Procedures Unit 3: The Urinary System
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The kidneys and ureters are located in the ____________ space.
What glands are located directly superior to the kidneys?
suprarenal or adrenal glands
What is the specific name for the mass of fat that surrounds each kidney?
perirenal fat or adipose capsule
What degree of rotation from supine is needed to place the kidneys parallel to the film?
Which two bony landmarks can be palpated to locate the kidneys?
the xiophoid process and the iliac crests
Which term describes an abnormal drop of the kidneys when the patient is placed erect?
A buildup of nitrogenous waste in the blood is called:
The longitudinal fissure, found along the central medial border of the kidney, is called:
The peripheral or outer portion of the kidney is called:
What is another name for the glomerular capsule?
the Bowman's capsule
The term that describes the total functioning portion of the kidney is:
the renal parenchyma
Which structure of the medulla is made up of a collection of tubules that drain into the minor calyx?
the renal pyramids
Which two processes move urine through the ureters to the bladder?
peristalsis and gravity
What is the name of the junction found between the distal ureters and the urinary bladder?
Which one of the following structures is located more anteriorly?
A. Proximal ureters
B. Urinary bladder
C. Suprarenal glands
A. Proximal ureters
(this multiple choice question has been scrambled)
What is the name of the small gland found just inferior to the male bladder?
The total capacity for the average adult bladder is:
What two ways is contrast administered in urography?
intravenous injection and catheterization
The normal creatinine level for an adult should range between:
Normal BUN levels for an adult should range between:
Glucophage is a drug that is taken for the management of:
True/False: Urticaria is the formal term for excessive vomiting:
false (it is the term for hives)
A reaction, based on fear or anxiety, is called:
The leakage of contrast media from a vessel into surrounding tissue is:
extravasation or infiltration
For most IVU’s, veins in the _________ are recommended for venipuncture.
True/False: The bevel of the needle needs to be facing downward during the actual puncture into a vein.
false (it should face up)
Which specific aspect of the kidney is visualized during an IVU exam?
the collective system of the kidney
The term for voiding is:
The inability to urinate is:
True/False: If an IVU and BE are both scheduled, the IVU should always be performed first.
True/False: A retrograde urogram examines the anatomy and function of the pelvicalyceal system.
false (it is a non-functional exam)
True/False: The Brodney clamp is used for male and female retrograde cystourethrograms.
false (males only)
What kVp range is recommended for an IVU?
How many tomograms are usually produced during an IVU?
Where is the CR centered for a nephrotomogram?
midway between the xiophoid process and the iliac crest.
Which specific position, taken during an IVU, will place the left kidney parallel to the film?
RPO 30 degrees
At what stage of an IVU is the renal parenchyma best seen?
within one minute following the injection
Which position will best demonstrate possible nephroptosis?
How will an enlarged prostate appear on a post void radiograph taken during an IVU?
the prostate gland will indent the floor of the bladder
What specific anatomy is examined during a retrograde ureterogram?
primarily the ureters
What CR angle is utilized for the AP projection taken during a cystogram?
10-15 degrees caudal
Which specific position is recommended for a male patient during a voiding cystourethrogram?
30 degree RPO
What 6 structures make up the urinary system?
2 kidneys, 2 ureters, 1 urinary bladder, and 1 urethra
What is another name for the entire urinary system?
the excretory system
How much urine does the average adult excrete in a day?
What is referred to as the excretory ducts?
the 2 ureters, the urinary bladder, and the urethra
What are the 3 main functions of the urinary system?
- removing waste products from the blood
- maintaining fluid and electrolyte balance
- secreting substances that affect BP
What occurs when waste products build up in the blood?
uremia (also known as blood poisoning)
What 4 structures make up the excretory system?
- pelvicalyceal system (calyces of the kidneys)
- urinary bladder
What is the voluntary emission of urine?
What is the involuntary emission of urine?
What is the function of the adrenal glands and where are they located?
they are retroperitoneal endocrine glands that furnish epinephrine and cortical hormones also known as the suprarenal glands. they are located on top of the kidneys.
True/False: The suprarenal (adrenal) glands can be seen radiographically.
What organs are retroperitoneal and are located posterior to the liver and spleen?
Give the dimensions of the kidneys.
4-5 inches long, 2-3 inches wide, and 1 inch thick
Which kidney is longer and narrower than the other?
From what vertebral level do the kidneys extend?
Describe the shape and orientation of the kidneys.
- they are convex anteriorly and posteriorly
- concave on the medial side
- convex on the lateral side
- the medial side is anterior to the lateral side
- they are angled 30 degrees posteriorly
Why would you place the patient prone during an IVU?
to utilize gravity and push a kidney stone through the ureter (because it curves anteriorly)
What 2 things may cause the kidneys to drop about 2 inches?
- an upright position
Describe the orientation of the ureters.
- exit the kidneys on the medial side
- are anterior to the kidneys
- enter the bladder on the posterior lateral sides
What is the functional unit of the kidney?
What takes place in the nephron and about how many does each kidney have?
- urine is filtered and formed
- about 1 million
Where do the collecting ducts of the nephron empty into?
the renal pyramids
How long after contrast is injected are the nephons full?
How long does it take for a patient to filter our 60 cc of contrast?
What is the condition of the kidney not filtering, causing swelling?
What are the 3 normal ureter constrictions?
- ureteropelvic junction
- brim of the pelvis
- ureterovesical junction
Where does the renal pelvis become the ureter?
at the ureteropelvic junction (UP junction)
Where do the ureters enter the bladder?
ureterovesical junction (UV junction)
What is the most common site for kidney stone impaction?
the ureterovesical junction
What is the collapsable reservoir for urine?
the urinary bladder
What structures form the trigone?
the ureteral openings and the apex or neck of the bladder
How far apart are the ureteral openings in the bladder?
about 1 inch apart (the bladder can stretch, spreading them further apart)
Where do you measure for tomos and with what?
- midpoint between the xiophoid process and crest, down midsaggital plane
How do you determine the fulcrum level for a tomo?
measure in cm with a caliper and divide by 3
Describe the first cut of a tomo.
- the first cut is the deepest
- most posterior
The passageway to the exterior of the body (for urine):
What controls the flow of urine?
a sphincter at the neck or apex of the urethra
Give the approximate lengths of the urethra, both genders.
- 1 1/2 inches- female
- 7-8 inches- male (3 sections)
Name the 3 sections of the male urethra and their location.
- prostatic urethra, proximal (1 inch, surrounded by prostate)
- membranous, middle (1/2 inch, passes through urogenital diaphragm)
- spongy, distal (the shaft of the penis)
Which procedures of the urinary system require the use of an artificial contrast medium?
What must always be done prior to injection of contrast medium?
a scout film
Name some purposes of a scout film.
- ensure gas and fecal matter are cleared away
- dectect abnormalities (kidney stones)
In what are the kidneys enclosed?
a dense fatty capsule (perirenal fat or adipose capsule)
Name four common ionic contrast mediums and when they are used.
- conray 30
- conray 43
- reno 30
- reno 60
- usually for retrograde studies
Name two ways contrast can be injected into the vein.
A procedure in which contrast is injected into the renal artery:
What is a benefit/function of a renal arteriogram?
demonstrates the kidney's blood vessels and the adrenal glands
Name three non-ionic contrast mediums and when the are used.
- omnipaque (multipurpose)
- visopaque (lower osmolality, less likely to cause a reaction)
- optiray 350
_________ contrast administration allows the contrast to enter the kidney in the same direction as normal blood flow.
_________ contrast administration allows contrast to move against the normal blood flow.
A procedure in which a long thin needle is used to make a direct injection into the pelvis of the kidney through the abdominal wall:
- percutaneous antegrade urography
- usually done under CT guidance, risky, not done often
What does IVP stand for and give two alternate names.
- intravenous pilogram
- IVU- intravenous urogram
- XU- excretory urogram
A procedure that is a functional study of the urinary system through intravenous contrast administration:
During an IVU, contrast is filtered as a waste product by the ____________ and filtered through the urinary system making it radiopaque.
A procedure that is a non-functional study of the urinary system.
- retrograde urography
- example: cystogram
What three projections are routinely taken during a retrograde urogram?
- pilogram (contrast filling renal pelvis)
- urogram (ureters)
Name the advantage and disadvantage of a retrograde urogram as opposed to an IVU.
- advantage: better anatomic detail, contrast isn't diluted by urine
- disadvantage: does not show function
Name a urinary system procedure that is usually done in surgery by the urologist.
Name a study of the urinary system that includes only the bladder and it's main purpose.
- to see the place where the ureters inter the bladder (ureterovesical junction)
Name projections normally taken for a cystogram and why.
- AP of bladder
- both obliques (40-60 degrees)
- obliques are dones to see the entrance of the ureters into the bladder, posterior
A urinary system study that is an exam of the bladder and the lower ureters:
A urinary system study taht is an exam of the bladder and the urethra:
Describe steps of a cystourethrogram that are specific for a male patient.
- a bolus is used to inject contrast through the urethra (not drip)
- 30 degree RPO
- Brodney clamp used on distal end of penis, which is positioned over soft tissue of leg
__________ contrast media is more likely to cause a reaction than ___________ contrast because it ____________, but both contain ____________.
- disassociates (breaks apart)
Name some mild reactions to contrast injection.
nausea, vomiting, urticaria (hives), itching, sneezing, extravasation, vasovagal response (fear induced)
Name some moderate reactions to contrast injection.
excessive urticaria (hives), tachycardia, giant hives, excessive vomiting
Name some severe reactions to contrast injection.
very low BP, cardiac or respiratory distress, loss of consciousness, convulsions, laryngeal edema, cyanosis, SOB, shock
What should be done for patients who have had previous reactions to contrast media?
sometimes sedated and given benedryl or epinephrine before injection
Name two common side effects of contrat media injection.
- temporary hot flash
- metallic taste in the mouth
How long should glucophage be witheld after contrast injection?
48 hours (when lab values are normal again)
List patient prep steps for urinary studies.
- mild laxatives (dulcolax pack)
- light supper, then NPO after midnight
- good hydration
A form of bone and bone marrow cancer that causes lesions in the kidneys:
What should patients with ongoing kidney issues do prior to a urinary study?
drink 8-10 glasses of water several days prior to the procedure
What is the purpose of compression during a urinary system procedure?
- to keep the proximal areas full of contrast (usually over ASIS area)
- also Trendelenburg position
Name some contraindications for compression during urinary system procedures.
- urinary/kidney stones
- abdominal mass or aneurysm
- suprapupic catheter
- traumatic injury
Describe differences in shielding according to gender.
- male patients: all exams, except of the urethra
- female patients: ususally not shielded due to anatomy
- pregnant females: exam is limited
Always do ____________ procedures before ____________ procedures.
Name some indications for an IVU.
to evaluate masses, cysts, tumors, kidney stones, UTIs, hydronephrosis, effects of trauma, renal hypertension, pre-operative evaluation
What is urolithiasis?
Chronic or acute infection of the upper urinary tract or inflammation of renal pelvis:
Unusual dialation of the pelvicalcyeal:
What is done specifically for patients with renal hypertension?
a hypertensive IVU (projections are taken much faster)
Name some contraindications for IVUs.
renal failure, anuria (no urine output), asthma, previous contrast reaction, circulatory/cardiovascular disease, elevated creatinine, sickle cell, diabetes mellitus, multiple myeloma
How is renal ability demonstrated?
through BUN and creatinine levels
What procedure should patients with uremia or anuria have in lieu of an IVU?
ultrasound (unable to filter and eliminate contrast)
Calculate mL to cc.
they are the same
Routine amount of contrast prepared for a urogram:
30-100 mL (usually 50-60 cc)
After injection, how long does it generally take the contrast to appear in the pelvicalyceal system?
The initial "flush" of kidneys immediately after injection is the ___________ phase.
When is the contrast most concentrated in the kidneys?
15-20 after injection
For an AP oblique KUB, what is better visualized according to elevation?
downside ureter and elevated kidney
Why would a lateral projection be taken during an IVU?
to localize an anomoly or tumor, special projection
Reasons for cystograms:
- vesicoureteral reflux (urine backflow from bladder)
- recurrent UTI
- neurogenic bladder (impared nerves)
- stricture in urethra
- posterior urethral valves
Where do you center for an AP/PA projection of a cystogram?
- 2-3 inches above the pubic symphysis
- 10-15 degrees caudal (10-15 degrees cephalic for prone)
Is more or less lordosis desired for a cystogram?
For cystograms, name different angulations according to areas of interest.
- regular: perpendicular
- bladder neck/proximal urethra: 5 degree caudal with normal lumbar curve; 15-20 degree caudal for no lumbar curve
- PA: 10-15 degees cephalic
- prostate gland: 20-25 degrees cephalic
- voiding studies: perpendicular to pubic symphysis
What position is used for a male cystourethrogram?
35-40 degree RPO
For a female voiding cystourethrogram, what projections are taken before and during voiding?
What procedure is done to study stress incontenence and what procedure used to be done?
- bead chain cystogram
The most common fusion anomoly in which the kidneys are rotated so that the lower poles are connected and the ureters exit the kidneys anteriorly:
horse shoe kidney
A pathology that is not radiopaque and must be viewed via a filling defect and is the forth leading cancer in men:
bladder tumor (evaluated with a cystoscope)
blood in urine
A mal positioned kidney (examples: kidney in pelvis or thorax or 2 kidneys on the same side) usually accidentally discovered:
One of the most common IVU pathologies; kidney swells up painfully; can be caused by stones (20 percent are radiolucent):
A destructive process in which death of pappilla and renal pyramids occurs (usually with diabetic, sickle cell, or drug abusing patients); filling defects show dead/ non functioning areas:
renal pappillary necrosis
An inherited pathology in which patient develops multiple kidney cysts that inpair function (usually diagnosed around age 40):
polycystic kidney disease
Pathology in which kidney is extremely porous; can appear to be holding water. The patient can't void normally because the kidneys hold it in:
Pathology in which renal pelvis begins to calcify; excretory function impaired; usually affects only one kidney which is not removed unless problems occur.
Pathology in which distal ureter becomes over dialated where it enters the bladder; has a radiolucent "halo" around it. An endoscopic incision at the UV junction to allow normal release.
Describe the differences in a malignant vs. benign renal cell carcinoma.
- malignant: tumor has blood supply with irregular borders
- benign: perfectly circular with no blood to the tumor and smooth borders
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