Week 11- genito-urinary system

Question 1

what anatomy is covered when imaging the genito-urinary system?

Answer 1

abdominal aorta

Renal V

IVC

Kidneys

Ureters

Testicular/ Ovarian A + V

Superior mesenteric A

Inferior Mesenteric A

Bladder

Question 2

What is it called when you image the following:
1- Kidneys & Ureters
2- Urinary bladder
3- Urethra

Answer 2

1. Urography
2. Cystography
3. Urethrography

Question 3

what urography procedures are there?

Answer 3

IV urography
Antegrade urography
Retrograde urography

Question 4

what cystography procedures are there?

Answer 4

retrograde cystography

Voiding cystography

Question 5

what is the path of IV contrast urography

Answer 5

Cubital fossa
Basilla Vein
Axillary vein
Subclavian Vein
Brachiocephalic Vein
SVC
R atrium
R ventricle
Pulmonary trunk
Lungs
Pulmonary veins
L atrium
L ventricle
Aorta
L/R renal arteries

Question 6

Indications for IVPs

Answer 6

• Kidney Stones
• Tumours in the Kidney, ureter and/or bladder
• Scarring from UTI
• Post-surgery
• Congenital abnormalities
• Obstruction in kidney or ureter
• Hydronephrosis
• Mass/Cyst in Kidney
• Pyelonephritis
• Glomerulonephritis
• Haematuria

Question 7

Contraindications for IVP

Answer 7

• Renal Failure
• Previous Allergy to iodine
• Generalized allergic reactions
• Multiple Myeloma
• Pregnancy
• Thyrotoxicosis
• Diabetes
• Sickle Cell Anaemia
• Pheocromocytoma
• Severe decreased Liver Function
• Metformin
• Interleukin 2 Chemotherapy

Question 8

IVP imaging procedure

Answer 8

1. Control imaging
2. Pressure is applied to the bladder area, with a strap and sponge
3. Once the nephrogram images have been obtained a “Full ureter filling image is attempted
4. RPO and LPO Renal images are taken
5. RPO and LPO images are taken of the bladder area to show the VUJ in the bladder
6. If an obstruction becomes evident, then delayed images need to be take to see how the obstructed kidney is performing.

Question 9

Tomographic principles

Answer 9

The X-ray tube takes a plain X-ray image by moving

The focal plane remains clear and all other structures are blurred above and below the focal plane

Question 10

4 steps to setting up a tomogram

Answer 10

Set up the patient as per a normal X-ray

Move the X-ray tube to its caudal extent, and do a test run

Once the fulcrum position is determined, the x-ray tube is set to the start position

Question 11

What consists of a antegrade contrast urography

Answer 11

1. Contrast is injected into the kidneys
2. Patient is usually lying prone on the x-ray table or fluoro table

This procedure is often done in the OR

Usually 50MI of 370 iodinated contrast is used

Question 12

370 is a high osmolarity. Why is this okay in an antegrade urography?

Answer 12

Contrast is being injected straight into the ureters to be eliminated: it bypasses the kidney and is not filtered, therefore, does not affect the kidneys

Question 13

indications for antegrade uropgraphy

Answer 13

• Kidney Stones
• Tumours in the Kidney, ureter and/or bladder
• Scarring from UTI
• Post-surgery
• Congenital abnormalities
• Obstruction in kidney or ureter
• Hydronephrosis
• Mass/Cyst in Kidney
• Pyelonephritis
• Glomerulonephritis
• Haematuria

Question 14

Contraindications for antegrade urography

Answer 14

• Renal Failure
• Previous Allergy to iodine
• Generalized allergic reactions
• Multiple Myeloma
• Pregnancy
• Thyrotoxicosis
• Diabetes
• Sickle Cell Anaemia
• Pheocromocytoma
• Severe decreased Liver Function
• Metformin
• Interleukin 2 Chemotherapy

Question 15

why would we put a needle directly into the patients kidney and inject contrast rather than an intra-venous?

Answer 15

this procedure is used to insert a “Nephrostomy Tube” that then is taped and secured to the back of the patient so that the kidney drain externally, as there is an obstruction in the ureter.

Question 16

What technique is used to put the Nephrostomy tube into the Kidney?

Answer 16

Seldinger

Question 17

ureteric catheter insertion procedure with antegrade urography

Answer 17

1. Use Seldinger technique to locate a wire into the Kidney
2. The wire is then advanced down the Ureter under the guidance of contrast and fluoroscopy
3. When the wire reaches the bladder, the Ureteric Stent is placed over the wire
4. The wire is withdrawn
5. Removal of the catheter is done by an Antegrade approach and a clamp is introduced into the Kidney

Question 18

what is retrograde contrast urography used for?

Answer 18

• Removal of Calculi via dormia basket, laser, smashing (US)
• Insertion if stents
• Exploration of pathology

Question 19

contraindications for retrograde urography

Answer 19

• Same for all Iodinated contrast media
• Operating Theatre staff will assess the patients compatibility to undergo an operation
• If there are issues the operating theatre staff will discuss them with the radiographer and determine solutions to proceed

Question 20

what does the radiographer need to do during a retrograde urography in the operating theatre

Answer 20

• To record the times sequence of the images
• To record the sequence of pathological imaging
• To image all relevant anatomy
• Record the place (which operating Theatre), Surgeons name, Radiographers name, date and time
  2. Archive the images

Question 21

what is external shock wave lithotripsy (ESWL)

Answer 21

• Use of high energy ultrasound waves that are focused on the kidney stone
• The focused shock wave “smashes” or disintegrates the stone
• Patients are usually sedated or unconscious

Question 22

what happens during ESWL

Answer 22

• he x-ray is used to centre over the kidney stone
• Most modern machines automatically centre the ultrasound device in the process
• The stone can move as it breaks up. We go chasing the fragments to break each piece up

Question 23

what is a risk of ESWL

Answer 23

kidney rupture can occur
Extreme pain (stone breaks up and irritates the kidney)

Question 24

what is cystography

Answer 24

Specifically looking at the pathology of the bladder by using X-rays and iodinated Contrast media. This can be done via fluoroscopy or CT

Question 25

indications for cystography

Answer 25

- Tumours - Reflux to the ureter - Bladder diverticula - UTI’s - Inflammation - Fistula - Foreign bodies - Post-surgical assessment - Bladder trauma

Question 26

contraindications for cystography

Answer 26

- iodinated contrast contraindications | - Blockage in the urethra (unable to place ureter scope)

Question 27

imaging steps of cystography

Answer 27

1. Urinary catheter is inserted into the urethra 2. A balloon is inflated so the catheter is secure and doesn’t slide out of the ureter 3. Contrast is then let passively flow into the bladder, with occasional screening to see if there are any filling defects 4. This procedure may be done in the operating theatre with w ureter scope, visually checking the bladder or in Radiology under fluoroscopy 5. The patient may be asked to roll partially to take oblique X-rays 6. If reflux occurs contrast will move up the ureter

Question 28

imaging steps for micturition (voiding) cystogram

Answer 28

1. Same set up for a Cystogram 2. Same initial x-ray procedure as for Cystogram done under fluoroscopy in Radiology 3. Then the patient voids under fluoroscopy to visualise how the bladder empties 4. Spot imaging may be done to document the emptying of the bladder 5. Residual contrast in the bladder after voiding indicates incomplete emptying. This may cause infections as the urine in the bladder can become stagnant.

Question 29

causes of voiding abnormalities that lead to needing a micturition cystogram

Answer 29

- Infections - Inflammation - Mass: tumour/cysts - Calculi

Question 30

imaging sequence for micturition (voiding) cystogram

Answer 30

1. Control image 2. Filling x-ray 1st, 2nd ,3rd etc. 3. RPO or LPO and Lateral 4. Voiding x-ray 1st, 2nd, 3rd etc. 5. Post voiding

Question 31

who are urethrograms more commonly performed on and what happens during a urethrogram?

Answer 31

- Most often performed on males (longer urethra) - A catheter is inserted into the urethra - Contrast is inserted. - Images taken are mostly laterals and obliques

Question 32

urethrogram indications

Answer 32

- Stricture - Trauma - Fistula or false passage (Vesicovaginal/Vesico colic) - Congenital - Prostatic Abscess/mass - Functional problems voiding - Urethral diverticula

Question 33

urethrogram contraindications

Answer 33

- Contrast Allergies - Previous listed Iodinated contrast contraindications - Acute UTI

Question 34

what cant a patient do before a urethrogram and why

Answer 34

don’t have sex/masturbate (sperm can be caught in the Strictures/blockages etc.), making diagnosis more difficult

Question 35

patient prep for a Hysterosalpingogram

Answer 35

1. Abstain from sex/ use contraception 2. Performed to coincide with the menstrual cycle. 3. diagnostic complications: - Dilution of contrast - Filling or fluids mixing defect mimicking a pathology - Infection - Allergy inducing 4. Determine the patient is not pregnant 5. Have the patient urinate before the procedure 6. Control image of the pelvis 7. Patient privacy is paramount! 8. Relevant equipment: towels, 20 ml contrast, speculum, forceps, sterile field

Question 36

indications for Hysterosalpingogram

Answer 36

- Infertility - Fallopian tube patency - Possible therapy; flush out the fallopian tubes - Spontaneous abortions/ miscarriage (a lot of them) - Post-surgery - Post radiation therapy - Assessment of caesarean suture (rare) - Congenital abnormality assessment (rare)

Question 37

contraindications for Hysterosalpingogram

Answer 37

- Pregnancy (possible or known) - Acute infection - Contrast allergy - During menses - Constant vaginal bleeding - Recent surgery - Poor kidney function

Question 38

Hysterosalpingogram post procedure care

Answer 38

1. Slight pain may occur after 2. Sanitary pad 3. Slight bleeding: from irritation from the equipment in the lining of the uterus 4. Severe bleeding is not normal 5. Possible trauma 6. Cramp: mild to severe 7. Contrast in the uterine veins 8. Infection