Technique’exploration of’Urinary System

I- INTRODUCTION :

• The technical exploration of the urinary tract are many
• They are essential before any urinary symptoms , because the clinical examination is still insufficient
• The ultrasonnographie is 1 examination of the^time intention
• The ASP is indicated as an adjunct to ultrasound to search for a particular stones
• L 'UIV , has long been the gold standard for exploring the urinary tract , CT urography is today become the key consideration
• MRI or uro MRI is an alternative to other imaging techniques in case of against-indications to CT urography and child
• Cystography is indicated for the search for’an R VU and for the study of Vureter
• Endoscopic explorations , isotopic and urodynamic complement V imaging data

II- ANATOMICAL RECALL :

III- TECHNIOUES :

1- ASP or AUSP :

• • Directed supine (DD) face on a large-format photograph
  • After complete evacuation of the bladder.

• Success Criteria :

– Good visibility of the outside edge of the psoas
– Lack of motion blur : sharpness of intestinal gas
– Visibility of kidney or upper poles 11^th articulations cost – vertebral
– Visibility of the lower edge of the pubic symphysis

• Scans :

– T he two renal silhouettes (situation , cut , contours).
– outer edges of the psoas (visible D12 – L1).
– distribution of digestive lights.
– bone frame : metastasis, trauma.

• especially noted in the stone disease (Search abnormal opacity in projection of the urinary tract (reins, bassinet, ureters, prostate).

2- ULTRASOUND -DOPPLER :

• exam 1 intention :
• available , harmless , cheap, repetitive. .
• Can be performed in emergency, in children, the pregnant woman +++.

• Analysis :

– reins: form , cut , situation , echostructure
– parenchyma, CPC.
– bladder: repletion, empty.
– prostate and vesicles
– ureters : not visible (lumbar and pelvic)
– urethra : non visible.
– kidney vessels or vascularization of masses : DOPPLER
– jets urétéraux;

• Examines the nature of a solid or liquid mass.
• Highlights calculations (especially transparent radio).
• Lets make further consideration : oranges Neighborhood.
• Surveillance, control.
• Puncture, drainage.
• Limits :

– operator dependent
– gas, obesity
– unappreciated renal function

NB : several surgical approaches for bladder : suprapubic , endocavitaire (endovesical , endorectale endovaginale)

3- UROGRAPHY INTRAVENOUS (UIV) :

• Long regarded as the gold standard of the urinary tract ,she is dethroned by uroTDM
• functional and morphological examination

a- PRINCIPE :

• injecting a contrast medium into a peripheral vein iodine which is eliminated by the kidney allowing to opacify urine
• allows a detailed study of the renal parenchyma and excretory cavities,

b- CONTRAINDICATIONS INICATIONS :

• Renal failure: may aggravate IR
• Pregnancy : prefer 1^Ere half of the cycle.
• Intolerance iodine.
• myeloma : moisturize the patient : prevent the tubular precipitation of the protein Bence Jones

c – TECHNIQUE :

→ Preparation of the patient :

• young 12 H with fluid restriction.
• ATCD patient , premedication if allergy.

→ Review itself :

• after previous urination, ASP is conducted face.
• injection IV (large vein) a water soluble triode PC : 1-1.5 cc / kg bolus (10ml /s).
• taking photographs :

* Néphrotomographie
– Nephrography early cortical : 15-20 s
– nephrography tubular : 40-60 s
* Cliché secretion : PC level caliceal cups : 3^th mn
* morphological cliché ( excretion) : Urogrammes
– 5-10-15 -20 mn : Study of CPC , ureters , of the bladder begins to fill
– disposal of excretory cavities : compression and decompression outside the IC ( syndrome obstructif, recent abdominal surgery , … )
– sometimes late shots : syndrome obstructif
* Study of the bladder : Cystogramme ( descending cystography) :
– repletion : 30-45mn
– shot per micturition (cervical opening, urethra)
– postvoid cliché

d- DISADVANTAGES :

• review radiating
• Do not detect small renal and ureteral tumors
• Does not differentiate a solid tumor and a cyst

4- UCR :

• Complementary to the UIV
• ascending cystography
• Technique :

– catheterization (women) ou urethral (man) after rigorous aseptic

– PC triode injection solution
– Taking photographs (repletion , per micturition, post micturition)

• Must be done outside of any infection (sterile urine culture )
• Indications :

– Reflux vesico urétéral :RVU +++
– Bladder, urethra

5- UROSCANNER :

• Currently regarded as the test of choice
• noninvasive method
• Provides a comprehensive study of the urinary tract

– morphologic : reins , excretory tract
– functional : excretory different phases

• comprehensive study of the AP cavity
• More

– review radiating : limit the protocol especially in children
– several Constraints:
* Anatomical and physiological VE: as peristalsis ureteral, complex anatomy
* opacification Quality : depends on renal function, concentration , …

a- AGAINST- INDICATIONS : idem UIV

b- TECHNIQUE :

• Preparation : avoid digestive opacification, satisfactory hydration
• Injection ftirosémide : HYPERDIURESE

– PC Dilution (decrease artifacts) ; distension of the urinary tract
– CI: Congestive heart failure, Prior diuretic therapy, dehydration, renal colic

• Different phases of acquisition : protocol 4 phases :

– without injection : detection calculations (but unsystematic), des calcifications (or renal tumor), base density solid masses
– Cortico-medullary (25 at 80 sec after injection ICH): detection of vascular abnormalities or hypervascular lesions especially in pre-surgical
– nephrographic (85 at 120 sec) : Detection and characterization of renal masses
– Excretory (3 at 15 me): excretory pathway analysis →→ mandatory stage

• other protocols ( Simplified or variants) :

– A single injection with 3 acquisitions
– A single injection with 1 excretory acquisition
– Double injection combining nephrography (2it is bolus) and excretory stage (1^is bolus)
– Triple injection combine corticomedullary stage, nephrographic and excretory

c -INDICATIONS :

• hematuria
• Suspicion of urothelial tumor
• etiologic hydronephrosis
• Balance of stone disease ( multiple stones and recurrent)
• renal or ureteral trauma
• Control of surgical assemblies
• Review of complex urinary tract infections

6- IRM / CLOCK IRM :

a- INTEREST :

• non-invasive, non-radiating
• Exploration of a review : vessels, parenchyma , AND

b- INDICATIONS :

• child ; pregnant woman , silent kidney, CI PCI

c- DISADVANTAGES :

• Expensive, few available.
• Review lengthened in time
• Respiratory artifacts and ureteral peristalsis

d- CONTRAINDICATIONS : see during MRI

e- TECHNIQUE :

→ 2 types of sequences :
– spontaneous contrast in sequence (urine)
* Interest kidney if silent
* Morphological study of VE
– Sequence with Gadolinium
* morphological and functional information

7- OTHER EXPLORATION AND REVERT antegrade :

• Ufri : retrograde urétéropyélographie.
• PR : retrograde pyelography.

(opacification VE from a probe placed ureteral meatus or in the pelvis).

• antegrade pyelography : opacification of VE higher by direct puncture of the renal pelvis.

8- EXPLORATIONS VASCULAR :

• AngioTDM
• Angio IRM
• renal arteriography.

9- INTERVENTIONAL RADIOLOGY :

• Puncture for diagnostic purposes (Ultrasound-guided, scannographie).
• Puncture therapeutic (drainage by percutaneous nephrostomy, drainage of an abscess, dilation of ureteral stenosis,…)

10- EXPLORATIONS ISOTOPIOUES : SCINTIGRAPHY : renal function

11- EXPLORATIONS URODYNAMIOUES

IV- etiologies :

1- BIRTH DEFECTS :

• Syndrome junction.
• renal ectopia.
• ureteroceles.
• megaureter.
• Valves of the posterior urethra.

2- STASIS SYNDROME : (obstructive or not)

• diagnostic.
• level.
• cause: RVU, gallstone, tumor, TBC,…
• impact on the renal parenchyma.

3- TUMORS :

• kidney and urothelial malignancies
• benign tumors.
• cysts.

4- PATHOLOGY gallstone

5- INFECTIOUS DISEASES :

• Specific : TBC.
• No specific banal germ : PNA ,
• pyonephrosis, cystitis.
• Abscess

6- TRAUMA

Course of Dr A. Acheuk-Youcef – Faculty of Constantine