6. CM is injected under fluoro screening. Film taken when patient in 30° LAO and RAO. 7. Micturating cystourethrography(MCUG) is done to finalise the evaluation 57 COMPLICATION Due to CM: – Adverse reaction to CM but rare Due to technique: – Acute urinary tract infection – Urethral trauma – Intravasation of CM: if excess pressure is used to overcome the stricture 58 29  12/9/24 MICTURATING CYSTOURETHOGRAPHY(MCUG) 59 Introduction Also known as voiding cystourethrography Study of the urinarry bladder, urethra with the patient need to micturate to complete the examination Usually done for child and young baby INDICATIONS Vesicoureteric reflux Functional of urethra during micturate Bladder abnormalities Stress incontinence 60 30  12/9/24 Related equipment ¢ X-Ray system/machine with angulated table, foot pad and imaging device(spot film) ¢ Fine catheter(Eg: Umbilical catheter)/small size folley(5-7F) ¢ Lubricating gel ¢ LOCM contrast media 25-50ml ¢ Normal saline ¢ Galley pot ¢ Gauze 61 62 31  12/9/24 PATIENT PREPARATION Micturate prior to examination Preliminary film taken using the undercouch tube, cone at the bladder area. 63 Procedure sequence 1. Patient supine on the table 2. Insert the catheter with lubricating gel (Hibitane) place at the tip. 3. Make sure hold the patient (child) to avoid any movement. 4. Drain excessive urine 5. Insert CM till bladder dilated. Images taken when the CM fill the bladder till any reflux noted. 6. Spot film taken during micturation and any reflux is noted. Boy should micturate in LAO or RAO. 7. Post micturation image cover the full-length abdomen is taken. 8. If there is suspected of vesico-vaginal fistula, lateral image should be taken 64 32  12/9/24 FILM SEQUENCE Image should include sacrum and symphisic pubis for bladder neck descent assessment Images taken: 1. Lateral bladder 2. Lateral bladder with any reflux 3. Lateral bladder straining 4. Lateral bladder micturation 5. Post micturate image(lateral & AP) 65 AFTERCARE If any dysuria happen, the child will be given simple anelgesic and try to uribate in a warm bath. Antibiotic given. 66 33  12/9/24 COMPLICATION Due to CM ¢ Adverse reaction ¢ Cystitis Due to Technique ¢ Acute UTI ¢ Catheter trauma ¢ Bladder complication ¢ Ectopic ureteral orifice ¢ Retention of folley catheter 67 34