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GU Studies

Retrograde Urography

Anatomy

Students should be able to identify the following structures on radiographic images:

Kidneys (cortex, medulla, renal pyramids, renal papillae, minor calyces, major calyces,  renal pelvis, hilum),  psoas muscles, Ureters, Bladder, Urethra, Suprarenal (adrenal) glands (not part of the urinary tract but often visible).

Indications, Contraindications, and Patient Preparation

Indications

  • Renal insufficiency or patients with contraindications to IV contrast (e.g., allergy, poor renal function).
  • Anatomic evaluation of pelvicaliceal system and ureters when IVU is inconclusive.
  • Evaluation of ureteral obstruction, stricture, or mass.
  • Direct urine sampling from each kidney for culture and microscopic analysis.

Contraindications

  • Active urinary tract infection (risk of worsening infection with instrumentation).
  • Severe urethral trauma (catheterization contraindicated).
  • Patients unable to tolerate anesthesia or cystoscopy.

Patient Preparation

  • No dietary restrictions required.
  • Patient empties bladder prior to catheterization.
  • Procedure explained; informed consent obtained (operative procedure).
  • Aseptic technique required (performed in cystoscopic suite).

Procedure Overview

Retrograde urography is an operative fluoroscopic procedure performed in the cystoscopic suite to visualize the pelvicalyceal system and ureters by direct retrograde instillation of iodinated contrast through ureteral catheters.

The procedure begins with cystoscopy, during which the ureteral orifices are located and catheters are passed retrograde into the ureters under sterile technique.

A preliminary image is taken to verify catheter position before contrast administration.

Contrast is then injected slowly under fluoroscopic control, filling the renal pelvis and calyces (pyelogram phase) and subsequently the ureters (ureterogram phase) as the catheters are withdrawn.

Table positioning is adjusted to control contrast flow:

  • Trendelenburg (head down) retains contrast within the renal pelvis and calyces.

  • Head-up (35–40° elevation) promotes ureteral drainage and demonstrates tortuosity or narrowing.

Throughout the procedure, the technologist monitors respiration and motion, ensuring exposures are taken on end-expiration to reduce blurring.

The patient’s report of fullness or pressure helps gauge adequate pelvic filling and prevents overdistention.

Contrast Medium: Nonionic iodinated contrast (3–5 mL per renal pelvis; increased if dilated).

Imaging Equipment: Fluoroscopy with spot or digital capture capability.

Radiation Protection: Collimate to kidneys and ureters; use shielding only when it does not obscure anatomy.

Team Coordination: Performed jointly by a urologist, radiologist, and technologist under sterile conditions.

Routine Projections (ARRT Required)

Preliminary AP

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine in modified lithotomy position (knees flexed in stirrups)
  • Adjustments: MSP centered; arms clear of field; ensure bladder included if possible
  • CR: Perpendicular, centered midway between xiphoid process and iliac crests (kidney level)
  • Patient instructions: Suspend respiration on end-expiration; remain still
  • Exposure: Standard abdominal technique; collimate kidneys through bladder

Evaluation Criteria

  • Coverage (what anatomy must be included and how you verify it’s complete): Kidneys through bladder; ureteral catheters visible
  • Rotation checks (how symmetry or alignment tells you if positioning is correct): Spinous processes midline; iliac wings symmetrical
  • Motion checks (how sharpness confirms patient cooperation/exposure timing): Sharp renal outlines and bowel gas margins
  • Technique checks (what contrast, density, soft tissue visibility, and artifacts to look for): Proper contrast visualization of catheters before injection
  • Clinical aim (when applicable, e.g., reflux, obstruction, displacement, etc.): Confirm catheter placement and baseline anatomy prior to contrast administration

AP Pyelogram

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine
  • Adjustments: Optional 10–15° Trendelenburg to retain contrast in renal pelvis
  • CR: Perpendicular to level midway between xiphoid process and iliac crests (kidney level)
  • Patient instructions: Suspend respiration on end-expiration; report any discomfort
  • Exposure: Collimate to kidneys; short exposure time

Evaluation Criteria

  • Coverage: Entire pelvicalyceal system visualized bilaterally
  • Rotation checks: Kidneys symmetric; spine centered
  • Motion checks: Distinct calyceal fornices and infundibula visible
  • Technique checks: Adequate contrast density without overfilling; no venous contamination
  • Clinical aim: Demonstrate calyces, infundibula, and renal pelvis for shape, distention, or filling defects

AP Ureterogram

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine
  • Adjustments: Elevate head of table 35–40° to demonstrate ureteral tortuosity and promote drainage
  • CR: Perpendicular at level of iliac crests
  • Patient instructions: Deep inspiration, then suspend respiration on end-expiration
  • Exposure: 14 × 17 inches lengthwise; capture images as catheter is withdrawn

Evaluation Criteria

  • Coverage: Ureters from UPJ through UVJ
  • Rotation checks: Iliac wings symmetrical; ureters projected lateral to spine
  • Motion checks: Crisp ureteral margins
  • Technique checks: Uniform contrast column; avoid overdistention or reflux
  • Clinical aim: Assess ureteral patency, narrowing, or extrinsic displacement

AP Obliques (RPO / LPO)

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine, rotated 25–30°
  • Adjustments: Flex knee of elevated side; MSP parallel to table
  • CR: Perpendicular at iliac crests, 2 inches lateral to MSP on elevated side
  • Patient instructions: Suspend respiration on end-expiration
  • Exposure: Routine abdomen technique; collimate to urinary tract

Evaluation Criteria

  • Coverage: Kidney on elevated side elongated; dependent ureter free of spine overlap
  • Rotation checks: Appropriate elongation and foreshortening
  • Motion checks: Sharp kidney and ureteral outlines
  • Technique checks: Adequate contrast through pelvis and UVJ
  • Clinical aim: Open ureter from superimposition and profile suspected side

Supplemental Projections

Lateral

CR Location & Positioning

  • SID: 40 inches
  • Patient position: True lateral; knees slightly flexed; arms elevated out of field
  • Adjustments: MCP centered to IR; supports between knees
  • CR: Perpendicular at level of iliac crests
  • Patient instructions: Suspend respiration on end-expiration
  • Exposure: Collimate kidneys through pelvis

Evaluation Criteria

  • Coverage: Kidneys, ureters, and posterior bladder wall in profile
  • Rotation checks: Femoral heads superimposed
  • Motion checks: Sharp margins of kidneys and bladder wall
  • Technique checks: Proper penetration through abdomen
  • Clinical aim: Localize anterior/posterior displacement or demonstrate perinephric extravasation

Lateral Decubitus

CR Location & Positioning

  • SID: 40 inches
  • Patient position: Supine (dorsal) or prone (ventral) with side against grid
  • Adjustments: Horizontal beam; MCP centered; no rotation
  • CR: Horizontal and perpendicular at level of iliac crests
  • Patient instructions: Suspend respiration on end-expiration
  • Exposure: Collimate to urinary tract

Evaluation Criteria

  • Coverage: Entire collecting system with horizontal fluid–contrast levels
  • Rotation checks: Pelvis not rotated; spine vertical
  • Motion checks: Sharp margins of dependent and nondependent walls
  • Technique checks: Adequate penetration through abdomen
  • Clinical aim: Confirm leak location or evaluate hydronephrosis fluid levels

Hows & Whys of Retrograde Urography

Anatomy

  • How is the pelvicalyceal system demonstrated during a pyelogram?
    By instilling iodinated contrast directly through the ureteral catheter, outlining minor and major calyces, infundibula, and the renal pelvis.
  • How is the ureter assessed during a ureterogram?
    Contrast is injected while the catheter is withdrawn, showing the full ureteral course and allowing evaluation of strictures, stones, or displacement.

Positioning

  • Why is mild Trendelenburg used during the pyelogram phase?
    It retains contrast in the renal pelvis and calyces for better definition before it drains into the ureters.
  • Why is the head of the table raised during the ureterogram?
    Head-up angulation promotes ureteral drainage, displays tortuosity, and prevents premature pelvic reflux.
  • Why are obliques sometimes added?
    Oblique positioning elongates the elevated kidney and removes the down-side ureter from spine overlap, clarifying filling defects.
  • Why might a lateral or decubitus projection be used?
    It demonstrates anterior or posterior displacement and localizes urinary leaks or perinephric fluid collections.

Technique & Image Evaluation

  • How do you confirm adequate pelvic filling without overdistention?
    The calyces and infundibula are clearly outlined without effacement of fornices, and the patient reports only mild fullness or pressure.
  • How can you ensure the ureter is not superimposed on the spine?
    Slight oblique rotation or head-up positioning moves the ureter lateral to the vertebral column along the psoas margin.
  • How do you differentiate a true filling defect from motion artifact?
    A true filling defect maintains position and shape on sequential images; motion artifacts shift or blur between exposures.
  • How is a stricture documented accurately?
    Use slow, steady injection with catheter withdrawal, imaging at the narrowed site and proximal dilatation for measurement.

Clinical Applications

  • Why is retrograde urography used instead of IVU in some patients?
    It bypasses systemic circulation, making it safer for those with renal insufficiency or IV contrast allergy.
  • Why is cystoscopy required for retrograde studies?
    Direct endoscopic visualization is necessary to locate ureteral orifices, insert catheters, and monitor the procedure.
  • Why is slow, low-pressure injection critical?
    To prevent reflux, renal pelvis rupture, or pyelovenous backflow.
  • Why is patient feedback about fullness important?
    It indicates the renal pelvis is sufficiently filled; pain signals overdistention and the need to pause injection.
  • Why is this considered an operative procedure?
    Because it requires aseptic technique, cystoscopy, and coordination among the radiologist, urologist, and technologist in a sterile environment.

 

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Radiographic Procedures Review Guide Copyright © 2025 by Carla M. Allen and Taylor M. Otto is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

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