Retrograde (ascending) pyeloureterography. Conducting retrograde pyelography Of the drugs most often used

> X-ray (pyelography) of the kidneys, types of pyelography

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Pyelography is an X-ray examination of the kidneys with preliminary filling of the urinary tract with a contrast agent. With the help of pyelography, the size, shape, location of the calyxes and pelvises of the kidneys, the structure and function of the ureters are assessed.

Most often, retrograde (ascending) pyelography is performed. In this case, the contrast agent is injected through the ureter using a catheterized cystoscope. Antegrade (descending) pyelography is usually used when ureteral obstruction makes it impossible to inject contrast through the ureter or when the patient has contraindications for cystoscopy. In the descending variant of the study, contrast is injected directly into the pyelocaliceal system of the kidney by puncture or by installing a drain.

Liquid, gas (pneumopyelography) or both (double contrast) can be used as contrast.

Indications for pyelography

Pyelography is prescribed to confirm the diagnosis of hydronephrosis, pyelonephritis, urolithiasis, or cancer. The images show tumors, stones, blood clots, and other obstructions to the passage of urine. The study helps surgeons plan the course of the upcoming operation.

Who sends for the study, and where can I take it?

Nephrologists, urologists, oncologists, surgeons send for pyelography. It is advisable to undergo it in a medical or diagnostic medical center equipped with an X-ray machine and specializing in the diagnosis and treatment of pathology of the urinary organs.

Contraindications for pyelography

The study is contraindicated in case of hypersensitivity to contrast and during pregnancy. The retrograde method is not used in case of impaired patency of the ureters, insufficient capacity of the bladder, hematuria (the presence of blood in the urine), and the antegrade method is used in case of impaired blood clotting.

Preparation for pyelography

Pyelography technique

During retrograde pyelography, the patient lies on a special table with legs bent at the knee and hip joints, the position of which is fixed with special stirrups. After preliminary anesthesia, the doctor inserts a cystoscope into the bladder, and through it to the level of the renal pelvis - a special catheter. Under X-ray control, a contrast agent is slowly injected through the catheter. When the required filling of the pyelocaliceal system is reached, radiographs are performed in the anteroposterior projection, and in some cases additionally in semi-lateral and lateral projections.

During antegrade pyelography, the patient lies on a special table with his back up. After preliminary administration of local anesthesia, the doctor inserts a needle into the pyelocaliceal system (below the level of the XII rib) to a depth of approximately 7-8 cm and connects a flexible tube to it. Under the control of fluoroscopy, a contrast agent is injected through it. Then radiographs are performed in the posterior-anterior, anteroposterior and semi-lateral projections.

Deciphering the results of pyelography

Normally, the passage of the contrast agent through the catheters occurs without difficulty, the cups and pelvises of the kidneys fill quickly, have even, clear contours and normal sizes. The mobility of the kidneys (assessed during inhalation and exhalation) should not be more than 2 cm.

Incomplete filling of the upper urinary tract with contrast, dilatation, and delayed emptying after catheter removal indicate the presence of a tumor, stone, or other obstruction. Impaired mobility of the kidneys may indicate pyelonephritis, paranephritis, tumor or abscess of the kidney. With hydronephrosis, the pyelocaliceal system of the kidneys expands.

The results of the study (images and the conclusion of the radiologist) should be shown to the doctor who sent for pyelography.

Conducting intravenous urography

After the injection of a contrast agent, images are taken at various time intervals. To obtain a picture in the nephrophase, it is recommended to take a picture immediately after the injection of a contrast agent ("at the end of the needle"). But more often in adults, the first picture is taken after 5 - 7 - 10 minutes, since the nephrophase is well expressed in the first pictures.

The second shot is in 10 - 15 - 20 minutes. It is believed that normally the greatest intensity of the shadow occurs after 12-15 minutes. Usually, after the second picture, it is already possible to assume what pathological changes in the kidney, and further tactics, further pictures depend on this.

The third shot - after 30 - 40 minutes (if necessary). In the picture after 20 - 30 minutes, the bladder is usually clearly visible. At the end of the entire series, the picture - vertical shot(to exclude nephroptosis) and an orthostatic test.

This study usually ends, but sometimes it becomes necessary in delayed shots. They can be performed 1, 2, 3 or more hours after intravenous administration of a contrast agent. The fact is that with poor kidney function, the contrast agent is released slowly and the full picture of CHLS is detected late.

Infusion urography- modification of intravenous urography. If kidney function is reduced (see Zimnitsky's test and other functional tests), then sometimes infusion urography has to be done.

This method is used in cases where intravenous urography does not provide a clear detailed image of the cups and pelvis, so there is not enough diagnostic information (especially in the initial stages of tuberculosis and in chronic pyelonephritis in patients with poor concentration ability of the kidneys).

Retrograde pyelography is a more complex, instrumental method. For its implementation, special tools and a specialist urologist are required. An instrument called a cystoscope is inserted into the bladder. With its help, a special ureteral catheter is inserted into the ureter, and through it a contrast agent is introduced to the desired level (up to the pelvis) in a small amount - 7-8, 5-6 ml. Rough and rapid introduction of a contrast agent into the pelvis in large quantities leads to a sharp increase in intrapelvic pressure, hyperextension of the PCS and the occurrence of pyelorenal reflux, the contents of the pelvis enter the blood stream, extravasation occurs in the kidney and an attack of acute pyelonephritis may occur. Sometimes there are refluxes with intravenous urography.

With intravenous urography, the contrast agent is excreted by the kidneys at a concentration of 5%, and with retrograde pyelography, it is injected directly into the urinary tract at a high concentration (60-30%), so the image of the PCS is clearer and it is possible to identify already initial, small changes in the fornic apparatus of the cups. Therefore, retrograde pyelography is used when anatomical changes are not clearly identified with the help of intravenous urography. Kidney function cannot be detected using this method. In children, retrograde pyelography is rarely used, since special children's instruments are needed, the procedure is unpleasant, painful, and it is difficult for boys to perform it. In adults, this method is used quite often. Limitation of use is associated with the need for catheterization and the risk of infection.

Contraindications for retrograde pyelography are acute inflammatory processes in the kidneys and urinary tract and gross hematuria.

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In recent years, there has been a tendency to reduce the number of retrograde pyeloureterography and limit the indications for it. This is due to the introduction into practice of infusion urography - a method that is more physiological, less dangerous and gives no less clear image of CHLS; revision of the real diagnostic possibilities of the method and the high probability of complications in the form of pelvic-renal refluxes with the development of acute pyelonephritis, acute prostatitis and epididymitis.

However, retrograde pyeloureterography has its indications for use. It is necessary in the diagnosis of kidney tuberculosis, as it allows you to identify early destructive changes in the calyces; with medullary necrosis, as a complication of acute pyelonephritis; with papillary tumor of the pelvis and urate nephrolithiasis; stricture of the ureteropelvic segment and ureter; if necessary, specify the number and localization of stones, etc.

Retrograde ureteropyelography. Tuberculosis of the kidney

Retrograde ureteropyelography, polymegacolicosis

The danger of retrograde pyelography is also due to the possible injury of the urethra during the introduction of a cystoscope. Injury to the urethral mucosa, which is devoid of a submucosal layer and is in direct contact with the venous sinuses of the cavernous bodies, can lead to urethrovenous reflux with penetration into the blood of infection, the development of septicemia, and in men also to acute prostatitis and acute epididamitis.

The role of infection in causing complications is probably exaggerated. It is dangerous in the presence of predisposing factors (dyskinesia, pyelorenal reflux, trauma, etc.). A.Ya. Pytel and Yu.A. Pytel (1966) found that the fornic zone of the calyces, due to its special structure, is prone to rupture even with a relatively small increase in intrapelvic pressure.

After breaking the integrity of the fornix, urine or radiopaque fluid penetrates into the renal sinus. Leakage of the contents of the pelvis into the interstitial tissue of the kidney, penetration into its vessels as a result of a violation of the integrity of the mucous cup in the region of the fornices is called fornic reflux. If the pelvic contents flow into the tubules of the papilla without tearing the mucous calyx and then this content penetrates from the tubules into the interstitial renal tissue, then such a reflux is called tubular.

Refluxes lead to renal extravasation, renal hemodynamic disorder due to ischemia and edema of the interstitial tissue. High temperature, especially accompanied by chills and leukocytosis after retrograde pyelography, indicates pyelorenal reflux with the penetration of contrasted urine through the interstitial spaces into the venous and lymphatic system and the risk of developing acute pyelonephritis.

To prevent complications during catheterization of the ureter, the catheter should be inserted to a height of no more than 15-20 cm. Before the introduction of radiopaque fluid, it is necessary to locate the catheter from an overview image of the urinary system, since it can be inserted high or curled up in the dilated ureter.

With a high location of the catheter, it should be pulled up to the level of the III-IV lumbar vertebra. This correction is necessary because sometimes the ureteral catheter, despite turning the cystoscope 180° before turning the catheter in the bladder, does not guarantee that it will not move further up the ureter. Especially high is the risk of damage to the kidney during its dystopia.

With impaired passage of urine, retrograde pyelography is fraught with danger, which is caused not so much by the use of radiopaque fluid as by passing the catheter past a stone or stricture. The presence of a foreign body (catheter) in the ureter causes significant swelling in pathologically altered tissues, similar to swelling of the urethra in the stricture area after bougienage, and therefore the passage of urine is even more disturbed. Therefore, with hydronephrosis, it is impossible to insert a catheter into the pelvis and leave it for a long time after retrograde pyelography, so that contrast urine flows through it.

Low catheterization is required, in which the introduction of even a large amount of radiopaque fluid into the pelvis does not pose a danger. In addition, in the pelvis, even with its normal function, after contraction, there remains a certain amount of residual urine. The high introduction of the catheter, in which the pelvis is completely emptied, causes its threshold inhibition, disorder of the CHLS function and, subsequently, dyskinesia. The latter can cause pelvic-renal reflux and the occurrence of pyelonephritis.

The catheter should not be inserted into the upper cystoid of the ureter, since with an increase in intrapelvic pressure, it plays the role of a hydraulic buffer, into which the excessively injected radiopaque fluid is poured. This is because when the threshold pressure in the pelvis is reached, the ureteropelvic segment opens and an excess portion of urine enters the upper cystoid. The amount of radiopaque substance 10-20% concentration should not exceed 4-6 ml, which corresponds to the normal capacity of the pelvis.

Sometimes on the pyelogram, when the pelvis is filled with 4-6 ml of radiopaque fluid, the lower calyx is not detected. The absence of an image of the shadow of the latter on the pyelogram is not an indication for greater filling of the PCS. In these cases, the calyx is located anteriorly and is detected when examining the patient on the stomach. A similar technique should be used in the absence of a shadow of the upper calyx and the non-filling of the ureteropelvic segment.

Single-stage bilateral retrograde pyelography is unacceptable, since in the event of acute pyelonephritis it is often difficult to determine the side of the lesion for choosing an operation, and with bilateral pyelonephritis, the patient is in an extremely serious condition. In addition to pyelonephritis, acute renal failure may develop. If there is an urgent need for bilateral pyelography, then it should be carried out separately, with an interval of 2-3 days. To reduce the risk of retrograde pyelography, it is recommended to perform it immediately before surgery.

Retrograde pyeloureterography can lead to erroneous interpretation of pyeloureterograms due to the fact that during the study, a radiopaque substance is injected against the flow of fluid, and a foreign body (catheter) is inserted into the urinary tract. So, a false idea of ​​the stricture of the pelvic-ureteral segment may occur due to spasm of the segment in response to a high insertion of the ureteral catheter, especially with dyskinesia and hyperkinesia of the pelvis, when the shadow of an additional vessel is projected onto the ureter, with insufficient filling of the pelvis and the initial part of the ureter with radiopaque fluid. .

There may be a discrepancy in the length of the stricture of the ureteropelvic segment on the pyeloureterogram, which is detected during surgery. This is explained by the fact that when a radiopaque fluid is introduced into the VMP, it fills the narrow section of the ureter not only at the site of the stricture, but also above it, since the narrowed part creates an obstacle to the rapid and tight filling of the ureter above the stricture. Therefore, after filling the pelvis, it is necessary to take a picture in the vertical position of the patient, then, under the action of gravity, the ureter is filled with a fluid current to the place of the true stricture.

Sometimes, with a stricture of the ureteropelvic segment and a low catheterization of the ureter, when a radiopaque fluid is injected into the pelvis, a “fountain” is detected, similar to that observed on the ascending urethrogram with sclerosis of the bladder neck.

In the case of kidney damage during retrograde pyelography with extravasation of the radiopaque substance into the thickness of the parenchyma, there is a need for differential diagnosis with a kidney tumor. Penetration of the contrast fluid beyond the pelvis, communication of the perforated canal with the pelvis or calyx can create a false picture of a kidney tumor. With perforation of the ureter, it is also sometimes difficult to interpret the x-ray picture.

With incomplete perforation of the ureter, the shadow of the contrast fluid can fill not only the lumen of the ureter, but also be located along it, creating the appearance of expansion. A similar picture can be observed when the catheter is rolled up in the ureter and stretched excessively with contrast fluid. In such cases, the fluid spreads in the direction that the loop formed by the coiled catheter is facing. So, if the tip of the catheter is turned downwards, then the contrast fluid stretches the lower third of the ureter.

So, with retrograde pyeloureterography, a clear image of the PCS and ureters is achieved. This method makes it possible to judge the morphological structure of the upper urinary tract and, which is especially valuable, reveals minor destructive changes in the calyces, papillae, pelvis and ureter. The negative side of retrograde pyeloureterography is determined by the need for cystoscopy and ureteral catheterization, which is associated with the risk of serious complications.

• General information
• Normal pyelogram
• Advantages and disadvantages of retrograde pyelography

Retrograde pyeloureterography was first performed in 1906 by Voelcker and Lichtenberg. This method is based on obtaining shadows of the upper urinary tract in the X-ray image after their retrograde filling with a contrast agent. Thanks to the use of high concentrations of contrast agents, it is possible to obtain a clear image of the calyces, pelvis and ureter on retrograde pyeloureterograms.

For retrograde pyeloureterography, liquid and gaseous contrast agents are used. Among liquid substances, solutions of sergozin, cardiotrast, diodeon, triiotrast are most often used; among gaseous substances, oxygen, less often carbon dioxide.

Preparation of the patient for retrograde pyelography is the same as for the overview image.

Since pyelography should not be performed simultaneously on both sides, ureteral catheterization, as a rule, should be unilateral. A unilateral study is tolerated by patients much easier than a bilateral one. With simultaneous catheterization of both ureters, spasms of the calyces and pelvis often occur, which can distort their image on pyelograms and make it difficult to interpret the latter.

Bilateral pyeloureterography is permissible only in exceptional cases, when it is necessary to quickly resolve the issue of pathological changes in the kidneys and upper urinary tract.

Catheterization of the ureter is performed with a special catheter. Depending on the diameter of the ureter or the presence of various degrees of narrowing, catheters of various thicknesses are used. Most often use ureteral catheters No. 4, 5, 6 on the Sharière scale. It is preferable to use catheter No. 5 for catheterization, the caliber of which provides an easy outflow of contrast fluid in case of overflow of the pelvis.

Immediately before the introduction of a contrast agent into the pelvis, it is advisable to take an overview picture to determine the level of the end of the catheter in the urinary tract. Inject a contrast agent into the urinary tract should only be in the form of heat, which prevents the occurrence of spasms in the pelvic-cup system and in the ureter.

The use of contrast agents in very high concentrations for retrograde pyelography is unnecessary, since such contrast agents give too intense, “metallic” shadows that interfere with the correct interpretation of radiographs, and, therefore, increase the possibility of diagnostic errors. It is quite enough to use 20-40% solutions of radiopaque substances to obtain a good pyelogram.

In the presence of profuse hematuria, retrograde pyelography is not recommended, since blood clots in the renal pelvis can give filling defects on the pyelogram and, therefore, be mistaken for a tumor or calculus.

More than 5 ml of liquid contrast medium should not be injected into the pelvis. This amount is equal to the average capacity of the pelvis of an adult and is quite sufficient to obtain distinct shadows of the upper urinary tract on the radiograph, provided that the upper end of the catheter is at the level of the border of the upper and middle thirds of the ureter. In cases where the patient underwent excretory urography before retrograde pyelography, the latter, showing the size of the pelvis, allows you to more accurately determine the amount of contrast fluid that needs to be injected into the urinary tract for this patient for retrograde pyeloureterography.

Do not inject contrast fluid into the pelvis without taking into account the above amount, and also until the moment when the patient experiences pain or discomfort in the kidney area. Such pain indicates overstretching of the calyces and pelvis, which is a very undesirable circumstance in a pyelographic study.

Numerous works (A. Ya. Pytel, 1954; Hinman, 1927; Fuchs, 1930, etc.) have proved that the introduction of any solution into the pelvis at a pressure above 50 cm of water. Art. enough for this solution to penetrate beyond the cups into the renal parenchyma.

With a slow injection of a contrast fluid warmed to body temperature and light pressure on the syringe plunger, the subject does not experience pain.

If the first pyelogram shows that the pelvis is insufficiently filled with a contrast agent, a larger amount of contrast agent should be additionally injected into the pelvis, taking into account the estimated capacity of the pelvis based on the presentation created during the first pyelogram.

When the pelvis is overdistended, pelvic-renal reflux can easily occur, due to which the contrast agent penetrates into the blood stream. This may be accompanied by low back pain, fever, sometimes chills, and mild leukocytosis. These phenomena usually last no more than 24-48 hours.

A prerequisite for performing retrograde pyelography, as well as any urinary tract catheterization in general, is the strictest observance of the laws of asepsis and antisepsis.

If during retrograde pyelography pain occurs after the introduction of 1-2 ml of a contrast agent into the pelvis, then its further administration should be stopped and an x-ray should be taken. Most often, colic-like pain with the introduction of a small amount of a contrast agent is observed with dyskinesia of the upper urinary tract or when filling the upper pelvis of a doubled kidney, the capacity of which is usually very small - 1.5-2 ml. In the presence of dyskinesia, the study should be stopped and carefully repeated after a few days, with preliminary administration of antispasmodics before pyelography.

In cases where sharp colicky pains occurred during retrograde pyelography, in order to prevent the possible development of pyelonephritis, the patient should be prescribed antibacterial drugs (urotropin, antibiotics, nitrofurans, etc.). Recommended by some clinicians, the addition of antibiotics to the contrast agent injected into the pelvis in order to prevent inflammatory complications turned out to be an ineffective method. Thus, studies by Hoffman and de Carvalho (1960) showed that with and without antibiotics (neomycin) the number of complications in retrograde pyelography is the same.

The addition of anesthetic agents (novocaine) to the contrast agent injected into the pelvis, which was previously recommended and used by us, in order to prevent pain and pyelorenal reflux, also did not justify itself. This is understandable, since the applied 0.5% novocaine solution has practically no local anesthetic effect on the urothelium of the upper urinary tract.

Retrograde pyelography should be performed on one side, and if there are indications, then on the other, but not simultaneously. In any case, the doctor must have a clear idea of ​​the functional and morphological state of both kidneys and upper urinary tract, and this requires excretory urography or bilateral retrograde pyelography.

In the history of medicine, sad cases of erroneous diagnosis and incorrect therapy are known, when a doctor, having only one-sided pyelogram data, made a diagnosis and applied treatment, which in the end only brought harm to the patient. With this in mind, one should first of all remember polycystic kidney disease, a single kidney, tuberculosis and a tumor of the kidney, when on the basis of a unilateral pyelogram it is impossible to correctly diagnose and apply the correct type of treatment. We should also not forget about the existence of numerous variants of the kidneys, pelvis and ureters, which, with unilateral pyelography, can be mistaken for pathological changes. The same structure, although unusual, of the pyelocaliceal system on both sides speaks more in favor of the normal variant, with the exception of only renal polycystic.

Usually, retrograde pyelography is performed on a patient who is in a horizontal position on his back. However, this position of the patient does not always allow a good filling of the pelvis and cups with a contrast agent. It is known that large and small cups have a different location and the angle of their departure from the pelvis in relation to the horizontal plane of the body is different, due to which they cannot always be filled with a uniform contrast agent. This circumstance can be misinterpreted and lead to an erroneous assessment of the results of the study. Further, since the projection of individual cups can be superimposed on one another, this makes it difficult to decipher the pyelograms. Therefore, to exclude such errors, if necessary, pyelograms should be made in various positions of the patient's body. Most often, along with the position of the patient on the back, the oblique-lateral position on the side and on the stomach is used. For a picture in the lateral position, the patient is placed on that side of the body, the urinary organs of which are to be examined; the other side of the body should be tilted to the table at an angle of 45 °. The trunk and chest in this position should be supported by sandbags placed under the shoulder and thigh. Sometimes it is necessary to produce several oblique pyelograms at different degrees of torso inclination before the necessary picture is obtained.

When the patient is in the supine position, the upper and partly the middle calyx groups are first filled with contrast fluid as the most deeply lying parts of the pelvicalyceal system. In the position of the patient on the abdomen, the lower group of cups and the initial section of the ureter are better detected on the radiograph. Because of this, in doubtful cases, pyelography should be performed in various positions of the patient.

Sometimes, when performing retrograde pyelography with the patient in the usual supine position, it is not possible to fill the upper sections of the ureter and the pelvic-cup system with a contrast agent. In such cases, it is recommended to give the patient a position with an elevated "pelvis according to Trendelenburg.

To recognize nephroptosis, along with the usual position of the patient on the back, an x-ray should be taken in the vertical position of the body after filling the upper urinary tract with a contrast agent and removing the ureteral catheter. The downward displacement of the kidney with the occurrence of bends in the ureter confirms the diagnosis of nephroptosis and allows us to differentiate this suffering from renal dystopia, when there is a congenital shortening of the ureter.

To recognize diseases of the ureter, retrograde ureterography is often used, which is especially valuable in the diagnosis of ureteral stenosis, stones, tumors, and its various anomalies. For this purpose, after introducing a contrast agent into the pelvis and obtaining a pyelogram along the catheter, 3 ml of a contrast agent is additionally injected and the catheter is slowly removed. The patient is given the position of Fowler and after 25-30 seconds an x-ray is taken in the supine position. The chosen time of 25-30 seconds is optimal for filling the entire ureter with contrast agent.

Close to this type of pyelography is the so-called delayed pyelography, which allows you to clarify the diagnosis of atony of the upper urinary tract or determine the degree of hydronephrotic transformation. After the patient, who was in a horizontal position, was made pyelography, the catheter is quickly removed from the urinary tract, then the patient should sit or stand for 8-20 minutes, after which a second radiograph is taken. If in the second picture the contrast agent is still in the pelvis or ureter, then this indicates a disturbed evacuation of it from the urinary tract.

Recently, various modifications of retrograde pyelography have been used, pursuing the goal of earlier recognition of the most minor destructive changes in the kidneys. First of all, this applies to targeted images using a tube, which creates compression of the studied area of ​​the upper urinary tract. X-rays are made in the supine and standing position of patients. This method allows you to get a clearer image of individual sections of the upper urinary tract. It has found application in identifying the cause of the narrowing of the ureteropelvic segment and for the diagnosis of specific and nonspecific papillitis.

Normal pyelogram

On fig. 42, 43, 44, 45, 46, 47 show the most common variants of normal renal pelvis and calyces.

Rice. 42. Normal retrograde pyelogram. a - branched pelvis of the intrarenal type; b - ampullar pelvis of extrarenal type
Rice. 43. Normal bilateral retrograde pyelogram. Woman 24 years old.
Rice. 44. Normal right-sided pyelogram. Woman 32 years old. - normally filled pelvis (5 ml); b - the pelvis, overstretched with a contrast liquid (10 ml), as a result of which the cups are significantly deformed.
Rice. 45. Retrograde pyelogram. Woman 37 years old. A variant of the normal structure of the pelvis and calyces.	Rice. 46. ​​Retrograde pyelogram. Man 39 years old. Ampullary type of pelvis, small cups (no necks).
	Rice. 47. Retrograde pyelogram. A 31-year-old man, a common variant of the pelvicalyceal system

The existence of numerous forms and variants of the normal renal pelvis and calyces sometimes presents great difficulties in their interpretation according to pyelography. It is necessary to have a lot of experience in order to correctly interpret various types of pyelograms (Fig. 48, 49, 50).

Judging by the data of normal pyelograms, the right renal pelvis is most often located at the level of the II lumbar vertebra. The left renal pelvis is located 2 cm above the right. However, it is not uncommon to see that both pelvises are located below the indicated level.

There are cases when, with an unusual pyelographic image, there is a difficulty in resolving the question: is it a pathological picture or is it a rare variant of the normal pelvis and calyces? In such cases, the image of the other kidney and the radiograph of the examined kidney in a different projection help. Usually there is a certain tendency for the symmetry of the arrangement of the pelvis and calyces in the same individual. If the pyelogram of the second kidney is approximately the same as the first, then pathological changes in it are excluded.

It should be remembered that the images of the hollow spaces of the urinary tract may depend on various circumstances. The slightest increase in pressure inside the pelvis or inside the ureter can completely change their contours as a result of the changed neuromuscular tone of the upper urinary tract (Fig. 44, a, b).

Ureterogram. Normally, the shadow of the ureter is located along the lateral edge of the transverse processes of the lumbar vertebrae. The ureter should not form loops or articulated, angular curvature.

To identify a pathologically displaced kidney, loop-shaped bends and curvature of the ureter, pyeloureterography or excretory urography should be performed in the vertical and horizontal position of the patient. In the supine position of the patient, the picture should be taken after the lowered kidney returns to its normal position, i.e., after the patient is given a Trendelenburg position or when the renal region is massaged.

To establish anomalies or changes in the ureter, when injecting a contrast agent into the ureter, the catheter should be slowly removed from the latter, filling the ureter with a contrast agent. With this technique, the ureter fissus, ureteral tumor, stenosis, etc. will not be viewed. The diagnosis of "ureteral narrowing" can be convincing when the ureteral dilatation over the site of narrowing is demonstrated on the radiograph.

Pyelography with gaseous contrast agent(oxygen), or pneumopyelography. This type of pyelography is used when it is necessary to reveal the so-called invisible stone, i.e., a stone that does not block X-rays and, therefore, does not give a shadow in the overview image (Fig. 51, 52). Upon introduction of oxygen into the pelvis, the latter surrounds the calculus and creates conditions that significantly increase the contrast of the latter and, consequently, its visibility on the radiograph. With pneumopyelography, oxygen should be injected into the pelvis in an amount of 8 to 10 cm3, while avoiding an excessive increase in intrapelvic pressure. Pneumopyelography is by far the best method for detecting invisible stones. It allows not only to diagnose the calculus as such, but also to establish precisely its localization (pelvis, calyces, ureteropelvic segment, etc.).

So-called invisible stones of the pelvis, calyx, or ureter can sometimes be identified on retrograde pyelography based on the presence of a filling defect. In such cases, low-concentration solutions of sergozin (5-8%) are used.

Destructive processes in the kidney and in the upper urinary tract are detected mainly by retrograde pyeloureterography using high concentration contrast agents.

Great attention deserves retrograde pyelography with the simultaneous use of various contrast agents: liquid - X-ray positive and gaseous - X-ray negative. The most widely used method is Klami (Klami, 1954). It is based on the use of a solution of hydrogen peroxide (3%) simultaneously with a liquid contrast agent. This is recommended when, if the patient has pyuria or hematuria emanating from the kidney or from the upper urinary tract, it is not possible to establish the source of the pathological process using conventional retrograde pyelography. A contrast agent containing hydrogen peroxide, in contact with the focus of ulceration or destruction, whether in the calyx, papilla or pelvis, begins to foam, as purulent cells, exudate and blood decompose hydrogen peroxide into oxygen and water. This chemical reaction contributes to the penetration of the contrast agent not only into the superficial, but also into the deep layers of the destructive, inflammatory focus, which is revealed on the pyelogram by the corresponding small-spotted shadow. This method is used mainly for the diagnosis of early stages of renal tuberculosis, tumors of the kidneys and pelvis (Klami, 1954). As our observations show, this method also allows you to establish the focus of fornic bleeding and the localization of the calyx-fornic-venous canal in renal bleeding (A. Ya. Pytel, 1956).

To exclude possible diagnostic errors in Klami retrograde pyelography, it should be preceded by excretory urography and conventional retrograde pyelography. This is especially important in so-called invisible stones and tumors of the upper urinary tract.

Since 1961, the Broome method has been used, based on the use of both liquid and gaseous contrast agents in retrograde pyelography. Carbon dioxide is used as the gaseous substance. The technique of this technique is as follows. After introducing 2-3 ml of liquid contrast agent into the pelvis through the ureteral catheter, 6-8 ml of carbon dioxide is injected, and then the contents of the pelvis are aspirated with repeated introduction of carbon dioxide into it. Next, x-rays are taken. This method is most suitable for diagnosing papillary neoplasms of the pelvis and ureter, as well as for recognizing the so-called invisible stones.

- This is a type of x-ray examination that allows you to get an image of the bladder, ureters and renal pelvis. Very often, pyelography is performed during cystoscopy, that is, an examination of the bladder using an endoscope (a long, flexible tube with a light guide and a video camera). During cystoscopy, a radiopaque contrast agent is injected into the ureters through a catheter.

As ultrasound techniques and technology (high frequency sound waves) and contrast agents have improved, other imaging modalities such as intravenous urography and renal ultrasound (renal ultrasound) are now more commonly used.

What is an x-ray study?

In X-ray studies, the image of internal organs, tissues and bones is obtained using invisible electromagnetic radiation. X-rays, passing through the structures of the body, fall on a special plate (similar to photographic film), forming a negative image (the denser the structure of the organ or tissue, the brighter the image on the film).

Other imaging modalities that are used to detect kidney disease are plain radiography of the kidneys, ureters, bladder, CT scan of the kidneys, ultrasonography of the kidneys (ultrasound of the kidneys), renal angiogram, intravenous urography, renal venography, and antegrade pyelography.

How does the urinary system work?

The body takes nutrients from food and converts them into energy. After the body has received the necessary nutrients, the decay products are excreted from the body through the intestines or remain in the blood.

Maintains water-salt balance, allowing the body to function normally. The kidneys also remove urea from the blood. Urea is formed by the breakdown of proteins in the body, which are found in meat, poultry meat and some vegetables.

Other important kidney function include the regulation of blood pressure and the production of erythropoietin, a hormone that is needed for the formation of red blood cells in the bone marrow.

Parts urinary system and their functions:

The two kidneys are two bean-shaped organs located below the ribs on either side of the spine. Their function:

• removal of liquid waste from the blood in the form of urine
• maintenance of water-salt and electrolyte balance of blood
• release of erythropoietin, a hormone that is involved in the formation of red blood cells
• regulation of blood pressure.

The structural, functional unit of the kidneys is the nephron. Each nephron consists of a glomerulus formed by capillaries and renal tubules. Urea, along with water and other waste materials, passes through the nephron, which produces urine.

The two ureters are narrow tubes that carry urine from the kidneys to the bladder. The muscles in the wall of the ureters continually contract and relax to force urine into the bladder. Every 10 to 15 seconds, urine flows from each ureter into the bladder in turn. If urine is thrown from the bladder through the ureters to the kidneys, an infection may develop.

The bladder is a triangular hollow organ located in the lower abdomen. The bladder is held together by ligaments that attach to other organs and bones in the pelvis. The walls of the bladder relax and expand to store urine, and then contract and flatten, pushing the urine out through the urethra (urethra). A healthy adult bladder can store up to two cups of urine for two to five hours.

The two sphincters are circular muscles that prevent the flow of urine by closing like a rubber band around the opening of the bladder.

Bladder nerves - give a signal to a person to empty the bladder.

The urethra (urethra) is the tube that carries urine out of the body.

Indications for pyelography

Pyelography is prescribed to patients with suspected blockage of the urinary tract, for example, a tumor, a stone, a blood clot (thrombus) or due to a narrowing (stricture) of the ureters. Pyelography assesses the lower segment of the ureter, to which the flow of urine is difficult. Pyelography is also used to determine the correct position of a catheter or stent in the ureter.

Advantage of pyelography is that it can be performed even if the patient is allergic to contrast, because a minimal amount of contrast is used (unlike intravenous urography). Pyelography may be considered in patients with impaired renal function.

Your doctor may have other reasons for recommending pyelography.

Complications of pyelography

You can ask your doctor about the radiation exposure of pyelography and the complications associated with your medical condition. It is helpful to keep a record of the radiation exposure you received during previous x-rays. Complications associated with radiation exposure depend on the number of x-rays and/or radiation therapy over a long period of time.

If you are pregnant or suspect you may be pregnant, tell your doctor. Pyelography during pregnancy is contraindicated, since radiation can lead to developmental abnormalities in the child.

If a contrast agent is used, there is a risk of developing allergic reactions. Patients who are aware of the possibility of developing an allergic reaction to contrast should alert their doctor.

Patients with kidney failure or other kidney disease should notify their doctor. In some cases, the contrast may cause kidney failure, especially if the patient is taking glucophage (a drug used to treat diabetes).

Possible complications of pyelography include, but are not limited to: sepsis, urinary tract infection, bladder perforation, bleeding, nausea, and vomiting.

Contraindication for pyelography significant dehydration of the patient.

There may be other complications that depend on your state of health. Discuss all possible problems with your doctor before the pyelogram.

There are certain factors that can affect pyelography results. These factors include, but are not limited to, the following:

• gas in the intestines
• barium in the intestine from a previous x-ray of the gastrointestinal tract

Before pyelography

• Your doctor will explain the procedure to you and invite you to ask any questions you may have regarding the pyelogram.
• You will be asked to sign an informed consent form that confirms your consent to the pyelogram. Read the form carefully and clarify anything you don't understand.
• You must stop eating for a certain amount of time before the pyelogram. Your doctor will tell you how long you should not eat before the pyelogram.
• If you are pregnant or suspect that you may be pregnant, you must notify your doctor.
• Tell your doctor if you have ever had a reaction to any contrast agent, or if you are allergic to iodine or seafood.
• Tell your doctor if you are sensitive or allergic to any medications, latex, plaster, or anesthetic medications.
• Tell your doctor about all medications you are taking (including vitamins and dietary supplements).
• If you have trouble with frequent bleeding or are taking medicines that reduce blood clotting (anticoagulants), such as aspirin, you should tell your doctor. You may need to stop taking these medications before the pyelogram.
• The doctor may prescribe a laxative the night before the pyelogram, or a cleansing enema may be given a few hours before the pyelogram.
• To help you relax, you may be prescribed a sedative. Since sedative medication can cause drowsiness, you should take care of how you get home after the pyelogram.
• Depending on your health condition, your doctor may prescribe other special training for you.

During pyelography

Can be done on an outpatient basis or as part of an examination while you are in the hospital. The pyelography procedure can be modified according to your condition and your doctor's practice.

Typically, the pyelography procedure goes as follows:

After pyelography

For some time after the pyelogram, you will be monitored by medical staff. The nurse will measure your blood pressure, pulse, respiratory rate, if all your indicators are within the normal range, then you can return to your hospital room or go home.

It is necessary to carefully measure the volume of urine excreted per day, and observe the color of the urine (possibly the appearance of blood in the urine). Urine may turn red even if there is a small amount of blood in the urine. A slight admixture of blood to the urine after pyelography is possible and is not a cause for concern. Your doctor may recommend that you watch your urine during the day after the pyelogram.

After pyelography You may experience pain during urination. Take pain medication prescribed by your doctor. Aspirin and certain other pain medications can increase your risk of bleeding. Therefore, take only those medicines recommended by your doctor.

Be sure to consult a doctor if you are concerned about the following symptoms after a pyelogram:

• fever and/or chills
• redness, swelling, bleeding, or other discharge from the urethra
• strong pain
• an increase in the amount of blood in the urine
• difficulty urinating

The article is informational. For any health problems - do not self-diagnose and consult a doctor!

V.A. Shaderkina - urologist, oncologist, scientific editor