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Direct retrograde and antegrade pyelography. Carrying out retrograde pyelography

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

This information cannot be used for self-medication!
Consultation with a specialist is required!

What is pyelography and how is it performed?

Pyelography is an X-ray examination of the kidneys with preliminary filling of the urinary tract with a contrast agent. Using pyelography, the size, shape, location of the calyces and pelvis 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 catheterization cystoscope. Antegrade (descending) pyelography is usually used in cases where, due to obstruction of the ureter, it is impossible to administer contrast through it, or when the patient has contraindications to cystoscopy. In the descending version of the study, the contrast is introduced directly into the renal collecting system by puncture or by installing a drainage.

The contrast can be a liquid, a gas (pneumopyelography), or both at the same time (double contrast).

Indications for pyelography

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

Who sends you for the study, and where can you get it?

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

Contraindications for pyelography

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

Preparation for pyelography

Method of performing pyelography

When performing retrograde pyelography, the patient lies on a special table with his 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 guidance, a contrast agent is slowly injected through the catheter. When the required filling of the collecting system is achieved, radiographs are taken in the anteroposterior projection, and in some cases additionally in semilateral and lateral projections.

When performing antegrade pyelography, the patient lies on a special table with his back up. After preliminary local anesthesia, the doctor inserts a needle into the collecting system (below the level of the 12th rib) to a depth of approximately 7–8 cm and connects a flexible tube to it. Under fluoroscopic control, a contrast agent is injected through it. Then radiographs are taken in posteroanterior, anteroposterior and semilateral projections.

Interpretation of pyelography results

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

Incomplete filling of the upper urinary tract with contrast, its dilation, and delayed emptying after catheter removal indicate the presence of a tumor, stone, or other obstruction. Impaired kidney mobility may indicate pyelonephritis, paranephritis, tumor or kidney abscess. With hydronephrosis, the renal collecting system dilates.

The results of the study (images and the radiologist’s report) should be shown to the doctor who referred for pyelography.

The development of radiology and the development of methods for diagnosing renal pathology have made it possible, since the forties of the twentieth century, to introduce into medical practice methods that make it possible to study the structure and functional ability of the urinary organs.

Almost every major city has private clinics and laboratories such as “Invitro”, which offer their wide examination services.
We will try to understand the possibilities of this diagnostic method, such as urography, and find out its disadvantages.

About terminology

Urography is any X-ray examination of the urinary organs with mandatory confirmation of visual changes by photographs (x-rays), including the structures of the kidneys, ureters, bladder, and urethra.

Some authors consider the term “pyeloureterography” to be more acceptable. It actually includes x-ray monitoring of the entire urinary tract and specifies the scope of the procedure. Others stop at “renal urography” if we are talking only about an isolated study of renal structures.

When prescribing a “tomography”, the doctor relies on layer-by-layer images of an organ to clarify the location and size of organ damage using different depths of penetration of X-rays. A series of images allows you to select the optimal image.

Patients don’t have to pay attention to this, but when paying for diagnostics in a private clinic, the cost will vary, you need to be prepared for this and check in advance. In addition, you should pay attention to what type of urography is intended to be used. Currently used:

  • overview;
  • excretory urography (infusion).

Each method has its own indications and negative sides.

The value of survey urography

An overview image of the kidneys actually includes the bone structures of the spine, partly the abdominal organs, and soft tissues. This is a standard examination method that allows you to obtain a minimum of information about:

  • the location of both kidneys;
  • large concretions (stones);
  • gross changes in structure, contours, dimensions.


The renal collecting apparatus of the kidneys is not visible during survey urography

This type of examination is usually used in primary diagnosis. It does not require the introduction of contrast.

The method is carried out with the obligatory use of a radiopaque substance. The essence of the method: a medical drug is administered intravenously (stream or drip), which is clearly visible under the influence of x-rays. It quickly accumulates in the urinary system. As it is processed and excreted by the kidneys, the calyces and pelvis are completely filled, then the substance passes into the ureters, bladder and urethra.

By controlling the isolation process over time, it is possible to take optimal pictures of these structures, from which much more information is obtained than with survey urography. Using the established standards for the start of contrast flow, it is possible to register a delay in one of the kidneys, and, therefore, judge its functional ability.

Contrast requirements

The quality of the resulting image and the reliability of information about pathological changes depend on the choice of contrast agent. The required drug should not:

  • “go away” and accumulate in tissues;
  • participate in general metabolism;
  • have toxic properties.

Ready-made preparations are used that have maximum radiopacity with minimal allergenic properties.

Products containing iodine are more often used. A day or two before the test, the patient is supposed to do a test to identify individual sensitivity. If a rash, skin itching, or swelling occurs, administration of the drug is strictly contraindicated.

In practice we use:

  • Cardiotrust,
  • Triyombrust,
  • Visipack,
  • Urografin.


Drugs are injected into a vein slowly or in a dropper

How is preparation for urography carried out?

A prerequisite for the patient’s readiness for urography is thorough cleansing of the intestines from gases and feces.

To do this, preparation for urography includes tips:

  • 3 days in advance, stop eating carbohydrate foods, foods that cause increased gas formation and fermentation in the intestines (brown bread, carbonated water, do not eat vegetables and fruits, kefir, cottage cheese);
  • take a laxative the day before;
  • do an enema in the evening and 3 hours before the examination;
  • take Carbolen or activated carbon, chamomile infusion.

The difficulty lies in the fact that the possibility of complete cleansing depends not only on the nature of the diet, but also on the individual characteristics of the intestines, liver, and age of the patient.

  • For young people, diet is important, for older people with intestinal atony - enemas.
  • Weakened bedridden patients swallow a large volume of air, so they are advised to walk more around the house, in the hospital room.
  • Outpatients are usually better prepared because they are able to move around a lot.
  • It must be taken into account that the use of iodine-containing substances impairs the liver’s ability to absorb intestinal gases.

Your attending physician will tell you exactly how to prepare for the test. There is no general opinion whether it is possible to eat in the morning on the day of the procedure.

Some prefer to do it on an empty stomach, while others do not exclude a light breakfast. This is especially true for children and patients with diabetes. It has been proven that hunger only increases gas formation.

If it is impossible to eliminate gases, there is a method of filling the intestines with water to displace the gas bubble. At the same time, the image of the renal structures improves.

Medical institutions ask you to sign your consent to conduct the study. Before entering the X-ray room, you must remove all metal objects from yourself. They often suggest changing into hospital gowns.

Patients with severe fear and anxiety are given sedatives.

After the procedure, drinking plenty of fluids is recommended to speed up the removal of the contrast agent.

Who is indicated for infusion urography?

Excretory urography of the kidneys and lower urinary organs is prescribed to patients to identify and exclude:

  • congenital anomalies of the urinary system;
  • chronic inflammatory diseases;
  • tumor processes;
  • functional bladder changes in children;
  • urolithiasis with attacks of renal colic;
  • kidney prolapse;
  • hydronephrosis;
  • traumatic injury.

The study is carried out when the patient detects such unclear symptoms as:

  • hematuria;
  • partial or complete blockage of the ureter;
  • unusual kidney mobility.

Contrast urography is necessary in preparation for surgery and for monitoring after surgery.

When and how many pictures to take is determined by the radiologist. They are usually carried out from the first minute, first at intervals of 5-7 minutes, then 12-25 minutes over the course of an hour.

If the drug is administered slowly by drip, then radiographs are taken after 45 minutes or an hour.

When a contrast agent is administered, patients may feel fever, a moderate burning sensation in the vein, and less commonly, nausea or dizziness. Unpleasant symptoms disappear within a few minutes.

What are the contraindications?

Contraindications are associated with a possible reaction to the contrast agent and exacerbation of certain diseases. Similar conditions are possible under:

  • an allergic reaction to the drug identified before using contrast;
  • pregnancy in any trimester;
  • unclear internal bleeding;
  • identifying reduced blood clotting;
  • renal failure with impaired excretory function;
  • acute stage of glomerulonephritis;
  • thyrotoxicosis;
  • pheochromocytoma (adrenal tumors).

Particular attention is paid to the examination of patients with diabetes mellitus taking the drug Glucophage from the biguanide group. It contains the substance metformin, which, when combined with iodine contrast, can cause a sharp increase in the level of lactic acid in the patient’s blood and lead to acidosis.


Glucophage should be discontinued in agreement with the endocrinologist two days before the x-ray examination

For patients with diabetes, it is especially important to ensure that the excretory function of the kidneys is sufficiently preserved so that the contrast is removed from the body in a timely manner.

What to do if urography is contraindicated?

If there are contraindications, the doctor decides to replace the research method with others. Perhaps they will be less informative, but they will be safe for the patient.

In such cases, it is recommended to do an ultrasound examination of the kidneys, computed tomography (CT) or magnetic resonance examination (MR).
The most appropriate method is MRI urography or magnetic resonance layer-by-layer examination of the kidneys.

Competitive survey methods

During magnetic resonance imaging, the organ is exposed to a magnetic field and radio frequency waves. The computer allows you to obtain the required image at different depths.

MRI urography helps diagnose:

  • kidney size, thickness of the cortex and medulla;
  • anatomical structure of the vascular bundle, calyces and pelvis;
  • tissue structure density;
  • cystic changes;
  • tumors;
  • dynamics of cyst or tumor growth;
  • functional ability of the kidney;
  • damage to the urinary tract.

Diagnosis can be carried out both without contrast and with the introduction of a contrast agent. It is believed that the second option improves diagnosis by 15%.


CT scans typically have a superior view with an optimal “cut” at the level of the kidneys

For MRI contrast, agents containing gadolinium salts are used. It is a soft metal with highly soluble salts. Considered to be slightly toxic. It has the ability to penetrate cells and enhance the magnetic signal. Possible application:

  • Premovista,
  • Magnevista,
  • Dotarema,
  • Omniscan.

There is no cross-reaction to iodine. Just as with excretory urography, a skin test is first performed to identify allergies.

The technique has been widely used in the early diagnosis of tumors in recent years. But if there are contraindications to urography, you can trust its results.

Vaccination cystography is chosen by the doctor if a thorough examination of the bladder is necessary. The method involves installing a catheter through the urethra into the ureter and injecting a radiopaque substance into the bladder.


Modern devices allow you to monitor the picture during voiding cystoscopy on the monitor

The first photograph is taken against the background of a filled bladder. The patient is then asked to urinate and a second radiograph is taken along the way.

The method is intended to detect vesicoureteral reflux. During urination, the detrusor muscle tenses and intravesical pressure increases. If the ureteral sphincters are weak and cannot cope with containment, then the contrast rises into the ureters. They are visible in the second photo.

If necessary, only a specialist can choose a method for replacing excretory urography. MRI does not have a radioactive effect on the patient, so it can be used with great indications for examining a child.

Types of urography

To study the patency of the urinary tract, including the ureters, antegrade (descending) and retrograde (ascending) pyeloureterography are used.

Retrograde urography is performed on one side only. Using a cystoscope, a catheter of the required size is inserted into the ureter (taking into account the degree of narrowing). Through it, the pelvis and ureter are carefully filled with a contrast agent. Usually about 5 ml of solution is administered to an adult.

Practice has shown that bilateral catheterization is poorly tolerated by patients due to spasm of the pelvis and calyces. To prevent pain, the solution is preheated to body temperature and administered very slowly.

The images are taken with the patient in a horizontal position on his stomach and back, as well as in a vertical position. This is necessary to completely fill the calyces in all parts of the kidneys.

Features of antegrade pyelography

Antegrade pyelography allows you to examine the upper urinary tract. There are 2 options depending on the method of contrast administration:

  • percutaneous;
  • using pyelo-(nephro)ostomy.

The percutaneous method is indicated when other methods have failed to identify kidney and upper urinary tract disease. For example, if during excretory urography there is no release of a contrast agent due to impaired renal function or if it is impossible to perform retrograde urography due to:

  • reduced bladder size;
  • stone in the ureter;
  • sharp narrowing;
  • compression of the outflow tract by the tumor.

Percutaneous puncture antegrade pyelography is performed mainly when hydronephrosis is suspected, when other diagnostic methods do not provide confidence in the detected pathology. This method allows not only to identify hydronephrosis, but also to detect its cause (stone, scar narrowing, tumor).

Usually, before antegrade urography, survey films and excretory venous urography are performed. They are needed to select the site of puncture of the pelvis.

How is the antegrade urography procedure performed?

The patient is placed on his stomach on an x-ray table. An anesthetic is injected locally into the skin and muscles. Then a puncture needle is made at the projection point of the renal pelvis. To control the position of the needle in difficult cases, an x-ray is necessary.

Another guideline is to obtain colored urine from a syringe when administering a blue indigo carmine solution intravenously 10 minutes before puncture.

Urine is completely removed from the pelvis (it is sent for testing to the laboratory), and a contrast agent in a volume of 10 to 20 ml is injected into the kidney with a syringe.

Images are then taken with the patient lying on his stomach, side and upright.

After that, the entire contents of the pelvis are removed with a syringe and the needle is removed from the body.


After the operation, an artificial nephrostomy is left for the first days for flushing the kidney, introducing antimicrobial drugs into the pelvis and control urography

The introduction of contrast through pyelo-nephrostomy drainage is used mainly in the postoperative period, when the drainage is specifically left in the pelvis for this purpose. The end of the tube is treated with alcohol and secured with a clamp.

Contrast can be administered no earlier than 14 days after surgery. Usually 6–8 ml of solution is sufficient. A larger amount can cause overstretching of the pelvis.

If the tone of the ureters is preserved, then after a minute the contrast agent moves into the lower sections. Delay indicates decreased motor function.

Medical reviews from operating urologists speak about the accumulated experience of performing antegrade percutaneous urography in the diagnosis of polycystic kidney disease and hydronephrosis in children.

The authors describe an interesting diagnostic phenomenon: against the background of antegrade pyelography, doctors observe the excretion of a contrast agent in the opposite kidney after 15–20 minutes. This is explained by the entry of part of the drug into the general circulation and confirms the fairly good excretory function of the other kidney.

What are the advantages of excretory urography and what are the disadvantages?

Excretory urography of the kidneys must be approached with an understanding of its positive and negative properties. When compared with the retrograde method, the following can be considered an advantage:

  • obtaining information about the functional and morphological state of the kidneys on both sides;
  • the same goes for the bladder;
  • no need for preliminary cystoscopy;
  • almost painless form of examination;
  • the ability to examine trauma patients who are in serious condition.


The method of excretory urography is preferable to use in children

After the retrograde method, the following are possible:

  • fever,
  • chills,
  • increased symptoms of intoxication.

The disadvantages include:

  • unclear contrast of shadow images;
  • reduced urinary tract volume;
  • non-simultaneous and uneven filling of the cups;
  • a picture of the ureters “cut out” in sections;
  • inability to detect initial small changes in the structure of the kidneys.

Depending on the completeness and quality of the information obtained during the examination, a diagnosis is made and a treatment method is selected. All of the above methods for examining the kidneys are good in their own way. Patients should remember that it is better to entrust urography to experienced specialists, as well as clinical institutions that diagnose and treat urological pathology.

At the initial stage of diagnosis, many patients are prescribed a survey radiograph of the paired organ and ureteric canals. But this technique only makes it possible to evaluate their location and structure, without giving a specific answer about their functional capabilities. This method of examination helps doctors plan upcoming surgical interventions.

Pyelography is an examination method that can be used to obtain an image of an organ and canals. Often, pyelography is performed when the bladder is examined with an endoscope. In this case, the contrast component is administered using a catheter.

Since methods and technologies have improved, today they are increasingly using other methods of examination - and ultrasound.

How is pyelography performed?

It is more correct to call such a study pyeloureterography, because quite often it is necessary to obtain images of the pelvis and ureteric passages. One of the types of pyelography is pneumopyelography, performed using oxygen or carbon dioxide.

This method makes it possible to identify the presence of negative lesions, new formations and bleeding. In addition, a double contrast technique is used - gas and liquid contrast are used simultaneously.

Today, pyelography is performed in three ways.

Retrograde

In this method, the drug is administered through the ureter using a long cystoscope with a catheter. Today, the same drugs that are administered intravenously are often used, but in higher concentrations, diluted with glucose.

With this research method, the image is contrasted because a highly concentrated composition is used. But it is possible to examine the smallest changes in the kidneys and...

Intravenous

Before performing it, it is necessary to test the kidneys for their functionality. Most likely, you will have to take laxatives or give enemas to cleanse the stomach.

A needle is inserted into a vein, through which a contrast liquid with a medicinal composition is injected. Over the next thirty to sixty minutes, the patient will have to lie on a special table while X-rays are taken. You may need to hold your breath at your doctor's command.

Using a contrast component, the ureteral system will be highlighted. Using this image, a specialist will be able to examine all organs and determine the problem. The procedure ends with emptying the bladder.

Ureteropyelography

With its help, images of the upper ureteric passages are obtained. At the same time, using catheterization to introduce the contrast component. The study uses an iodine-containing composition. It is absorbed in a certain amount into the mucous membrane of the ureteral canal, entering the blood, but is still used for patients with a high level of sensitivity who cannot tolerate the introduction of contrast into a vein.

Note that ureteropyelography is performed in case of uninformative images or their low quality, in case of kidney failure. The main purpose of the method is to assess the anatomical structure and condition of the upper ureteric passages.

Indications for the procedure

It is prescribed for patients in whom a blockage of the ureteral canals is suspected by a neoplasm, calculus, blood clot, or narrowing of the passage.

Pyelography will help evaluate the lower sections of the canals, to which the flow of urine may be difficult. In addition, this method is used to determine the normal location of the catheter or.

The advantage is that the examination can be carried out even if the patient has obvious allergic signs to the contrast agent or impaired kidney function.

Contraindications

There are some factors that can affect the result of the study:

  • gas formation in the intestinal tract;
  • the presence of barium in the gastrointestinal tract from a previous x-ray.

Preparation for pyelography

The specialist will explain the essence of the process and answer all your questions. You will be asked to sign an agreement form, with which you will confirm your consent to this type of research. It is recommended that you carefully study such a document, clarifying obscure points.

You will have to give up food for a certain time, which the doctor will tell you about. By the way, it will not be superfluous if you tell your doctor what medications you are taking today.

If you experience frequent bleeding or use medications that reduce blood clotting, you should also tell your doctor about this. You'll probably have to take a break from this for a while.

If there are some peculiarities in the body or certain diseases, the doctor prescribes preparatory measures taking them into account.

Methodology

The procedure can be performed on an outpatient basis or in a hospital setting. Typically, the study goes like this:


Decoding the results

Under normal conditions, contrast fluid moves easily through the catheter, filling cups and pelvises that have smooth contours and correct dimensions. During breathing, the mobility of the paired organ should not exceed two centimeters.

Incomplete filling of the upper zones of the ureteric passage with contrast, expansion or delayed emptying after removal of the catheter may indicate existing tumors, stones and other obstacles. Deviations in the mobility of the paired organ indicate that pyelonephritis is developing, an abscess has appeared, and is growing. If diagnosed, then expansion is observed.

The results obtained after the examination must be passed on to the attending physician.

Advantage of pyelography

To obtain good quality images, a retrograde examination is performed with the injection of contrast fluid through the ureteral meatus. Using this method, new formations and injuries to the channels for urine output are diagnosed.

In addition, the procedure makes it possible to examine almost all ureteric passages in one session. This allows you to reduce the examination time and reduce the amount of contrast element that is introduced into the human body. As a result, the load on the paired organ is reduced, and the number of adverse reactions associated with allergenic manifestations is reduced.

Complications

Complications may arise due to the radiation exposure the body receives during procedures. Many experts recommend keeping records of such procedures, recording the radiation exposure.

If a woman is pregnant or there is a suspicion of such a condition, then pyelography is not prescribed. The fact is that radiation can cause abnormal development of the fetus.

When contrast is used, the risk of an allergic reaction increases. The patient, who knows his problems, should notify the doctor about this.

People suffering from kidney failure are required to notify a specialist about this. The fact is that the contrast agent can worsen the situation. Pyelography is contraindicated in case of dehydration.

After the procedure, the patient may experience sepsis, infection in the ureter, perforation of the ureter, bleeding, nausea and even vomiting.

After pyelography

You will be monitored by medical staff for some time after this examination. You measure the pressure in the arteries, pulse, breathing. If all of the above indicators are within normal limits, you will be sent to the ward or sent home.

You will have to measure the volume of biological fluid that will be released during the day and monitor its shade (there is a possibility that there will be blood particles in it). A slight redness of the urine is acceptable, there is no reason for concern. An experienced specialist will give you the necessary recommendations that will help in your observations.

You may begin to experience pain while passing urine. At such moments, you are allowed to use painkillers prescribed by the doctor. Do not take aspirin and a number of drugs with similar effects that can increase blood flow. In this matter, it is recommended to strictly adhere to the doctor’s prescriptions.

It is imperative to go to the hospital if you start to worry about:

  • fever or chills occur;
  • redness, swelling, bleeding and other discharge will appear;
  • a feeling of pain will begin, the level of blood in the biological fluid will increase;
  • in the process of emission of urine certain difficulties are experienced.

Taking into account the characteristics of your body, the doctor will prescribe additional research.

Conclusion

It can be concluded that pyelography allows one to evaluate the structure and structural features of the ureteric canals, partially. Using this method, a large number of diseases can be diagnosed. The examination is carried out according to various modifications, which are used in cases where other methods are not suitable due to pathological abnormalities existing in the body.

Urostereoradiography is a method of radiopaque examination of the urinary tract using stereoscopy.

The technique of this study consists of taking two images (after filling the urinary tract with a contrast agent) with the X-ray tube shifted in both directions by a distance of 3-3.5 cm, i.e. 6-7 cm, all other conditions being equal. Both x-rays taken at the angle of vision of the eyes are viewed using a special stereo-negatoscope or stereo binoculars. The difficulty in obtaining perfectly identical two radiographs lies in the existence of dynamic changes in the urinary tract that occur during the time from the first to the second image. This circumstance makes it difficult to obtain a clear stereoscopic effect. However, despite this, urostereography can be very valuable in the diagnosis of various types of urological suffering, such as nephrolithiasis, hydronephrosis, tuberculosis, tumors of the calyces and renal pelvis. Urostereoradiography makes it possible to establish a more accurate localization of the disease process in the kidney, such as a tuberculous cavity, stone, tumor, which is very important for choosing a surgical method of treatment, especially organ-preserving.

Antegrade pyelography

Antegrade pyelography is an x-ray method for studying the upper urinary tract, based on the direct injection of a contrast agent into the renal pelvis either by percutaneous puncture or through pyelo-(nephrostomy) drainage. Consequently, there are two types of antegrade pyelography: antegrade percutaneous pyelography and antegrade pyelography with the introduction of a contrast agent through the pyelostomy. While antegrade pyelography by introducing a contrast agent into the pelvis through a pyelo-(nephrostomy) has been used for a long time, percutaneous puncture pyelography has found its use relatively recently.

The first report on puncture of the renal pelvis with filling it with contrast fluid and immediate pyelography was made by Kapandi in 1949, and Ainsworth and Vest in 1951 proposed using this method in urological practice. In the USSR, the first report on the use of antegrade percutaneous pyelography was made by A. Ya. Pytel in 1956 at the All-Russian Conference of Radiologists and Radiologists in Moscow, and he introduced this method into our practice. Antegrade percutaneous pyelography is indicated in those difficult cases when other methods of urological examination do not allow the recognition of diseases of the kidneys and upper urinary tract. This primarily applies to those diseases in which the excretory urogram does not show the release of a contrast agent as a result of impaired renal function, and retrograde pyeloureterography cannot be performed due to the presence of a small bladder capacity, ureteral obstruction (stone, stricture, obliteration, tumor, periureteritis and etc.). Puncture percutaneous antegrade pyelography is indicated mainly for hydronephrosis, hydroureter, or when these diseases are suspected, when other research methods do not allow a correct diagnosis.

Using percutaneous antegrade pyelography in such cases, it is possible not only to recognize hydronephrosis, but also to find out its cause (stricture, stone, tumor). By combining antegrade pyelography with urokymography, it is possible to obtain an idea of ​​the motor function of the upper urinary tract, which is important for deciding the feasibility of a particular plastic surgery.

Sometimes only thanks to antegrade pyelography it is possible to recognize a neoplasm of the pelvis or a tumor implant in the ureter (Goodwin, 1956; A. Ya. Pytel, 1958; Granone, 1961; Brazilay et al., 1961). Further, antegrade pyelography is indicated in cases where other research methods cannot accurately determine the level of ureteral stenosis, as well as the extent of ureteral obliteration or stricture, which is very important for deciding the type and nature of the upcoming reconstructive operation.

Before antegrade pyelography, a survey image and excretory urography are performed, since with their help the contours of the kidney can be identified, and with some preservation of kidney function, the shadow of the pelvis. Evaluation of these preliminary radiographs in relation to the size, shape and position of the kidney can be significant in choosing the site for puncture of the pelvis.

The patient is placed (on his stomach) on an X-ray table (some foreign urologists perform a puncture of the pelvis with the patient in a sitting position, which we do not recommend). Lumbar puncture of the renal pelvis is performed under local novocaine anesthesia; anesthetize the skin and underlying muscles through which the puncture needle will be passed. Under the XII rib, retreating to the right or left 10-12 cm outward from the midline of the spine, the skin and underlying tissues are pierced with a needle (diameter 1-1.5 mm) from the outside inward and upward towards the medial third of a normally located kidney. If the patient’s kidney is significantly enlarged and therefore can be easily palpated, then it should be punctured in the middle part, medial from its longitudinal axis. Gradually inserting a needle into the depths of the lumbar tissue and creating a vacuum with a syringe, usually at a depth of 9-12 cm (depending on the patient’s fatness and the thickness of the abdominal wall), the renal pelvis is punctured (Fig. 56). As soon as the needle penetrates the pelvis, its contents appear in the syringe - either pure urine, or urine mixed with pus, blood, etc. If urine does not appear in the syringe, you should immediately take an x-ray, which will help you navigate needle location.

Rice. 56. Scheme of puncture of the renal pelvis for antegrade pyelography.

For better orientation and obtaining data on the functional capacity of the kidney, it is advisable to administer 5 ml of 0.4% indigo carmine solution intravenously 10 minutes before puncture of the renal pelvis. The appearance of blue-colored liquid in the syringe indicates a correctly performed puncture and the preserved functional ability of the kidney.

Urine from the pelvis is aspirated and sent for microscopic and bacteriological examination. Then 10-20 ml of a 40-50% solution of sergosine, triyotrast or cardiotrust is injected into the pelvis and the contents of the pelvis are mixed with the contrast agent by moving the syringe piston. After this, X-rays are taken in the prone position. If necessary, X-rays are taken on the patient's side and in an upright position. If hydronephrosis is very large, it may be necessary to inject a larger amount of contrast agent into the pelvis (Fig. 57 , 58 , 59 ).

Rice. 57. Ureterogram. Male 28 years old. Ureteral obstruction. Filling defect of the lower third of the ureter (see fig. 58 ).

Rice. 58. Antegrade pyelogram. Male 28 years old. Giant hydronephrosis due to varicose veins of system v. spermatica int. Nephrectomy. recovery (see fig. 57 ).

Rice. 59. Antegrade pyelogram. Male 47 years old. Obliteration of the ureter. Calculous hydronephrosis. Nephrectomy. Recovery.

However, the amount of contrast agent administered should be 5-10 ml less than the amount of urine aspirated from the renal pelvis. This condition must be strictly observed, since overstretching of the pelvis is dangerous because the resulting significant increase in intrapelvic pressure can cause pyelo-renal reflux and lead to serious complications.

At the end of the study, its contents are aspirated from the pelvis with a syringe, and in the case of infected hydronephrosis, antibiotics are injected into the pelvis after urine is removed. Some foreign urologists remove the needle immediately after introducing a contrast agent into the pelvis, even before the image, and do not aspirate the contents of the pelvis after the X-ray. Using this technique, they observed no complications.

Having experience in performing antegrade percutaneous pyelography in 78 patients, we have never observed any serious complications. This is also supported by literature data from recent years. However, it must be borne in mind that in the first years of the introduction of this method into practice by foreign urologists, complications such as perforation of the renal parenchyma, trauma to the kidney vessels, and erroneous puncture of the liver and spleen were observed during puncture of the renal pelvis. However, if a small-diameter needle is used to puncture the pelvis, usually no serious complications or consequences are observed even with accidental puncture of these organs.

It should be borne in mind that antegrade percutaneous pyelography cannot always be performed, since there may be cases when it is not possible to puncture the pelvis. Thus, Casey and Goodwin (1955) reported that in 7 out of 55 patients they were unable to puncture the pelvis. Among 86 patients, we were unable to puncture the pelvis in 8 people, and in 78 patients the puncture of the pelvis was performed easily. For percutaneous antegrade pyelography, gas (oxygen, carbon dioxide) can be used instead of liquid contrast agents; This study is called antegrade pneumopyelography.

In addition to percutaneous puncture antegrade pyelography, there is antegrade pyelography, when a contrast agent is injected into the pelvis through pyelo-(nephrostomy) drainage. This research method is used in the postoperative period; its results make it possible to judge the morphological and functional state of the upper urinary tract: the size of the pelvis and calyces, their tone, the degree of disturbance in the passage of urine from the pelvis to the bladder through the ureter and its causes, as well as to identify stones that were not accidentally removed during surgery, the location and the extent of the ureteral stricture, etc. If the patient has a pyelostomy (nephrostomy), it should be used to perform antegrade pyelography. This simple research method makes it possible to very often identify certain urinary passage disorders and promptly undertake the necessary treatment.

Antegrade pyelography is usually performed no earlier than 14-15 days after surgery. The peripheral end of the pyelo-(nephrostomy) drainage tube is treated with alcohol and its lumen is closed with a clamp; centrally to the latter, a drainage tube is punctured, through which a contrast agent is injected (usually 6-8 ml). It is impossible to overstretch the pelvis due to the possibility of pyelo-renal reflux and an outbreak of pyelonephritis. After the contrast agent is injected into the pelvis, the patient must take several deep breaths and exhales, and then X-rays are taken.

With good tone of the upper urinary tract, usually within a minute the contrast agent moves through the ureter. If the tone of the upper urinary tract has not yet been restored, which is expressed in a decrease in the motor function of the calyces, pelvis and ureter, the contrast agent penetrates the ureter no earlier than 3-4 minutes. Determining the degree of tone of the upper urinary tract allows the doctor to decide on the time to remove the patient's drainage tube from the kidney and close the nephrostomy. It should be borne in mind that in order to obtain a true picture of the condition of the upper urinary tract on an antegrade pyelogram, the pressure in the renal pelvis when a contrast solution is introduced into it must be threshold, i.e., such that the opening of the ureteropelvic segment occurs and the contrast agent moves along ureter. Because the threshold pressure in the renal pelvis is very close to the pressure above which pyelorenal reflux occurs, it is necessary to very carefully inflate the pelvis during antegrade pyelography. The appearance in the patient of a feeling of heaviness and the slightest aching pain in the lower back when a contrast agent is administered indicates that the pressure in the renal pelvis is higher than permissible and, therefore, is not indifferent. When performing antegrade pyelography, the patient should not experience any discomfort. In order to avoid an increase in intrapelvic pressure above the permissible level during antegrade pyelography, we suggest using a syringe without a piston. The contrast agent from such a syringe penetrates into the pelvis under the influence of gravity and when the threshold pressure is reached, its flow stops. After the renal pelvis has emptied and the pressure in it has decreased, the flow of contrast agent into it from the syringe is resumed. This technique allows you to establish the capacity of the pelvis, avoid a sharp increase in pressure in it and, therefore, prevent the occurrence of pyelorenal reflux and other complications.

Antegrade percutaneous pyelography is also used in children. A. Yu. Svidler and L. I. Sneshko (1961) reported the results of antegrade pyelography in 10 children aged 8 months to 10 years with renal polycystic disease, hydronephrosis of a dystopic kidney, hydronephrosis due to achalasia of the ureter and closed pyonephrosis of tuberculous origin. Of the 10 patients, only one developed a small subcutaneous abscess at the puncture site. The authors believe that antegrade percutaneous pyelography in children, being a safe method, can be used successfully in some urological diseases.

Using both antegrade percutaneous pyelography and pyelography with the introduction of a contrast agent through the pyelo-(nephrostomy) stoma, we have repeatedly observed a peculiar phenomenon - an excretory urogram on the opposite side. Approximately 15-20 minutes after the introduction of a contrast agent into the pelvis of the kidney under study, shadows of the contrast agent appear on the opposite side, which fills the pelvis and calyces of the kidney. This phenomenon indicates the preservation of the fornical apparatus of the kidney under study, which ensures the absorption of the contrast agent into the general circulation followed by its subsequent release by the other kidney. This phenomenon, which confirms the good functioning of the renal parenchyma on the opposite side, is important in assessing the indications for appropriate surgical interventions.

Antegrade percutaneous pyelography is a very valuable diagnostic method when indicated. Antegrade pyelography with the introduction of a contrast agent through the pyelo-(nephro)stomy is of equally great value. Antegrade pyelography does not replace, but complements the basic methods of X-ray diagnosis of diseases of the kidneys and upper urinary tract. However, in some patients, antegrade pyelography is the only research method that allows one to correctly recognize the disease.

Antegrade pyelography provides images of the upper urinary tract in cases where retrograde ureteropyelography is not possible due to ureteral obstruction or when cystoscopy is contraindicated. The study begins with a percutaneous puncture of the pyelocaliceal system, after which a contrast agent is injected into it.

During antegrade pyelography, intrapelvic pressure can be measured, urine can be collected for bacteriological and cytological studies, as well as studies aimed at assessing the reserve capacity of the kidney before the upcoming surgical intervention.

After the X-ray examination is completed, a nephrostomy tube can be inserted into the kidney for temporary drainage or to facilitate other therapeutic or diagnostic procedures.

Target

  • Identify the cause of upper urinary tract obstruction - stricture, stone, blood clot, tumor.
  • Confirm the diagnosis of hydronephrosis based on the results of excretory urography or ultrasound and facilitate the establishment of nephrostomy drainage.
  • To assess the functional state of the upper urinary tract after surgical interventions on the ureter and urinary diversion operations.
  • Assess the reserve capacity of the kidney before the upcoming surgical intervention.

Preparation

  • The patient is explained that antegrade pyelography is an X-ray examination of the kidney.
  • The patient should refrain from eating and drinking for 6-8 hours before the test.
  • The patient should be warned that before and after the study he may be prescribed antibacterial therapy.
  • The patient is informed who will perform the study and where.
  • It should be explained to the patient that before puncture of the renal collecting system, he will be given sedatives and local anesthesia, that the urine pumped out during puncture will be examined, and in order to drain the upper urinary tract, a nephrostomy tube may be left in the kidney.
  • During the administration of local anesthetic and contrast agent, the patient may experience minor discomfort. In addition, during the administration of a contrast agent, a transient burning sensation or flushing of blood to the face may be observed.
  • The patient is warned that during the examination (while taking pictures) he will hear loud clicking sounds.
  • It is necessary to find out whether the patient is allergic to radiocontrast agents, iodine and foods rich in iodine (for example, shellfish). All cases of an allergic reaction must be recorded in the medical history. You should also find out whether the patient has diseases accompanied by increased bleeding.
  • It is necessary to ensure that the patient or his relatives give written consent to the study.
  • Before the procedure, the patient is sedated and all blood tests (including kidney function) are checked.

Equipment

X-ray machine (allowing fluoroscopy), ultrasound machine, percutaneous nephrostomy kit, manometer, surgical field treatment kit, gloves and sterile containers for urine samples, syringes and needles, contrast agent, local anesthetics, resuscitation kit.

Procedure and aftercare

  • The patient is placed on the X-ray table on his stomach. The skin in the area of ​​the intended puncture is treated with an antiseptic solution. Local anesthesia is performed.
  • To determine anatomical landmarks, previously taken x-rays or filmed ultrasound results of the kidney are studied. (This only matters if the kidney is in its usual place. Otherwise, the angle of the needle is corrected during the percutaneous puncture.)
  • Under the control of fluoroscopy or ultrasonography, the puncture needle is passed below the XII rib at the level of the transverse process of the II lumbar vertebra. The discharge of urine through the needle confirms its location in the expanded pyelocaliceal system (in adult patients the needle has to be inserted an average of 7-8 cm deep).
  • To prevent the needle from moving during the examination, a flexible tube is connected to it. To measure intrapelvic pressure, the tube is connected to a manometer. If necessary, a urine sample is taken.
  • To prevent overstretching of the collecting system, a volume of urine is evacuated from it equal to the amount of contrast agent that is planned to be administered.
  • The contrast agent is administered under fluoroscopic control. Pictures are taken in posteroanterior, semilateral and anteroposterior projections. To determine the location and degree of ureteral obstruction, fluoroscopic monitoring of the progress of the contrast agent is performed.
  • When intrapelvic pressure increases, dilation of the upper urinary tract, as well as intrarenal reflux, when drainage of the collecting system is necessary, a nephrostomy tube is installed in the kidney. If there is no need for drainage, the catheter is removed and a sterile bandage is applied to the puncture site.
  • Monitor vital signs for 24 hours (every 15 minutes for the first hour, every 30 minutes for the second hour, then every 2 hours).
  • The condition of the bandage is checked at the same frequency; this is necessary for the timely diagnosis of bleeding, hematoma or urinary leakage. If there is bleeding, apply a pressure bandage. When a hematoma forms at the puncture site, warm compresses are prescribed. If urine continues to leak from the puncture canal within 8 hours after the test or spontaneous urination is absent, you must notify the doctor.
  • Fluid intake and diuresis are monitored for 24 hours. Each urine sample is examined for gross hematuria. If hematuria does not stop after the third urination, notify the doctor.
  • Particular attention should be paid to the appearance of signs of urinary sepsis or reflux of the contrast agent into the systemic circulation (chills, fever, rapid pulse, rapid breathing, arterial hypotension).

Warning. Be alert for signs of possible damage to other organs, including abdominal or flank pain, pneumothorax, indicated by sudden onset of chest pain when breathing, shortness of breath, decreased vocal tremors on the affected side, and tachycardia.

  • When installing a nephrostomy tube, it is necessary to monitor its patency and the adequacy of drainage of the upper urinary tract. Use 5~7 milliliters of sterile saline to flush the tube.
  • After the study, antibacterial drugs and painkillers are prescribed.
  • In patients with hydronephrosis, the amount of fluid drunk and diuresis are taken into account, the dynamics of edema, arterial hypertension, pain in the lumbar region, acid-base balance and blood glucose levels are monitored.

Precautions

  • Antegrade pyelography is contraindicated in patients with bleeding disorders.
  • It is necessary to take into account the possibility of developing an allergic reaction to the administration of a contrast agent.
  • The study is contraindicated in pregnant women, unless its benefits outweigh the risk of complications in the fetus.

Normal picture

In the absence of pathology, after the administration of a contrast agent, the upper urinary tract is filled evenly, has clear, even contours and normal dimensions, the ureter has a normal course.

Deviation from the norm

Dilatation of the upper urinary tract indicates the presence of obstruction in the underlying sections. Antegrade pyelography allows you to determine the severity of dilatation, the level of obstruction and the presence of intrarenal reflux. With hydronephrosis, a narrowing of the ureteropelvic segment and an expansion of the pyelocaliceal system are noted. The method also allows one to obtain a clear image of the upper urinary tract after recent surgery (for example, visualization of a ureteral stent or prestenotic dilatation). Intrapelvic pressure exceeding 20 cm of water. Art., indicates obstruction. The results of bacterial or cytological examination of a urine sample obtained during antegrade pyelography can confirm the diagnosis of pyelonephritis or tumor.

Factors influencing the result of the study

  • The presence of gas and feces in the intestines or residual contrast with barium after an X-ray examination of the gastrointestinal tract (poor image quality).
  • Obesity (poor image quality).

B.H. Titova

"Antegrade pyelography" and others