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Does an Extra Kidney-Ureter-Bladder (KUB) Radiography Taken at ‘Upright Position’ During Routine Intravenous Urography

Provide Any Diagnostic Benefit?

Kamil Gurel, Safiye Gurel, Melike.E. Kalfaoglu, Cigdem Gökay

Abant Izzet Baysal University, Izzet Baysal School of Medicine, Department of Radiology

Bolu/TURKEY

Introduction• Intravenous urography (IVU) has long been the main imaging evaluation of urinary tract

disease.

• However, the use of US, CT, and MRI has surpassed the use of IVU in the last two decades.

Introduction• The declining use of IVU in clinical practice

presents a challenge for instruction in urographic technique and interpretation.

• Nevertheless, IVU might still be important in

the diagnosis of some urinary tract disease among other new modalities.

Purpose• The aim of this prospective study is to

assess the value of taking a kidney-ureter-bladder (KUB) radiography at upright position during routine IVU in terms of diagnostic benefit.

Methods and Materials• September 2003-March 2006, 164 consecutive

patients were referred for IVU exam

In our department, a basal standart IVU exam consists of totally 5 radiographies:

• Precontrast supine KUB • Post-contrast supine KUB at 7th and 15th minutes • Pelvic supine graphies for full bladder and post-voiding• When needed, additional compression and/or oblique radiographies

• For all patients, an additional post-contrast 15th min. upright KUB radiography was obtained

• Two reviewers analyzed the 15th min.

upright KUB comparing to 15th min. supine KUB radiographies together, resulting in a consensus interpretation.

Methods and Materials

Methods and Materials• This study is approved by our institutional

review board and informed consent was obtained from patients.

Methods and Materials• Statistical Evaluation Evaluations were expressed in

percentages.

Results• 164 patients 80 women, 84 men Mean age 44,5 ±15,4 years

Clinical Data:Urolithiasis………………………. (n=95) Collecting system dilatation....... (n=21) Flank pain……………………….. (n=10) Urinary tract infection.....……..... (n=10)Hematuria.………………………..(n=6)Renal Cyst.…………………….... (n=5)Control after ESWL ...………...... (n=3)Others (bladder ca,…)………….. (n=14)

Results

Diagnostic benefits of 15th min. upright KUB72 (43,9%) of 164 patients 1. Nephroptosis (n= 40)2. Better filling of collecting system (n=9)3. Differentiation of pheloboliths from urolithiasis (n=10)4. Emptying of collecting sistem (n=51)5. Milk of calcium (n=2)

Results

1.Nephroptosis (Asymptomatic) Downward displacement of kidney by more than two vertebral bodies or 5 cm

40 patients (24.3%) [bilateral (n=15), unilateral (n=25)]

Results

Supine Upright

57 yo, F, Right renal cyst and minimal pelvicaliectasia on US

43yo, M, Right flank pain

Supine Upright

2. Better filling of collecting system 9 patients (5.4%) [ureteral filling (n= 8),

upper pole infindibular filling (n=1) ]

Results

24 yo, F, nephrolitiasis

Supine UprightPre-contrast

Supine Upright

48yo, M, 48 yo, M, urinary tract infection

Supine Upright

Results

3.Differentiation of pheloboliths from urolithiasis

10 patients (16.4%) (lower urinary tract)

Supine Upright

44 yo, M, ureterolithiasis suspicion

L ureter

Supine Upright

Results

4. Emptying of collecting sistem51 patients (31%)

10, yo, F, minimal pelvicaliectasia at right kidney on US

Supine Upright

Results

5. Milk of calcium 2 patients (1.2%)

Discussion

• Recently IVU has almost been accepted as outdated.

• On the other hand alternative modalities have their own limitations, and despite their increasing use, the ideal “global” urinary tract examination still remains controversial

Assessment of Selected Imaging Modalities in the Evaluation of the Urinary Tract*

VariableIntravenousUrography

CT USMRImaging

Cystoscopy-RetrogradePyelography

Collecting system ++++ ++/+++ 0/+ ++ ++++ Parenchyma +++ ++++ ++ ++++ 0Renal masses (cysts, solidtumors)

++ ++++ +++ ++++ 0

Function ++++ ++++ 0 ++++ 0 Calculi +++ ++++ ++ 0 ++ Ureter ++++ +++ 0 ++ ++++ Bladder ++/+++ +++ 0/+ +++ ++++ Abdomen-retroperitoneum + ++++ +++ ++++ 0

Cost ++++ + ++++ + 0 Ionizing radiation ++ + ++++ ++++ +++ Note.—Assessment was performed with a scale from 0 to ++++, with 0 being the worst and ++++ the best. *Dyer RB, et al. Intravenous Urography: Tecnique and Interpretation. Radiographics 2006;

1(4):800-821.discussion 822-824.

Discussion

Nawfel RD, et al. Patient Radiation Dose at CT Urography and Conventional Urography. Radiology 2004; 232:126-132.

• The patient effective dose, therefore radiation risk for CT urography was 1.5 times greater than that for conventional urography

•Radiation risk is increased for smaller patients in CT urography and for larger patients in IVU.

• CT urography performed with multi–detector row CT may eventually replace IVU. However, the increased radiation risk from this examination compared with IVU should be considered in the context of the amount of information that is necessary for the diagnostic task.

*Nawfel RD, et al. Patient Radiation Dose at CT Urography and Conventional Urography. Radiology 2004; 232:126-132.

Discussion ‘Upright positioning’ seems to:• Be possible-technically- only in IVU• May be a part of routine IVU • Can supply data about verification of urine

flow • Can provide better filling• Show positional change in gravity-related

layering, nephroptosis and phleboliths

Discussion

Weak points of this study are:• There is no control grup (for comparison of

total number of films and patient radiation dose)

• Absence of interobserver variability assessment

Conclusion: • IVU, a cornerstone in urinary system

imaging, has slowly been withdrawn from routine clinical practice in the era of CT or MR urography.

• However, the capability of using gravitational forces by obtaining simply an upright radiography still provides some diagnostic benefits, in which CT or MR urography might easily miss.