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 thetime 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 11th 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 1Ere 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 :
– Nephrography early cortical : 15-20 s
– nephrography tubular : 40-60 s
* Cliché secretion : PC level caliceal cups : 3th 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
– 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 (1is bolus)
– Triple injection combine corticomedullary stage, nephrographic and excretory
c -INDICATIONS :
- 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 :
- 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.
- Valves of the posterior urethra.
2- STASIS SYNDROME : (obstructive or not)
- cause: RVU, gallstone, tumor, TBC,…
- impact on the renal parenchyma.
3- TUMORS :
- kidney and urothelial malignancies
- benign tumors.
4- PATHOLOGY gallstone
5- INFECTIOUS DISEASES :
- Specific : TBC.
- No specific banal germ : PNA ,
- pyonephrosis, cystitis.
Course of Dr A. Acheuk-Youcef – Faculty of Constantine