Antegrade pyelography

Author: Mikael Häggström

File:Antegrade pyelogram of grade III hydronephrosis with obstruction at the ureterovesical junction.jpg

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Preparation

The procedure can be started in supine position. It can be done in a clean technique (not necessarily sterile) with gloves and radiation protection.

• Generally use low radiation dose fluoroscopy with normal dose single projections.
• Close any indwelling urinary bladder catheter in order to detect any contrast ending up in the bladder.

Procedure with established nephrostomy

• Take an initial anteroposterior image including the presumed locations of the kidney, ureter and urinary bladder.
• Infuse iodinated contrast, usually at least a volume corresponding to about 15 ml of 240mg/ml iodine. Observe both the imaging and whether the patient develops flank pain. Optionally, note how much contrast has been infused at that point.
• Note the following:

• Location of the tip of the catheter in the kidney
• Any visible hydronephrosis or hydroureter
• Any contrast outside the catheter or urinary tract, including leakage along the outside of the catheter
• Flow into the urinary bladder (see below if none).

If contrast does not reach the urinary bladder

Infuse as much contrast as still comfortable by the patient. Observe the most distal part reached by contrast, and the shape thereof. Zooming in on this segment may detect subtle passage. Also turn your eye to the nephrostomy for leakage.

Obtain new projections after:

• Having the patient in a more standing position.
• Having the patient cough.

Report

The report may be a chronological description of the procedure, and should include:

• Catheter tip location
• Any visible hydronephrosis or hydroureter
• Location of the most distal part reached by contrast
• Even absence of leakage

Optionally also:

• Shape of the most distal part reached by contrast.
• Volume of contrast infused.
• Provocation with standing or coughing.

File:Antegrade pyelogram of grade III hydronephrosis with obstruction at the ureterovesical junction.jpg The tip of the nephrostomy is located in an inferior calyx. Approximately 50 ml of contrast is infused, whereupon the patient feels flank pain. There is grade III hydronephrosis and hydroureter, with tapering at the ureterovesical junction, and no contrast in the bladder. No leakage.