X-ray examination of the genitourinary system

Preparation of the patient for x-ray study of the kidney and upper urinary tract: the night before and the day of the examination - cleansing enema, on the morning of the study - a light Breakfast. Before x-rays of the bladder rather one morning enemas. Young people with good self defecation special preparation is not required.
Overview radiography. X-ray examination of the patient start with a review x-ray of the entire urinary system. Produce a snapshot of the kidneys, ureters, and bladder. In addition to bone skeleton, to survey the picture in most cases, you can see the form and the location of the kidneys, the lumbar region muscles (Fig. 37,). Radiography makes it possible to identify the stones of kidneys, ureters, bladder, prostate, urethra. Oxalates, phosphates and especially carbonates detain an x-ray to a much greater extent than the surrounding tissue, and therefore contribute clearly (Fig. 37, b), urates, xantinove, cystine stones give a faint shadow or not visible on survey images.

the kidneys and ureters
Fig. 37. Review x-rays of the kidneys and ureters (a), the shadow of kidney stone on the radiograph (b).

Stone-like dimming can be caused calcified areas veins - phlebolith (mainly in the pelvis), costal cartilage and lymph nodes. Mistake can be mistaken for stones encrusted with salt caseous lesions of the collapse of tuberculosis of the kidneys or calcified areas tumors. To distinguish this "false" shadows in the image of stone ureter, produce General view in direct and oblique projection when introduced into the ureter the catheter. Shadow stone coincides with the shadow of a catheter in both projections, the shadow of phlebolith, lymph node, etc., is located away from him.
Contrast radiography. The image of the renal pelvis and cups (pielografia) is obtained by filling their contrasting environments that delay x-ray to a greater extent than the surrounding tissue (solutions of iodine compounds)or less (oxygen, carbon dioxide).
Retrograde pyelography. After the introduction of a ureteric catheter into the renal pelvis 10-20-gram syringe with needle of appropriate gauge slowly injected through the catheter into the pelvis warmed to body temperature sterile 20% solution of contrast fluid (Sergazin, orochon and others) as 8-10 ml before the feeling of gravity in the area of the kidneys and produce x-ray.
In order to avoid an excessive increase of vnutriorgannogo pressure and cause pelvic-kidney reflux should not use ureteric catheter thicker № 5 on a scale of charger to contrast the fluid to drain back from the pelvis passing a catheter in the bladder.
To prevent attacks of pyelonephritis after retrograde pielografii it is recommended that intramuscular injection of 200 000 UNITS of penicillin.
Normal pyelogram is represented in the following form: the pelvis is located at the level of XII thoracal - II lumbar vertebra, cups situated laterally from the pelvis, XII edge crosses the left pelvis in the middle part of it, and the right on the border of the upper and middle third. The ureter is parallel to the spine, forming in the pelvic Department arc which is convex in the lateral direction.
There are two main types of the renal pelvis. The first type - ampoule-shaped pelvis relatively large size with three short and wide cups - top, middle and bottom, the pelvis is out of the renal parenchyma, medial from it; its capacity is approximately 8-10 ml In the second, branchy, the type of pelvis it is not particularly large, cups long, narrow; the pelvis is located inside the renal parenchyma (Fig. 38); capacity does not exceed 3-4 ml

vnepochechny and vnutripechenochny type renal pelvis
Fig. 38. Vnepochechny (right) and vnutripechenochny (left) type of the renal pelvis. Retrograde pyelogram.

Excretory urography. Along with retrograde pielografia widespread excretory (top-down, excretory, intravenously) urography. In the veins entering the solution of organic iodine compounds - monatomic (sergazina), diatomic (cardiotest, diodon), triatomic (tritryst), the molecule of which is excreted by the kidneys without removal of free iodine, causing the defeat of the urinary tract and the phenomenon yodizma. The contrast agent fills the renal pelvis and is allocated on the ureter into the bladder. On serial shots at certain intervals obtained images of all these divisions urinary tract (Fig. 39). Intravenous urography is most often used Sergazin (monoiodotyrosine sodium)containing 52% organic iodine (15-20 g of dry product for adult). Heated 40% solution of sergazina in the amount of 30-40 ml injected slowly into the cubital vein. The first picture makes 7-10 minutes, re - 15-20 and 30-45 minutes after administration of contrast agents. Dose of sergazina for children is determined by age: 0.1 g dry preparation of 1 year of a child's life.

excretory programme
Fig. 39. Excretory programme.

Excretory urography has a number of positive aspects: it is painless, does not require cystoscopy and urethral catheterization. It gives the impression not only of morphological picture of the urinary tract, but allows to judge about the function of each kidney in isolation, but by definition image often inferior retrograde pielografii, especially with reduced kidney function.
Excretory urography is contraindicated in acute liver disease, blood disease, basemovil, during menstruation, high azotemii.
Prewmarin and pneumotropica. If to surround the kidney layer of gas, you can get in the picture clear outlines of her. Gas in the amount of 500 to 600 cm3 enter through a long needle, which are injected into the corner between the XII edge and long muscles of the back when the patient on the opposite side. Technique of introducing needle same as when perinephral blockade. After going through the muscle wall, needle like dropping in and gets in okolopochechnuyu fibre. Avoid air embolism wait for 1-2 minutes, not whether there will be blood from the needles. This method is called "pneumoina". It is not quite safe, because the needle can injure large vessels, kidney, liver, spleen. In view of this, it is preferable to enter the gas, i.e. between the coccyx and the rectum ("the Pnevmostroimashina"). Under the control of the finger inserted into the rectum, the needle is injected to a depth of 4-5 cm, and after it enter 1000-1500 cm3 gas that within 30-40 minutes spreads retroperitoneal the tissue surrounding the kidney and ureter. Advantages of Pnevmostroimashina its safety, simplicity and in the fact that it gives an opportunity to get on the x-ray at the same time the image of both kidneys (Fig. 40). It is recommended to enter the air and oxygen, which is easily absorbed by hemoglobin, forming oxyhemoglobin. Detection of tumors and cysts of kidneys, adrenal tumor and retroperitoneal space, as well as renal anomalies, pneumotropica provides valuable data, especially in complex with pielografia.

Fig. 40. Pneumotropica.

Angiography of the kidneys. Diagnosis of kidney disease in some cases it may be refined through a serial renal angiography. Contrast liquid - 70% solution of tritryst or cardiotest in the quantity of 30 ml is injected into the aorta by translumbalno puncture or through a polyethylene catheter, retrograde entered into the aorta via Nude branch femoral artery (a. profunda femoris) or by percutaneous puncture femur artery (the Seldinger). The introduction of contrast fluid and images should be done with great speed (not less than 3 shots per second).
The first photo is made at the end of the introduction of a contrast solution, the next 2-3 pictures in the next second. The first picture is arteriogram - the image of the vascular network buds (Fig. 41), the second and third - programmah, - besides, visible and in the shadow of the kidneys, diffuse saturated by contrast agent, in the later image Cup-pelvis system and ureter - programme.

translumbalna angiography kidney
Fig. 41. Translumbalna angiography kidneys. Normal angiogram. Vascular phase.

Renal angiography can be applied for diagnostics of anomalies, tumors and cysts of kidneys. Accumulation of contrast fluid 6 spots and excessive branching small vessels are considered a sign of a tumor (see Fig. 104); rounded avascular area indicates the presence of cysts in the kidneys (see Fig. 60), the absence of major vessels of kidneys - on their atresia and congenital aplasia kidneys.
Lymphography. For detection of metastases of malignant neoplasms of the urogenital system - testicles, prostate, bladder, kidney - groin and retroperitoneal lymph nodes is used lymphangiography. In the skin interdigital folds between I and II finger each foot inject 0.5 ml colors (Blues Evans). After a few minutes happens staining lymph vessels stop. In the middle third of each rear feet under local anesthesia painted over lymphatic vessel cut through the skin. Thin forceps vessel allocate, bring it on a thin thread and pulling it, create the lymph and expansion vessel. In the advanced section of the vessel through a thin needle slowly over 3 hours to enter and 10 ml yodolipola. Regularity and duration of administration is achieved by the fact that the pressure on the piston of the syringe is carried out using the screw from a thin thread. Filling inguinal and retroperitoneal lymph nodes yodolipola comes through 20-24 hours. Lymph nodes metastasis of tumor, enlarged, they are determined filling defects or uneven accumulation of contrast agent (Fig. 42).

limforum when bladder tumors
Fig. 42. Limforum when bladder tumors.

Tomography. X-ray diagnostics of diseases of kidneys, urinary tract and adrenal complemented by layer-by-layer x-ray pictures - tomography. The kidneys are located in the layer removed on average 5-10 cm from the plane of the x-ray table when the patient on the back. Election radiography only this layer are removed layering shadow of the abdominal wall and intestines and other organs. Thanks to the contours of the kidneys and adrenal glands become more clear. Tomograms found sometimes stones or tumors of the kidneys that do not show up on regular shots. Tomography allows you to easily differentiate stones kidney stones, gall bladder, because they are located in different planes.
Cystography. During the filling of the bladder solution sergazina or gas (oxygen) can be obtained on x-ray image of its cavity. This method is called cystography.
In norm the bubble is filled by contrast agent, has a round shape; the density of a contrast medium is the same. Bladder smooth contours (Fig. 43).

normal zitohroma
Fig. 43. Normal zitohroma.

Urethrography. Patient is placed under the angle of 30 degrees to the plane of the table. On the side, rejected from the table leg stretched out on the adjacent table - bent in the hip and knee joint and several designated outwards. Penis stretches parallel to the soft tissues hips bent leg, and 10% solution of sergazina from a syringe with tapered rubber tip enter into the lumen of the urethra (Fig. 44). This urethrography called ascending.
In norm the front part of the urethra at the retrograde urethrogram represented as a uniform strip diameter 0,8-1 see Bulbous part of the urethra forms expansion in the form of convex downward arc. Membranous and prostatic of the urethra have as a narrow strip extending from bolotnoe the urethra at the right angle.
For a clearer image of the rear of the urethra applies downward urethrography: the bladder through a thin catheter is filled by contrast agent; the removal of the catheter in the moment "voiding", i.e. releasing contrast fluid with the position of the patient in the above position, is shot. The lumen of the prostatic urethra descending urethrogram clearly outlined (Fig. 45, a and b).

rising urethrogram
descending urethrogram
Fig. 45. Urethrogram. a - rising urethrogram; b - falling urethrogram

Most often urethrography applies for recognition of the contractions and obliterate urethra (gonorrhea, and traumatic origin) (see Fig. 131). It also allows you to get the image diverticula and urethral fistulas, parauretral moves.

Fig. 44. The position of the patient when urethrography.

Prostatopathy. A normal prostate gland through an x-ray is not outlined on the background of surrounding tissues. Only the stones of it, usually multiple, in the form of small shadows stand out against the pubic bone or above the edge of the symphysis (see Fig. 99).
Filling bladder oxygen, can be seen jutting out into the bladder cavity above the symphysis shadow prostatic hypertrophy (see Fig. 119).
Vesiculography (Fig. 46). Configuration changes seminal vesicles - extension of tunnels and cavities, zapustevanie or puckering their relevant for the detection of tuberculosis or cancer of the seminal vesicles or prostate. For the study makes a puncture naked essentially duct and enter 3-4 ml of 30% yodolipola in the seminal vesicles.

normal left vesiculography
Fig. 46. Normal left vesiculography.