To establish accurate diagnosis Patients with suspected dysfunction of the urinary system undergo urography. This method allows you to determine functional disorders, the presence of stones, as well as the condition of the kidneys, ureters and bladder. Retrograde urography is a type x-ray examination, which makes it possible to assess the condition of the urinary system. The diagnostic result is recorded on the images, but its implementation requires appropriate preparation of the patient, and the images are prepared in a specially equipped room under the strict supervision of a doctor.

What is this method

Urography or pyelography is the filling of the pelvis and ureter with contrast, followed by taking pictures using X-rays. It can be retrograde (ascending) or antegrade (descending). The latter is performed when it is impossible to administer contrast through the ureter. Then it is introduced directly into the pelvis using a puncture. The main contraindication for such manipulation is a blood clotting disorder.

The essence of the retrograde procedure is to maintain contrast agent using a catheter in urethra. Catheterization is carried out using a cystoscope and only on one side, since a double-sided catheter causes spasms of the pelvis and calyces in the patient. Contrast fills the ureter and renal pelvis. The temperature of the dye solution for administration should be 36–37 C, so as not to cause the patient pain syndrome, and it must be introduced very slowly.

The contrast agent is not visible through X-rays, so it makes it possible to trace the contours urinary organs, their patency and functioning.

The disadvantage of the method is that the study can only be carried out on the side where the kidney works. The positive thing is that the diagnosis does not result in allergies, since the contrast does not enter the bloodstream.

When is urography performed?

The technique is performed on patients to identify the following conditions:

• developmental defects of the urinary organs;
• chronic inflammation;
• neoplasms;
• ICD (stones);
• injuries;
• blockage of the ureter.

The study helps to see the pathological mobility of the kidneys, and is also necessary during preparation for surgery and in the postoperative period.

Impossibility of carrying out the technique

The procedure cannot be performed on patients with the following characteristics and pathologies:

• allergy to contrast;
• internal bleeding of unknown etiology;
• decreased blood clotting;
• impaired excretory ability of the kidneys;
• renal failure;
• acute glomerulonephritis;
• thyrotoxicosis;
• adrenal neoplasm.

Diagnosis is prohibited for women during pregnancy, since X-rays negatively affect not only female body, but also on the development of the fetus. The procedure should be performed with caution in patients with hormonal disorders ( diabetes mellitus), taking medications based on metformin, since in combination with iodine the drug leads the patient to severe acidosis. Such patients undergo the procedure only if the excretory function of the kidneys is preserved.

If the patient has contraindications to the procedure, the doctor replaces the diagnostic study with a less informative one, but safer for such a patient. This may be a CT, MRI or ultrasound of the kidneys.

Preparation rules

In order for the pictures to be clear, the patient must be prepared for the manipulation. Preparation involves cleansing the intestines from feces and gases. To do this, exclude foods that provoke flatulence from the patient’s diet:

• raw vegetables and fruits;
• legumes;
• mushrooms;
• cabbage;
• black bread;
• dairy products;
• carbonated drinks.

The patient must adhere to this diet for three days. To maximize bowel cleansing, the patient takes a laxative and sorbex or activated charcoal. Its dosage is determined by the doctor. The patient must undergo a cleansing enema in the evening, before the procedure and 3 hours before it is performed.

If patients are bedridden or weakened, they are advised to move more to improve intestinal motility and relieve gases.

The procedure is carried out on an empty stomach or after a light breakfast (unsweetened tea and a sandwich). If before the manipulation the patient experiences increased emotional arousal, he is given sedative medicine.

How is the examination carried out?

The manipulation is carried out in an equipped X-ray room. Before starting the procedure, a contrast agent is selected. It should not cause allergic reactions and meets the following criteria:

• non-toxic;
• does not accumulate in tissues;
• participates in metabolic processes.

To perform retrograde urography, contrast containing iodine is used. Before starting the procedure, the patient’s tolerance to the substance must be established. To do this, a test is carried out the day before. On skin make a small scratch and apply a few drops of iodine to it. After 15–20 minutes, see if there is an unnecessary reaction in the form of hyperemia, rash, itching, or swelling. If there is no reaction, then diagnostics can be performed.

The procedure is carried out maintaining sterility so as not to cause infection. urinary tract. The patient is in a supine position. First, a catheter is used to empty the pelvis and ureter of urine, and then a contrast agent is injected through it, filling the renal pelvis and ureter.

Usually 5–8 ml of contrast is sufficient. The patient should feel a slight heaviness in the lumbar region. The appearance of pain in the kidney area indicates overstretching of the renal pelvis, which occurs with the rapid administration of a large amount of contrast agent. This condition can cause pelvic-renal reflux.

Pictures are taken with the patient lying on his back, stomach, side and standing. This makes it possible to completely fill the pelvis with contrast and carry out objective research. It is recommended to repeat the image an hour after administration of the substance to assess the excretory function of the kidneys and ureters.

Experts also call this diagnostic method retrograde ureteropyelography. This interpretation gives an idea of ​​the scope of the research being carried out. Diagnostics is not performed when acute inflammation upper and lower parts of the urinary system.

Complications

During the diagnostic study, the following undesirable manifestations may develop:

• renal pelvic reflux;
• distension of the pelvis;
• lower back pain;
• allergies up to the development of anaphylactic shock.

Diagnosis is often complicated by the appearance of hematomas and blood clots at the puncture site. If the ureter is damaged, contrast may enter beyond it or into the kidney tissue, which subsequently causes an increase in body temperature. If sterility is not maintained, infectious infection often occurs, and the administration of contrast can provoke the development of renal colic.

Conclusion

The methodology used is informative and proper preparation, and also if there are no contraindications, helps to establish a diagnosis and carry out appropriate treatment.

is a type of x-ray that provides images of the bladder, ureters and renal pelvis. Very often, pyelography is performed during cystoscopy, that is, examination of the bladder using an endoscope (a long, flexible tube with a light guide and a video camera). During cystoscopy, an X-ray contrast agent is injected into the ureters through a catheter.

Since the methods and technology of ultrasound examination (high-frequency sound waves) and contrast agents have improved, then, at present, other research methods are more often used, such as intravenous urography and ultrasound examination kidneys (ultrasound of the kidneys).

What is X-ray examination?

During X-ray examinations, the image internal organs, tissues and bones are obtained using the invisible electromagnetic radiation. X-rays, passing through the structures of the body, fall on a special plate (similar to photographic film), forming a negative image (the denser the structure of the organ or tissue, the lighter the image on the film).

Other tests that are used to detect kidney disease are plain radiography of the kidneys, ureters, bladder, CT scan of the kidneys, renal ultrasound (renal ultrasound), renal angiogram, intravenous urography, renal venography and antegrade pyelography.

How does the urinary system work?

The body receives nutrients from food and converts them into energy. After the body has received the necessary nutrients, waste products are eliminated from the body through the intestines or remain in the blood.

Maintains water-salt balance, allowing the body to function normally. The kidneys also remove urea from the blood. Urea is formed by the breakdown in the body of proteins found in meat, meat poultry and in some vegetables.

Other important kidney function include the regulation of blood pressure and the production of erythropoietin, a hormone that is necessary for the formation of red blood cells in the bone marrow.

Parts urinary system and their functions:

The two kidneys are two bean-shaped organs located below the ribs on either side of the spine. Their function:

• removal of liquid waste from the blood in the form of urine
• maintaining water-salt and electrolyte balance in the blood
• release of erythropoietin, a hormone that is involved in the formation of red blood cells
• regulation of blood pressure.

The structural and functional unit of the kidney is the nephron. Each nephron consists of a glomerulus formed by capillaries and renal tubules. Urea, along with water and other waste substances, passes through the nephron, where urine is formed.

The two ureters are narrow tubes that transport urine from the kidneys to the bladder. The muscles in the wall of the ureters continually contract and relax, forcing urine into the bladder. Every 10 to 15 seconds, urine flows from each ureter into the bladder in turn. If urine backs up from the bladder through the ureters into the kidneys, an infection may develop.

The bladder is a hollow, triangular-shaped organ located in the lower section abdominal cavity. The bladder is held in place by ligaments that attach to other organs and bones of the pelvis. The walls of the bladder relax and expand to hold urine, and then contract and flatten, pushing urine out through the urethra (urethra). A healthy adult bladder can hold up to two cups of urine for two to five hours.

The two sphincters are circular muscles that prevent urine from flowing by closing like a rubber band around the opening of the bladder.

Bladder nerves – signal the person to empty the bladder.

The urethra (urethra) is the tube that carries urine out of the body.

Indications for pyelography

Pyelography prescribed to patients with suspected blockage of the urinary tract, such as a tumor, stone, blood clot (thrombus), or due to narrowing (stricture) of the ureters. Pyelography evaluates the lower segment of the ureter, to which the flow of urine is obstructed. Pyelography is also used to determine the correct position of a catheter or stent in the ureter.

Advantage of pyelography is that it can be performed even if the patient is allergic to contrast because a minimal amount of contrast is used (unlike intravenous urography). Pyelography can be prescribed to patients with weakened kidney function.

Your doctor may have other reasons for recommending pyelography.

Complications of pyelography

You can ask your doctor about radiation exposure from pyelography and complications related to your medical condition. It is useful to keep a record of the radiation exposure you received during previous x-rays. Complications associated with radiation exposure depend on the number of x-rays and/or radiation treatments per long period time.

If you are pregnant or think you may be pregnant, tell your doctor. Pyelography during pregnancy is contraindicated, since radiation can lead to developmental abnormalities in the child.

If a contrast agent is used, there is a risk of allergic reactions. Patients who are aware of the possibility of developing allergic reaction in contrast, you should warn your doctor.

Patients with renal failure or other kidney disease should notify their physician. In some cases, contrast may cause kidney failure, especially if the patient is taking Glucophage (a diabetes drug).

Possible complications of pyelography include, but are not limited to: sepsis, urinary tract infection, bladder perforation, bleeding, nausea and vomiting.

Contraindications for pyelography is significant dehydration of the patient's body.

Other complications are possible, depending on your health. Discuss any possible concerns with your doctor before a pyelogram.

There are certain factors that can affect pyelography results. These factors include, but are not limited to, the following:

• gas in the intestines
• barium in the intestines from a previous x-ray of the gastrointestinal tract

Before pyelography

• Your doctor will explain the procedure to you and invite you to ask any questions you may have about pyelography.
• You will be asked to sign a form informed consent, which confirms your consent to conduct pyelography. Read the form carefully and clarify anything that seems unclear to you.
• You must avoid eating for a certain period of time before the pyelogram. The doctor will warn you about the period of time before the pyelography that you should refrain from eating.
• If you are pregnant or think you may be pregnant, you should notify your doctor.
• Tell your doctor if you have ever had a reaction to any contrast dye, or if you are allergic to iodine or seafood.
• Notify your doctor if you are sensitive to or allergic to any medications, latex, adhesive, or anesthetic medications.
• Tell your doctor about all medications you take (including vitamins and dietary supplements).
• If you are worried frequent bleeding or you are taking medications that reduce blood clotting (anticoagulants), such as aspirin, you should tell your doctor about this. You may need to stop taking these medications before pyelography.
• The doctor may prescribe a laxative the night before the pyelography, or a cleansing enema may be performed a few hours before the pyelography.
• To help you relax, you may be prescribed sedative. Because the sedative medication may cause drowsiness, you should be careful about how you get home after the pyelogram.
• Depending on your medical condition, your doctor may prescribe other special preparations for you.

During pyelography

Can be executed in outpatient setting or as part of a check-up during your hospital stay. The pyelography procedure can be modified according to your condition and your doctor's practice.

Typically, the pyelography procedure proceeds as follows:

After pyelography

You will be monitored for some time after the pyelogram. medical staff. Nurse will measure blood pressure, pulse, breathing rate, if all your indicators are within normal limits, then you can return to your hospital room or go home.

It is necessary to carefully measure the volume of urine excreted per day and observe the color of the urine (possibly the appearance of blood in the urine). Urine may turn red, even if not large quantity blood in urine. A small amount of blood in the urine after pyelography is possible and is not a cause for concern. Your doctor may instruct you to monitor your urine during the day after your pyelogram.

After pyelography You may experience pain during urination. Take painkillers prescribed by your doctor. Aspirin and some other pain relievers may increase the risk of bleeding. Therefore, take only those medications recommended by your doctor.

Be sure to consult a doctor if you are concerned following symptoms after pyelography:

• fever and/or chills
• redness, swelling, bleeding, or other discharge from the urethra
• severe pain
• increased amount of blood in urine
• difficulty urinating

The article is for informational purposes only. For any health problems, do not self-diagnose and consult a doctor!

V.A. Shaderkina - urologist, oncologist, scientific editor

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IN recent years There was a tendency to reduce the number of retrograde pyeloureterography and limit the indications for it. This is due to the introduction into practice of infusion urography - a method that is more physiological, less dangerous and gives a no less clear image of the CLS; revision of the real diagnostic capabilities of the method and the high probability of complications in the form of renal pelvic reflux with the development of acute pyelonephritis, acute prostatitis and epididymitis.

However, retrograde pyeloureterography has its own indications for use. It is necessary in the diagnosis of kidney tuberculosis, as it allows to identify early destructive changes in the calyces; with medullary necrosis, as a complication of acute pyelonephritis; with papillary tumor of the pelvis and urate nephrolithiasis; stricture of the ureteropelvic segment and ureter; if necessary, clarify the number and location of stones, etc.

Retrograde ureteropyelography. Kidney tuberculosis

The risk of complications during retrograde pyelography is reduced with strict adherence to the examination technique, compliance with the indications and taking into account the individual characteristics of the patient (gender, age, condition of the urinary tract, etc.).

Retrograde ureteropyelography, polymegacolicosis

Most serious complications are associated with a threshold increase in intrapelvic pressure, leading to the occurrence of reflux, dyskinesia of the upper urinary tract, the development of acute pyelonephritis, as well as perforation of the kidney or ureter.

The danger of retrograde pyelography is also due to possible injury to the urethra during the insertion of a cystoscope. Trauma to the mucous membrane of the urethra, which is devoid of a submucosal layer and is in direct contact with the venous sinuses of the cavernous bodies, can lead to urethrovenous reflux with infection entering the blood, the development of septicemia, and in men, also to acute prostatitis and acute epididamitis.

The role of infection in causing complications is probably exaggerated. It is dangerous in the presence of predisposing factors (dyskinesia, pyelorenal reflux, trauma, etc.). A.Ya.Pytel and Yu.A.Pytel (1966) established that the fornical zone of the calyces, due to its special structure, is prone to rupture even with a relatively small increase in intrapelvic pressure.

After breaking the integrity of the fornix, urine or radiopaque fluid penetrates into the renal sinus. The flow of the contents of the pelvis into the interstitial tissue of the kidney, penetration into its vessels as a result of a violation of the integrity of the mucous membrane of the calyx in the fornix area is called fornical reflux. If the pelvic contents flow into the tubules of the papilla without tearing the mucous membrane of the calyx and then this content penetrates from the tubules into the interstitial kidney tissue, then such reflux is called tubular.

Refluxes lead to renal extravasation, a disorder of the hemodynamics of the kidney due to ischemia and edema of the interstitial tissue. High temperature, especially accompanied by chills and leukocytosis after retrograde pyelography, indicates pyelorenal reflux with the penetration of contrasted urine through the interstitial spaces into the venous and lymphatic system and the risk of developing acute pyelonephritis.

To prevent complications during catheterization of the ureter, the catheter should be inserted to a height of no more than 15-20 cm. Before introducing a radiopaque liquid, it is necessary to take a survey image urinary system determine the location of the catheter, as it may be inserted high or coiled in the dilated ureter.

If the catheter is located high, it should be pulled up to the level of the III-IV lumbar vertebra. This correction is necessary because sometimes the ureteral catheter, despite turning the cystoscope 180° before turning the catheter in bladder, does not guarantee against further movement up the ureter. The danger of kidney damage is especially high when it is dystopic.

If the passage of urine is impaired, retrograde pyelography is fraught with danger, which is caused not so much by the use of radiopaque liquid, but by passing the catheter past the stone or stricture. The presence of a foreign body (catheter) in the ureter causes significant swelling in the pathologically changed tissues, similar to swelling of the urethra in the area of ​​the stricture after bougienage, and therefore the passage of urine is further impaired. Therefore, in case of hydronephrosis, a catheter should not be inserted into the pelvis and left on long time after retrograde pyelography, so that contrasted urine flows through it.

Low catheterization is required, in which the introduction of even a large amount of radiopaque liquid into the pelvis does not pose any danger. In addition, even with normal function, a certain amount of residual urine remains in the pelvis after contraction. High insertion of the catheter, during which the pelvis is completely emptied, causes its inhibition beyond the threshold, a disorder of the pelvis function and subsequent dyskinesia. The latter can cause pelvic-renal reflux and pyelonephritis.

The catheter should not be inserted into the upper cystoid of the ureter, since when the intrapelvic pressure increases, it plays the role of a hydraulic buffer, into which the excessively injected radiopaque liquid is poured out. This occurs because when the threshold pressure in the pelvis is reached, the ureteropelvic segment opens and an excess portion of urine enters the upper cystoid. The amount of radiopaque contrast agent of 10-20% concentration should not exceed 4-6 ml, which corresponds to the normal capacity of the pelvis.

Sometimes the pyelogram, when the pelvis is filled with 4-6 ml of radiopaque liquid, does not reveal the lower calyx. The absence of an image of the shadow of the latter on the pyelogram is not an indication for greater filling of the mandibular joint. In these cases, the calyx is located anteriorly and is revealed when examining the patient on the stomach. A similar technique should be used in the absence of a shadow of the upper calyx and non-filling of the ureteropelvic segment.

Simultaneous bilateral retrograde pyelography is unacceptable, since when acute pyelonephritis occurs, it is often difficult to determine the side of the lesion to choose the operation, and with bilateral pyelonephritis the patient finds himself in extremely in serious condition. In addition to pyelonephritis, the development of acute renal failure. If there is an urgent need for bilateral pyelography, then it should be performed separately, with an interval of 2-3 days. To reduce the risk of retrograde pyelography, it is recommended to perform it immediately before surgery.

Retrograde pyeloureterography can lead to erroneous interpretation of pyeloureterograms as a result of the fact that during the study, a radiopaque substance is injected against the flow of fluid, and is injected into the urinary tract foreign body(catheter). Thus, a false idea of ​​the stricture of the ureteropelvic segment may arise due to spasm of the segment in response to high insertion of the ureteral catheter, especially with dyskinesia and hyperkinesia of the pelvis, with projection of the shadow of an additional vessel onto the ureter, with insufficient filling of the pelvis and the initial part of the ureter with radiopaque fluid .

There may be a discrepancy in the extent of the stricture of the ureteropelvic segment on the pyeloureterogram, which is detected at surgery. This is explained by the fact that when a radiopaque liquid is introduced into the VLP, it fills the narrow section of the ureter not only at the site of the stricture, but also above it, since the narrowed part creates an obstacle to the rapid and tight filling of the ureter above the stricture. Therefore, after filling the pelvis, it is necessary to take a picture with the patient in an upright position, then, under the influence of gravity, the fluid flow fills the ureter to the place of the true stricture.

Sometimes, with a stricture of the ureteropelvic segment and low catheterization of the ureter, when a radiopaque liquid is introduced into the pelvis, a “fountain” is revealed, similar to that observed on an ascending urethrogram with sclerosis of the bladder neck.

In case of kidney damage during retrograde pyelography with extravasation of a radiopaque substance into the thickness of the parenchyma, the need arises differential diagnosis with a kidney tumor. Penetration of the contrast fluid beyond the pelvis, communication of the perforated canal with the pelvis or calyx can create a false picture of a kidney tumor. In cases of ureteral perforation, it is also sometimes difficult to interpret the X-ray picture.

With incomplete perforation of the ureter, the shadow of the contrast liquid can fill not only the lumen of the ureter, but also be located along it, creating the appearance of expansion. A similar picture can be observed when the catheter in the ureter is folded and excessively stretched by contrast fluid. In such cases, the fluid spreads in the direction where the loop formed by the collapsed catheter is facing. So, if the tip of the catheter is facing downwards, then the contrast liquid stretches the lower third of the ureter.

So, with retrograde pyeloureterography, a clear image of the CLS and ureters is achieved. This method makes it possible to judge the morphological structure of the urinary tract and, what is especially valuable, reveals minor destructive changes in the calyces, papillae, pelvis and ureter. Negative side retrograde pyeloureterography determines the need for cystoscopy and catheterization of the ureter, which is associated with the risk of serious complications.

Retrograde (ascending) ureteropyelography was first performed in 1906. The method is based on obtaining an X-ray image of the upper urinary tract by retrogradely filling it with a radiopaque substance. For this purpose, liquid (sergosine, diodone, urotrast, etc.), gaseous (oxygen, less often carbon dioxide) radiopaque substances are used. Depending on the objectives of the study, a ureteral catheter (preferably No. 5) is inserted at different heights into the ureter (for urethrography, 3 - 5 cm, for pyelography, 20 cm). The position of the catheter is controlled by a survey image, and if there is an electron-optical converter - using a television screen. 5 ml of a radiopaque substance is slowly injected through the catheter, depending on the shape and volume of the renal pelvicaliceal system, determined by ultrasound or excretory urogram. Pain in the kidney area that occurs when a radiopaque contrast agent is administered indicates overstretching of the pelvis and calyces and the possibility of pelvic-renal reflux. With correctly performed pyelography, the occurrence of reflux is a sign pathological process in the kidney.

A necessary condition To perform retrograde uretero-pyelography, strict adherence to asepsis is required. In addition, to prevent possible inflammatory complications It is recommended to conduct the study in combination with antibacterial therapy.

When interpreting retrograde ureteropyelograms, attention should be paid to changes in position and anatomical structure upper parts of the urinary tract, on the nature of urodynamics, which can be judged by the degree of emptying of the pelvis and ureter.

To diagnose X-ray negative stones, retrograde ureteropyelography is performed with a low concentration of contrast agent or gas, usually oxygen, which is injected into the pelvis. This method is called retrograde pneumoureteropyelography. Against the background of gas, which has high permeability for x-rays, an X-ray negative stone is determined as a shadow, and against the background of a liquid contrast agent - as a filling defect.

Simultaneous bilateral retrograde ureteropyelography is permissible only in exceptional cases when it is necessary urgently, according to vital signs, resolve the issue of the nature of changes in the kidneys and upper urinary tract.

Contraindications to planned retrograde ureteropyelography are acute inflammatory processes in the male genital organs, lower and upper urinary tracts, kidneys, total hematuria. This study should be performed with great caution if the outflow of urine from the pelvis is impaired. After completing the study, to drain the radiopaque substance and urine, a catheter should be passed to the pelvis and left there for several hours.

With retrograde pyelography, even minor destructive changes in the calyces, papillae, pelvis and ureter are clearly detected. However, this method is not physiological. The need for cystoscopy and catheterization of the ureter, the danger of ureteropelvic reflux and the development of pyelonephritis limit the use of retrograde ureteropyelography; it is used only in cases where more physiological methods are not feasible or do not provide sufficient information.

Modern technical capabilities make it possible to perform pyelorentgenoscopy using an electron-optical converter, as well as to monitor urodynamics on a television screen both during excretory urography and retrograde pyelography.

• General information
• Normal pyelogram
• Advantages and disadvantages of retrograde pyelography

Retrograde pyeloureterography was first performed in 1906 by Voelcker and Lichtenberg. This method is based on obtaining shadows of the upper urinary tract in an x-ray image after retrograde filling with a contrast agent. Thanks to the use of high concentrations of contrast agents, it is possible to obtain a clear image of the calyces, pelvis and ureter on retrograde pyeloureterograms.

For retrograde pyeloureterography, liquid and gaseous contrast agents are used. Among liquid substances, solutions of sergosine, cardiotrast, diodon, and triiotrast are most often used; among gaseous substances, oxygen and, less commonly, carbon dioxide are used.

Preparing the patient for retrograde pyelography is the same as for a survey image.

Since pyelography should not be performed on both sides simultaneously, ureteral catheterization, as a rule, should be unilateral. A unilateral examination is tolerated much easier by patients than a bilateral one. With simultaneous catheterization of both ureters, spasms of the calyces and pelvis often occur, which can distort their image on pyelograms and complicate the interpretation of the latter.

Bilateral pyeloureterography is permissible only in exceptional cases, when it is necessary to quickly resolve the issue of pathological changes in the kidneys and upper urinary tract.

Catheterization of the ureter is performed with a special catheter. Depending on the diameter of the ureter or the presence various degrees To narrow it, catheters of various thicknesses are used. The most commonly used are ureteral catheters No. 4, 5, 6 on the Charrière scale. It is preferable to use catheterization No. 5, the caliber of which ensures easy outflow of contrast fluid in case of overflow of the pelvis.

Immediately before introducing a contrast agent into the pelvis, it is advisable to take a survey photograph to determine the level of location of the end of the catheter in the urinary tract. The contrast agent should be injected into the urinary tract only in a warm form, which prevents the occurrence of spasms in the pelvicalyceal system and in the ureter.

Application for retrograde pyelography of contrast agents in very high concentrations unnecessary, since such contrast agents give overly intense, “metallic” shadows, which interfere with the correct interpretation of radiographs, and, therefore, increase the possibilities diagnostic errors. The use of 20-40% solutions of radiopaque agents is quite sufficient to obtain a good pyelogram.

In the presence of profuse hematuria, retrograde pyelography is not recommended, since blood clots located in the renal pelvis can produce filling defects on the pyelogram and, therefore, be mistaken for a tumor or calculus.

Do not inject more than 5 ml of liquid contrast agent into the pelvis. This amount is equal to the average capacity of the pelvis of an adult and is quite sufficient to obtain distinct shadows of the upper urinary tract on an x-ray, provided that the upper end of the catheter is at the level of the border of the upper and middle thirds of the ureter. In cases where the patient underwent excretory urography before retrograde pyelography, the latter, showing the size of the pelvis, makes it possible to more accurately determine the amount of contrast fluid that needs to be injected into the patient’s urinary tract for retrograde pyeloureterography.

Contrast liquid should not be injected into the pelvis without taking into account the amount indicated above, and also until the moment when the patient experiences pain or discomfort in the kidney area. Such painful sensations indicate overstretching of the calyces and pelvis, which is a very undesirable circumstance during a pyelographic study.

Numerous works (A. Ya. Pytel, 1954; Hinman, 1927; Fuchs, 1930, etc.) have proven that the introduction of any solution into the pelvis at a pressure above 50 cm of water. Art. sufficient for this solution to penetrate beyond the calyces into the renal parenchyma.

With a slow injection of contrast liquid heated to body temperature and light pressure on the syringe piston, the patient does not experience pain.

If the first pyelogram shows that the pelvis is not filled with enough contrast material, additional injections should be made into the pelvis. more contrast agent, taking into account the estimated capacity of the pelvis based on the idea created during the first pyelogram.

When the pelvis is overstretched, pelvic-renal reflux can easily occur, due to which the contrast agent penetrates into the bloodstream. This may be accompanied by lower back pain, fever, sometimes chills and mild leukocytosis. These phenomena usually last no more than 24-48 hours.

A necessary condition when performing retrograde pyelography, as well as any catheterization of the urinary tract in general, is strictest observance laws of asepsis and antiseptics.

If, during retrograde pyelography, pain occurs after the injection of 1-2 ml of contrast agent into the pelvis, then further administration should be stopped and an x-ray taken. Most often, colic-like pain with the introduction of a small amount of contrast agent is observed with dyskinesia of the upper urinary tract or with filling of the upper pelvis double kidney, the capacity of which is usually very small - 1.5-2 ml. If dyskinesia is present, the study should be stopped and carefully repeated a few days later, with the preliminary administration of antispasmodics before pyelography.

In cases where sharp colicky pain occurred during retrograde pyelography, for the purpose of prevention possible development pyelonephritis, the patient should be prescribed antibacterial drugs (urotropine, antibiotics, nitrofurans, etc.). The addition of antibiotics to the contrast agent injected into the pelvis, recommended by some clinicians, to prevent inflammatory complications turned out to be an ineffective method. Thus, studies by Hoffman and de Carvalho (1960) showed that with and without the use of antibiotics (neomycin) the number of complications during retrograde pyelography is the same.

The addition of anesthetic substances (novocaine) to the contrast agent injected into the pelvis, previously recommended and used by us, in order to prevent pain and pyelorenal reflux, also did not justify itself. This is understandable, since the 0.5% novocaine solution used has virtually no local effect. anesthetic effect on the urothelium of the upper urinary tract.

Retrograde pyelography should be performed on one side, and if there are indications, then on the other, but not at the same time. In any case, the doctor must have a clear idea of ​​the functional and morphological state of both kidneys and the upper urinary tract, and this requires excretory urography or bilateral retrograde pyelography.

In the history of medicine, there are sad cases of erroneous diagnosis and incorrect therapy, when a doctor, having only data from a unilateral pyelogram, made a diagnosis and applied treatment, which ultimately only brought harm to the patient. With this in mind, you should first of all remember about polycystic kidney disease, a solitary kidney, tuberculosis and kidney tumor, when on the basis of a unilateral pyelogram it is impossible to correctly diagnose and apply the correct type of treatment. We should also not forget about the existence of numerous variants of the kidneys, pelvis and ureters, which with unilateral pyelography can be mistaken for pathological changes. The identical structure, although unusual, of the pelvicaliceal system on both sides speaks more in favor of the normal variant, with the exception of renal polycystic disease.

Typically, retrograde pyelography is performed on a patient in a horizontal position on his back. However, this position of the patient does not always allow for good filling of the pelvis and calyces with the contrast agent. It is known that the large and small cups have different locations and the angle of their departure from the pelvis in relation to the horizontal plane of the body is different, due to which they cannot always be filled evenly with a contrast agent. This circumstance may be misinterpreted and lead to an erroneous assessment of the research results. Further, since the projection of individual cups can overlap one another, this makes it difficult to decipher pyelograms. Therefore, to eliminate such errors, if necessary, pyelograms should be performed in different positions of the patient’s body. The most often used, along with the position of the patient on the back, is the oblique-lateral position on the side and on the stomach. To take a picture in a lateral position, the patient is placed on the side of the body whose urinary organs are to be examined; the other side of the body should be inclined towards the table at an angle of 45°. Torso and rib cage in this position they should be supported by sandbags placed under the shoulder and thigh. Sometimes it is necessary to perform several oblique pyelograms at different degrees of torso tilt before obtaining the required image.

When the patient is positioned on his back, the upper and partly the middle calyceal groups, as the deepest parts of the pyelocaliceal system, are first filled with contrast liquid. With the patient lying on his stomach, the lower group of calyces and the initial section of the ureter are better visible on the x-ray. Because of this, in doubtful cases, pyelography should be performed in different positions of the patient.

Sometimes, when performing retrograde pyelography with the patient in the usual position on his back, it is not possible to fill upper sections ureter and pelvicalyceal system with a contrast agent. In such cases, it is recommended to place the patient in a position with an elevated pelvis according to Trendelenburg.

To recognize nephroptosis, along with the usual position of the patient on his back, an X-ray should also be taken in an upright position of the body after filling the upper urinary tract with a contrast agent and removing the ureteral catheter. Downward displacement of the kidney with the appearance of bends of the ureter confirms the diagnosis of nephroptosis and allows us to differentiate this suffering from renal dystopia, when there is congenital shortening of the ureter.

To recognize diseases of the ureter, retrograde ureterography is often used, which turns out to be especially valuable in the diagnosis of ureteral stenosis, stones, tumors, and various anomalies. For this purpose, after introducing a contrast agent into the pelvis and obtaining a pyelogram through the catheter, an additional 3 ml of contrast agent is injected and the catheter is slowly removed. The patient is placed in the Fowler position and after 25-30 seconds an X-ray is taken in the supine position. Favorite Time 25-30 seconds is optimal for filling the entire ureter with contrast agent.

Close to this species pyelography is the so-called delayed pyelography, which allows you to clarify the diagnosis of atony of the upper urinary tract or determine the degree of hydronephrotic transformation. After a pyelogram has been performed on the patient in a horizontal position, the catheter is quickly removed from the urinary tract, then the patient must sit or stand for 8-20 minutes, after which a second radiograph is taken. If in the second image the contrast agent is still in the pelvis or ureter, then this indicates impaired evacuation from the urinary tract.

IN lately Various modifications of retrograde pyelography are used, with the goal of earlier recognition of the most minor destructive changes in the kidneys. First of all, this applies to targeted images using a tube, which creates compression of the studied area of ​​the upper urinary tract. X-rays performed in the supine and standing position of patients. This method allows you to obtain a clearer image of individual areas of the upper urinary tract. It has found application in identifying the cause of narrowing of the ureteropelvic segment and for diagnosing specific and nonspecific papillitis.

Normal pyelogram

In Fig. 42, 43, 44, 45, 46, 47 present the most common variants of normal renal pelvis and calyces.

Rice. 42. Normal retrograde pyelogram. a - branched pelvis of intrarenal type; b - ampullary pelvis of extrarenal type
Rice. 43. Normal bilateral retrograde pyelogram. Woman 24 years old.
Rice. 44. Normal right-sided pyelogram. Woman 32 years old. - normally filled pelvis (5 ml); b - pelvis, overstretched with contrast liquid (10 ml), as a result of which the cups are significantly deformed.
Rice. 45. Retrograde pyelogram. Woman 37 years old. Option normal structure pelvis and calyces.	Rice. 46. ​​Retrograde pyelogram. Male 39 years old. Ampullary type of pelvis, small cups (no neck).
	Rice. 47. Retrograde pyelogram. Male 31 years old, a common variant of the structure of the pyelocaliceal system

The existence of numerous forms and variants of the normal renal pelvis and calyces sometimes presents great difficulties in their interpretation based on pyelography data. It takes a lot of experience to interpret correctly various types pyelogram (Fig. 48, 49, 50).

Judging by the data of normal pyelograms, the right renal pelvis most often located at the level of the second lumbar vertebra. The left renal pelvis is located 2 cm above the right. However, it is not uncommon to see that both pelvises are located below the indicated level.

There are cases when, with an unusual pyelographic image, difficulty arises in deciding whether it is a pathological picture or whether it is rare option normal pelvis and calyces? In such cases, an image of the other kidney and an x-ray of the kidney being studied in a different projection helps. There is usually a certain tendency towards symmetry in the arrangement of the pelvis and calyces in the same individual. If the pyelogram of the second kidney is approximately the same as that of the first, then pathological changes in it are excluded.

It should be remembered that images of urinary tract cavities may depend on various circumstances. The slightest increase in pressure inside the pelvis or inside the ureter can completely change their contours as a result of the changed neuromuscular tone of the upper urinary tract (Fig. 44, a, b).

Ureterogram. Normally, the shadow of the ureter is located along the lateral edge of the transverse processes of the lumbar vertebrae. The ureter should not form loops or angled, angular curvatures.

To identify a pathologically displaced kidney, loop-like bends and curvatures of the ureter, pyeloureterography or excretory urography should be performed in the vertical and horizontal position of the patient. IN supine position The photograph of the patient should be taken after the prolapsed kidney has returned to its normal position, that is, after the patient has been given the Trendelenburg position or when the renal area has been massaged.

To identify abnormalities or changes in the ureter, when injecting a contrast agent into the ureter, slowly remove the catheter from the latter, filling the ureter with a contrast agent. With this technique, the ureter fissus, ureteral tumor, stenosis, etc. will not be visible. The diagnosis of “narrowing of the ureter” can be convincing when the radiograph demonstrates dilation of the ureter above the site of narrowing.

Pyelography with gaseous contrast agent(oxygen), or pneumopyelography. This type of pyelography is used when it is necessary to identify the so-called invisible stone, i.e. a stone that does not block X-rays and, therefore, does not produce a shadow on the survey image (Fig. 51, 52). Upon introduction of oxygen into the pelvis, the latter surrounds the calculus and creates conditions that significantly increase the contrast of the latter and, consequently, its visibility on the radiograph. During pneumopyelography, oxygen should be injected into the pelvis in an amount of 8 to 10 cm3, while avoiding an excessive increase in intrapelvic pressure. Pneumopyelography is by far the best method for identifying invisible stones. It allows not only to diagnose the calculus as such, but also to establish its exact location (pelvis, calyces, ureteropelvic segment, etc.).

So-called invisible stones of the pelvis, calyces or ureter can sometimes be detected by retrograde pyelography based on the presence of a filling defect. In such cases, low-concentrated solutions of sergosine (5-8%) are used.

Destructive processes in the kidney and upper urinary tract are detected mainly by retrograde pyeloureterography using high-concentration contrast agents.

Retrograde pyelography with the simultaneous use of various contrast agents: liquid - X-ray positive and gaseous - X-ray negative - deserves great attention. The most widely used method is Klami (1954). It is based on the use of a solution of hydrogen peroxide (3%) simultaneously with a liquid contrast agent. This is recommended when, if a patient has pyuria or hematuria emanating from the kidney or from the upper urinary tract, it is not possible to determine the source of the pathological process using conventional retrograde pyelography. A contrast agent containing hydrogen peroxide, in contact with the site of ulceration or destruction, whether in the calyx, papilla or pelvis, begins to foam as purulent cells, exudate and blood decompose hydrogen peroxide into oxygen and water. This chemical reaction promotes the penetration of the contrast agent not only into the superficial, but also into the deep layers of the destructive, inflammatory focus, which is revealed on the pyelogram by the corresponding fine-spotted shadow. This method is used mainly for diagnosing the early stages of renal tuberculosis, tumors of the kidneys and pelvis (Klami, 1954). As our observations show, this method also makes it possible to establish the focus of fornical bleeding and the localization of the calyceal-fornical-venous canal during renal bleeding (A. Ya. Pytel, 1956).

To exclude possible diagnostic errors during retrograde pyelography according to Klami, it should be preceded by excretory urography and conventional retrograde pyelography. This is especially important for so-called invisible stones and tumors of the upper urinary tract.

Since 1961, the Broome method has been used, based on the use of simultaneously liquid and gaseous contrast agents in retrograde pyelography. Carbon dioxide is used as a gaseous substance. The technique of this technique is as follows. After introducing 2-3 ml of liquid contrast agent into the pelvis through the ureteral catheter, 6-8 ml of carbon dioxide is injected, and then the contents of the pelvis are aspirated with reintroduction carbon dioxide into it. Next, radiography is performed. This method is most suitable for diagnosing papillary neoplasms of the pelvis and ureter, as well as for recognizing so-called invisible stones.