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Excretory Urography in the Diagnosis of Ureteropelvic Obstruction
THE JOURNAL OF UROLOGY
Vol. 67, No. 6, June 1952 Printed in U.S.A.
EXCRETORY UROGRAPHY IN THE DIAGNOSIS OF URETEROPELVIC OBSTRUCTION WILLIAM L. McLAUGHLIN (by invitation)
AND
JOHN P. BOWLER
From the Department of Urology, Dartmouth Medical School and Hitchcock Clinic, Hanover, New Hampshire, and the Department of Urology, Veterans Administration Hospital, White River Junction, Vermont
Urologists in general appear to favor retrograde pyelography over excretory urography in establishing a diagnosis of congenital ureteropelvic obstruction. This preference for retrograde study may be explained on the basis of the urologists' dissatisfaction with the delineation of the renal pelvis in the presence of hydronephrosis as obtained in the routine excretory urographic series. Certainly retrograde urograms yield, in most instances, clear-cut and decisive information about the interior of the normal as well as the diseased kidney. Despite this pictorial superiority of the retrograde urogram, inherent dangers exist in the execution of the procedure. The hazards of retrograde urography are well appreciated, and discussion about them between urologists is not infrequent. Nevertheless, the urologic literature records but few voices raised in protest against the indiscriminate use of retrograde urography in the study of the upper urinary tract. Such a one, however, was Prichard, who in 1945 stated: "Patients who have had both types of urograms (retrograde and excretory) prefer the intravenous; many have experienced pain, perhaps some shock, nausea and vomiting or hematuria; or perhaps a previously latent infection has been lighted following the retrograde procedure, demanding surgical drainage." It would appear eminently desirable, therefore, to make the excretory urogram a more precise diagnostic tool in the presence of ureteropelvic obstruction. The purpose of this paper is to present a modification of the usual technique of obtaining excretory urograms which, in selected patients, will enable the genitourinary surgeon to make a diagnosis of ureteropelvic obstruction without resorting to retrograde injection of contrast medium into the renal pelvis. MODIFIED TECHNIQUE
In order to present the basis for this excretory urographic technique, we will review a few of the physiologic and physical phenomena involved. The contrast media commonly used in excretory urography are organic compounds containing iodine. It is the density of the iodine ions in the excreted urine which, by absorbing the roentgenographic rays, creates an image on the roentgenographic film. Baumrucker and Prichard jn separate articles have pointed out that following the intravenous injection of iodine-containing contrast media, the specific gravity of the urine may rise as high as 1.065. Because of its high density, the urine containing the iodine compound will gravitate to the most dependent part Read at annual meeting, American Urological Association, Chicago, Ill., May 24, 1951. The opinions and views set forth in this article are those of the writers and are not to be considered as reflecting policies of the Veterans Administration. 1012
DIAGNOSIS OF URETEROPELVIC OBSTRUCTION
1013
A p
PA Fw.1. A, (upper) i~ patients wi~h ureteropelvic ob~tructio~s who are lying supine, greater part of contrast medmm-laden urrne fills upper portion of kidney and renal pelvis may not be well outlmed by roentgenography. B, (lower) With patient prone, urine containing contrast medium gravitates into pelvis and area of ureteropelvic junction may be well delineated by roentgenography. '
FIG. 2. As in prone position, contrast medium gravitates to most dependent portion of kidney, and ureteropelvic area may be delineated by roentgenography.
of the urinary tract. Application of this principle in excretory urography to the problem of ureteropelvic obstruction is presented in figures 1 and 2. In general, intravenous injection of 20 cc of a contrast medium containing a 35 per cent iodine compound in a patient with good renal function will be sufficient, but occasionally twice this amount may be necessary to bring into roentgenographic relief the poorly functioning, hydronephrotic kidney.
1014
'IYILLIAM L. MCLAUGHLIN AND JOHN P. BOWL~JR
The excretory urographic films should be developed and interpreted separately as the series progresses. The "delayed-film," i.e., one taken at an interval later than usual in the series and in the supine position, should be studied. This may b0 at the 45-minute or 60-minute interval, or even later. If there appears to be good delineation of the kidney, the patient is then placed prone on the x-ray table. After ten minutes of complete rest in this position, a postero-anterior (P.A.) roentgenogram is taken. The patient is then' placed supine and the table is tilted to the vertical position so that the patient is erect. Again the patient is kept completely quiet in this position for ten minutes before the roentgenogram is obtained.
Fm. 3. Excretory urogram of woman aged 20. Congenital uretcropelvic obstruction of right kidney due tD intrinsic narrowing. INTERPRETATION
One of the urographic signs commonly seen in ureteropelvic obstruction is the square or rounded, "derby hat effect" (Abowitz) of the renal pelvis. The calyces are usually proportionately dilated. Ordinarily the ureter in ureteropelvic obstruction is not visualized, or if it is, it usually appears normal distal to the ureteropelvic junction. Figures 3 to 5 demonstrate the effect of body position upon the location of the iodine-laden urine within the renal pelvis and calyces. It will readily be recognized that patients ,vith hydronephrosis due to ureteropelvic obstruction do not ahrnys have sufficient renal function to give good roentgenographic delineation of the renal pelvis. In such instances one may have to resort to retrograde study. It has been our practice to insert a No. 5 ureteral catheter approximately 4.0 cm. up the ureter on the affected side and to inject the contrast medium with the patient's body-position "head down," approxi-
DIAGNOSIS OF URETEROPELVIC OBSTRUCTION
1015
mately 25 degrees from the horizontal. This allmvs the medium to outline the ureter, and in the presence of ureteropelvic obstruction the ureter usually appears normal with very little contrast medium entering the kidney. Such a pro--
Fm. 4. Excretory urogram of man aged 2!l. Obstruction of right upper ureter due to aberrant blood vessels.
Fm. 5. Excretory urogram ill erect position of man aged 23. Ureteropelvic obstruction of right kidney due to intrinsic narro1,·ing. Note "fluid level" effect of contrast medium in middle cnlc·x.
cedure obviate;, the hazard of traumatizing the ureteropelvic junction, thereby producing edema and spasm \Yhich may create an acute surgical emergency. There may be other anatomic variations of the kidney and renal pelvis, such
1016
WILLIAM L. MCLAUGHLIN AND JOHN P. BOWLER
as incomplete rotation, posteriorly located pelvis, and the presence of calculi, which will decrease the usefulness of the three-position technique. EXPERIENCE
From January 1945, through December 1950, we have observed 33 patients who had congenital ureteropelvic obstruction which was confirmed at operation. In each of the 33 patients excretory urography was employed. In 7 patients retrograde urograms were obtained, and in only four of these was retrograde urography thought to be an essential part of establishing the diagnosis. In 11 patients the three-position technique outlined in this paper was employed. This procedure was considered to be helpful in establishing the diagnosis of ureteropelvic obstruction in eight patients. The diagnosis was clear-cut roentgenographically in the delayed A.P. film in the remaining three patients. We did not obtain retrograde urograms in any of these 11 patients. In the remaining 15 patients, the history, the physical examination and the routine excretory urograms were sufficient to enable us to make a correct preoperative diagnosis of ureteropelvic obstruction. SUMMARY
Retrograde urography in the presence of ureteropelvic obstruction carries a definite risk to the patient whereas excretory urography does not. Urine laden with contrast medium, because of its increased density, gravitates to the most dependent portion of the urinary tract. By obtaining excretory urograms at a delayed interval with the patient in the A.P., P.A., and erect positions, the ureteropelvic area can in many instances be delineated with sufficient clarity to obviate the necessity for retrograde urograms. REFERENCES J.: Obstructive hydronephrosis produced by aberrant blood vessels and diagnosed by intravenous urography. Radiology, 48: 33-36, 1947. BAUMRUCKER, G.: Estimation of renal function based on specific gravity changes following intravenous urography. J. Urol., 50: 290-300, 1943. PRITCHARD, W.: Notes regarding intravenous urograms. J. Urol., 53: 387-392, 1945.
ABOWITZ,
Vol. 67, No. 6, June 1952 Printed in U.S.A.
EXCRETORY UROGRAPHY IN THE DIAGNOSIS OF URETEROPELVIC OBSTRUCTION WILLIAM L. McLAUGHLIN (by invitation)
AND
JOHN P. BOWLER
From the Department of Urology, Dartmouth Medical School and Hitchcock Clinic, Hanover, New Hampshire, and the Department of Urology, Veterans Administration Hospital, White River Junction, Vermont
Urologists in general appear to favor retrograde pyelography over excretory urography in establishing a diagnosis of congenital ureteropelvic obstruction. This preference for retrograde study may be explained on the basis of the urologists' dissatisfaction with the delineation of the renal pelvis in the presence of hydronephrosis as obtained in the routine excretory urographic series. Certainly retrograde urograms yield, in most instances, clear-cut and decisive information about the interior of the normal as well as the diseased kidney. Despite this pictorial superiority of the retrograde urogram, inherent dangers exist in the execution of the procedure. The hazards of retrograde urography are well appreciated, and discussion about them between urologists is not infrequent. Nevertheless, the urologic literature records but few voices raised in protest against the indiscriminate use of retrograde urography in the study of the upper urinary tract. Such a one, however, was Prichard, who in 1945 stated: "Patients who have had both types of urograms (retrograde and excretory) prefer the intravenous; many have experienced pain, perhaps some shock, nausea and vomiting or hematuria; or perhaps a previously latent infection has been lighted following the retrograde procedure, demanding surgical drainage." It would appear eminently desirable, therefore, to make the excretory urogram a more precise diagnostic tool in the presence of ureteropelvic obstruction. The purpose of this paper is to present a modification of the usual technique of obtaining excretory urograms which, in selected patients, will enable the genitourinary surgeon to make a diagnosis of ureteropelvic obstruction without resorting to retrograde injection of contrast medium into the renal pelvis. MODIFIED TECHNIQUE
In order to present the basis for this excretory urographic technique, we will review a few of the physiologic and physical phenomena involved. The contrast media commonly used in excretory urography are organic compounds containing iodine. It is the density of the iodine ions in the excreted urine which, by absorbing the roentgenographic rays, creates an image on the roentgenographic film. Baumrucker and Prichard jn separate articles have pointed out that following the intravenous injection of iodine-containing contrast media, the specific gravity of the urine may rise as high as 1.065. Because of its high density, the urine containing the iodine compound will gravitate to the most dependent part Read at annual meeting, American Urological Association, Chicago, Ill., May 24, 1951. The opinions and views set forth in this article are those of the writers and are not to be considered as reflecting policies of the Veterans Administration. 1012
DIAGNOSIS OF URETEROPELVIC OBSTRUCTION
1013
A p
PA Fw.1. A, (upper) i~ patients wi~h ureteropelvic ob~tructio~s who are lying supine, greater part of contrast medmm-laden urrne fills upper portion of kidney and renal pelvis may not be well outlmed by roentgenography. B, (lower) With patient prone, urine containing contrast medium gravitates into pelvis and area of ureteropelvic junction may be well delineated by roentgenography. '
FIG. 2. As in prone position, contrast medium gravitates to most dependent portion of kidney, and ureteropelvic area may be delineated by roentgenography.
of the urinary tract. Application of this principle in excretory urography to the problem of ureteropelvic obstruction is presented in figures 1 and 2. In general, intravenous injection of 20 cc of a contrast medium containing a 35 per cent iodine compound in a patient with good renal function will be sufficient, but occasionally twice this amount may be necessary to bring into roentgenographic relief the poorly functioning, hydronephrotic kidney.
1014
'IYILLIAM L. MCLAUGHLIN AND JOHN P. BOWL~JR
The excretory urographic films should be developed and interpreted separately as the series progresses. The "delayed-film," i.e., one taken at an interval later than usual in the series and in the supine position, should be studied. This may b0 at the 45-minute or 60-minute interval, or even later. If there appears to be good delineation of the kidney, the patient is then placed prone on the x-ray table. After ten minutes of complete rest in this position, a postero-anterior (P.A.) roentgenogram is taken. The patient is then' placed supine and the table is tilted to the vertical position so that the patient is erect. Again the patient is kept completely quiet in this position for ten minutes before the roentgenogram is obtained.
Fm. 3. Excretory urogram of woman aged 20. Congenital uretcropelvic obstruction of right kidney due tD intrinsic narrowing. INTERPRETATION
One of the urographic signs commonly seen in ureteropelvic obstruction is the square or rounded, "derby hat effect" (Abowitz) of the renal pelvis. The calyces are usually proportionately dilated. Ordinarily the ureter in ureteropelvic obstruction is not visualized, or if it is, it usually appears normal distal to the ureteropelvic junction. Figures 3 to 5 demonstrate the effect of body position upon the location of the iodine-laden urine within the renal pelvis and calyces. It will readily be recognized that patients ,vith hydronephrosis due to ureteropelvic obstruction do not ahrnys have sufficient renal function to give good roentgenographic delineation of the renal pelvis. In such instances one may have to resort to retrograde study. It has been our practice to insert a No. 5 ureteral catheter approximately 4.0 cm. up the ureter on the affected side and to inject the contrast medium with the patient's body-position "head down," approxi-
DIAGNOSIS OF URETEROPELVIC OBSTRUCTION
1015
mately 25 degrees from the horizontal. This allmvs the medium to outline the ureter, and in the presence of ureteropelvic obstruction the ureter usually appears normal with very little contrast medium entering the kidney. Such a pro--
Fm. 4. Excretory urogram of man aged 2!l. Obstruction of right upper ureter due to aberrant blood vessels.
Fm. 5. Excretory urogram ill erect position of man aged 23. Ureteropelvic obstruction of right kidney due to intrinsic narro1,·ing. Note "fluid level" effect of contrast medium in middle cnlc·x.
cedure obviate;, the hazard of traumatizing the ureteropelvic junction, thereby producing edema and spasm \Yhich may create an acute surgical emergency. There may be other anatomic variations of the kidney and renal pelvis, such
1016
WILLIAM L. MCLAUGHLIN AND JOHN P. BOWLER
as incomplete rotation, posteriorly located pelvis, and the presence of calculi, which will decrease the usefulness of the three-position technique. EXPERIENCE
From January 1945, through December 1950, we have observed 33 patients who had congenital ureteropelvic obstruction which was confirmed at operation. In each of the 33 patients excretory urography was employed. In 7 patients retrograde urograms were obtained, and in only four of these was retrograde urography thought to be an essential part of establishing the diagnosis. In 11 patients the three-position technique outlined in this paper was employed. This procedure was considered to be helpful in establishing the diagnosis of ureteropelvic obstruction in eight patients. The diagnosis was clear-cut roentgenographically in the delayed A.P. film in the remaining three patients. We did not obtain retrograde urograms in any of these 11 patients. In the remaining 15 patients, the history, the physical examination and the routine excretory urograms were sufficient to enable us to make a correct preoperative diagnosis of ureteropelvic obstruction. SUMMARY
Retrograde urography in the presence of ureteropelvic obstruction carries a definite risk to the patient whereas excretory urography does not. Urine laden with contrast medium, because of its increased density, gravitates to the most dependent portion of the urinary tract. By obtaining excretory urograms at a delayed interval with the patient in the A.P., P.A., and erect positions, the ureteropelvic area can in many instances be delineated with sufficient clarity to obviate the necessity for retrograde urograms. REFERENCES J.: Obstructive hydronephrosis produced by aberrant blood vessels and diagnosed by intravenous urography. Radiology, 48: 33-36, 1947. BAUMRUCKER, G.: Estimation of renal function based on specific gravity changes following intravenous urography. J. Urol., 50: 290-300, 1943. PRITCHARD, W.: Notes regarding intravenous urograms. J. Urol., 53: 387-392, 1945.
ABOWITZ,