Investigations of the Urinary Tract

8/3/2019 Investigations of the Urinary Tract

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INVESTIGATION OF THE

URINARY TRACT

Test for Renal FunctionTest for Renal Function

Specific Gravity:Specific Gravity: It decreases when concentrating ability ofIt decreases when concentrating ability of

kidney damage.kidney damage.

But it also decreases when patient isBut it also decreases when patient is

dehydrated.dehydrated.

Normal value is =Normal value is =


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Blood Urea NitrogenBlood Urea Nitrogen

Urea is the primary metabolite ofprotein catabolismUrea is the primary metabolite ofprotein catabolism

and is excreted entirely by the kidney. The bloodand is excreted entirely by the kidney. The bloodurea nitrogen level is therefore related to theurea nitrogen level is therefore related to the

glomerular filtration rate.glomerular filtration rate.

Approximate 23rd of renal function must be lostApproximate 23rd of renal function must be lost

before significant rise in BUN level become evident.before significant rise in BUN level become evident.

Blood Urea Nitrogen : Creatinine ratio can provideBlood Urea Nitrogen : Creatinine ratio can provide

specific diagnostic information. Normal value is 10:1.specific diagnostic information. Normal value is 10:1.

Ratio dearrange :Ratio dearrange :

Severe dehydration upto 20:1Severe dehydration upto 20:1

Bilateral renal insufficiency upto 40:1.Bilateral renal insufficiency upto 40:1.

Hepatic insufficiencyHepatic insufficiency

Over hydrated patientOver hydrated patientLower ratio and low value of BUN


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Serum Cretinine :

ItIt isis anan endend productproduct ofof musclemuscle creatinecreatine metabolismmetabolism..

NormalNormal valuevalue isis 00..8282--11..22 mg/dlmg/dl ButBut itit doesdoes notnot reflectreflect earlyearly lossloss ofof renalrenal functionfunction..

ItIt derangesderanges whenwhen aboutabout 5050%% ofof kidneykidney functionfunction isislostlost..

OtherOther measuremeasure isisc

reatininec

reatinineclearan

ce

clearan

ce.. ItIt meansmeansvolumevolume of of plasmaplasma fromfrom whichwhich creatininecreatinine isis

completelycompletely removedremoved perper unitunit ofof timetime andand isis clinicalclinicalapproximateapproximate ofof thethe GFRGFR andand renalrenal functionfunction..

CreatinineCreatinine clearanceclearance == UV/PUV/P

UU andand PP refersrefers urinalurinal andand plasmaplasma concentrationconcentration ofofcretinine,cretinine,

VV isis UrineUrine flowflow raterate..

NormalNormal clearanceclearance isis 9090--110110 mlml /minute/minute..


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IMAGINGXX--ray KUB Showing kidney ureter & bladder.ray KUB Showing kidney ureter & bladder.

This will give us following informationThis will give us following information

Presence of scoliouis / spinabifida / degenerative diseasePresence of scoliouis / spinabifida / degenerative diseaseof spine/ metastasis /fracture/ Arthritisof spine/ metastasis /fracture/ Arthritis

all of these may have a relevance to the urologicalall of these may have a relevance to the urologicaldiagnosisdiagnosis

Renal stoneRenal stone

Ureteric stoneUreteric stone

Types ofrenal stoneTypes ofrenal stone

Oxalate stone (>60%) RadioOxalate stone (>60%) Radio--opaqueopaque irregular, sharpirregular, sharp

projectionprojectionPhosphate stonePhosphate stone -- Forms stag horn calculus. RadioForms stag horn calculus. Radio--

opaqueopaque

Uric acid stone and urate calculusUric acid stone and urate calculus RadiolucentRadiolucent

Cystine calculusCystine calculus -- RadioRadio--opaque due to sulphur contain.opaque due to sulphur contain.

Xanthine calculusXanthine calculus


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ULTRASONOGRAPHY

It provide Important information aboutIt provide Important information about

Size of kidneySize of kidney

Thickness of renal cortexThickness of renal cortexPresence and degree of hydronephrosisPresence and degree of hydronephrosis

Intrarenal mass as whether it isIntrarenal mass as whether it is

Cyst (Fluid filled)Cyst (Fluid filled)

Tumor (Solid and Complex)Tumor (Solid and Complex)Volume of urine in bladder before and afterVolume of urine in bladder before and after

micturationmicturation

Renal / uretric / bladder stoneRenal / uretric / bladder stone

Prostatic hypertrophyProstatic hypertrophyBladder malignancyBladder malignancy

TRANSrectal ULTRASONOGRAPHYTRANSrectal ULTRASONOGRAPHY

In case of suspected carcinoma of the prostateIn case of suspected carcinoma of the prostate

We can also take prostetic biopsy with assistance ofWe can also take prostetic biopsy with assistance of

TRUSTRUS


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INTRAVENOUS UROGRAPHYWhen contrast media is injected usually into vein in theWhen contrast media is injected usually into vein in theantecubital fossa, the substance is filtered from the bloodantecubital fossa, the substance is filtered from the bloodby the glomeruli and doesn't undergo tubular absorption.by the glomeruli and doesn't undergo tubular absorption.

PreparationPreparation

Bowel preparationBowel preparation Give laxative to clear feaces.Give laxative to clear feaces.

Patient should sent empty stomach for IVU.Patient should sent empty stomach for IVU.

TechniqueTechnique

Contrast medium usedContrast medium used urograffin / niopam 370urograffin / niopam 370

Dye is injected and successive xDye is injected and successive x--ray films are taken areray films are taken arerecorded over approximate 30 minute following contrastrecorded over approximate 30 minute following contrastinjected.injected.

Immediate filmImmediate film -- Nephrogram phaseNephrogram phase

After few minutesAfter few minutes -- collecting system calyx, pelviscollecting system calyx, pelvis

Later filmLater film ureterureter

End of studyEnd of study bladder and urethrabladder and urethra


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IVU Demonstrate

Renal calculi / uretric calculi / vesical calculiRenal calculi / uretric calculi / vesical calculi

Renal tumorRenal tumor

HydronephrosisHydronephrosisAny extramural or intramural obstruction (PUJ Obstruction /Any extramural or intramural obstruction (PUJ Obstruction /Uretric Compression)Uretric Compression)

Congenital anomaly of kidney / ureter / pelvisCongenital anomaly of kidney / ureter / pelvis

Hors shoe kidneyHors shoe kidney

Polycystic kidneyPolycystic kidney Duplication of renal pelvisDuplication of renal pelvis

Duplication of ureterDuplication of ureter

Congenital megaureterCongenital megaureter

To assess the normal functioning kidneyTo assess the normal functioning kidney

Renal tuberculosisRenal tuberculosis

Late changes shows calyceal stenosis, hydronephrosisLate changes shows calyceal stenosis, hydronephrosisdue to stricture of renal pelvis or the ureter draining thedue to stricture of renal pelvis or the ureter draining theaffected kidney.affected kidney.

Tubercular abscessTubercular abscess space occupying lesion.space occupying lesion.

BladderBladder shrunken with irregular walls thicknessshrunken with irregular walls thickness


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Hydronephrosis

Hydronephrosis

Polycystic Kidney


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Megaureter

Horse shoe KidneyRenal Calculi


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5 Minutes10 Minutes

15 Minutes


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Soft tissue mass

Renal pelvis

Stag Horn Calculus

Duplicated Pelvis

Ruptur kidney


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Retrograde Uretropyelography

Moderately invasive procedure that requireModerately invasive procedure that requirecystoscopy and placement of catheter in ureter.cystoscopy and placement of catheter in ureter.

A radioA radio--opeque contrast introduced in to theopeque contrast introduced in to theureter and renal collecting system throughureter and renal collecting system through

uretral catheter and radio graph of the abdomenuretral catheter and radio graph of the abdomenare taken.are taken.

It is useful whenIt is useful when --::

There is doubt about an intraluminal lesionThere is doubt about an intraluminal lesion

If renal function is deficientIf renal function is deficientBefore surgery for PUJ obstructionBefore surgery for PUJ obstruction

We can do retrograde stentingWe can do retrograde stenting

When patient is allergic to dyeWhen patient is allergic to dye


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ANTEGRADE PYELOGRAPHYANTEGRADE PYELOGRAPHY

DoneDone byby introductionintroduction ofof contrastcontrast mediummediumthroughthrough percutenouspercutenous NephrostomyNephrostomy

ThisThis procedureprocedure isis usefuluseful whenwhen

retrograderetrograde studiesstudies areare preventedprevented bybyobstructionobstruction atat thethe extremeextreme lowerlower endend ofof thetheureterureter or or excretoryexcretory urogramurogram areare

unsatisfactoryunsatisfactorywhenwhen nephrostomynephrostomy tubetube isis inin placeplace &&

imagingimaging ofof upperupper urinaryurinary tracttract isis desireddesired


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URETHROGRAPHYURETHROGRAPHY

Retrograde cystogran (RCU)Retrograde cystogran (RCU) RetrogradeRetrograde

injection ofdye and imagedinjection ofdye and imaged

radiographicallyradiographically

When lesion is in anterior urethraWhen lesion is in anterior urethra

Micturatingcystoram (MCU)Micturatingcystoram (MCU) -- Done afterDone after

filling bladder then with voidingfilling bladder then with voiding

cystourethrographycystourethrography

When lesion is in posterior urethra.When lesion is in posterior urethra.


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MCUMCU


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UROFLOMETRYUROFLOMETRY

ArtificiallyArtificially toto stimulatestimulate bladderbladder fillingfilling andand emptingempting whilewhileobtainingobtaining pressurepressure measurementsmeasurements..

PatientPatient attendsattends withwith fullfull bladderbladder andand isis allowallow toto voidvoid ininprivateprivate toto measuremeasure maximummaximum urinaryurinary flowflow raterate.. After After

voidingvoiding thethe residuaresidua urineurine isis measuredmeasured byby meansmeans of ofaltrasoundaltrasound toto assessassess thethe completenesscompleteness ofof bladderbladderemptyingemptying..

Normal bladder will accept

approximate

400-500 mm with filling rate 50

ml / minute.Pressure increases in bladder

should be

Less than 15 cm of water

Normal voiding pressure should

not

Exceed 60 cm of water in man

40 cm of water in woman.

Flow rate of between 20 and 25 ml per second


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USES OF URODYNAMIC

TESTINGToTo distinguishdistinguish genuinegenuine stressstress incontinenceincontinence

(due(due toto sphinctersphincter weakness)weakness) fromfrom

detreusordetreusor instabilityinstability inin womenwomen..

ClassificationClassification ofof neurogenicneurogenic bladderbladder

dysfunctiondysfunction..

ToTo distinguishdistinguish bladderbladder outflowoutflow obstructionobstruction

fromfrom idiopathicidiopathic detrusordetrusor instabilityinstability inin menmen..

InvestigationInvestigation ofof incontinenceincontinence


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CT (Computerized Tomography)

In renal carcinoma it will show :In renal carcinoma it will show :

The size and site of the tumor and degree of invasionThe size and site of the tumor and degree of invasion

of adjacent tissue.of adjacent tissue.

Presence or enlarge lymphnode at the renal hilum.Presence or enlarge lymphnode at the renal hilum. Invasion of the renal vein and vena cava.Invasion of the renal vein and vena cava.

Also to stage prostate and bladder carcinomaAlso to stage prostate and bladder carcinoma

It also shows urological stones.It also shows urological stones.

It also shows any congenital anomaly of the kidneyIt also shows any congenital anomaly of the kidney

ureter orpelvis.ureter orpelvis.


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Polycystic Kidney Renal Cell Carcinoma


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Magnetic Resonance Imaging &

Positron emission tomography


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Radioisotope scanning

DTPADTPA :: DiethyltriamineDiethyltriamine pentaaceticpentaacetic acidacidfilteredfiltered byby thethe glomeruliglomeruli andand notnot absorbedabsorbedbyby thethe tubulestubules.. UsingUsing gammagamma cameracamera

DTPADTPA labeledlabeled withwith TcTc 9999mm cancan followedfollowedduringduring itsits transittransit throughthrough individualindividual kidneykidneytoto givegive dynamicdynamic representationrepresentation ofof renalrenalfunctionfunction..

ItIt givesgives informationinformation aboutabout renalrenal functionfunction..DMSADMSA labeledlabeled withwith suitablesuitable radioactiveradioactiveisotopeisotope havehave similarlysimilarly beenbeen usedused totoinvestigatesinvestigates renalrenal functionfunction..

ItIt givesgives informationinformation aboutabout renalrenal anatomyanatomy..


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ENDOSCOPYENDOSCOPYInitiallyInitially NitzeNitze inin 18771877 invertedinverted cystoscopecystoscope for for

visualvisual inspectioninspection ofof lowerlower urinaryurinary tracttract..

ThenThen HopkinHopkin introducedintroduced RodRod lenslens telescopetelescope andandfibreopticfibreoptic illuminationillumination permitpermit toto visualizevisualize upperupperandand lowerlower urinaryurinary tracttract..

CystoscopyCystoscopy // CystourethroscopyCystourethroscopyEndoscopicEndoscopic inspectioninspection of of thethe urethraurethra andand

bladderbladder donedone whichwhich requirerequire irrigation,irrigation,illuminationillumination andand opticsoptics.. ToTo optimizeoptimize aa completecompleteexaminationexamination thethe rigidrigid endoscopeendoscope shouldshould beberotatedrotated andand 00,, 3030,, 7070,, 120120 degreedegree lenseslenses maymay beberequiredrequired.. FlexibleFlexible endoscopeendoscope cancan alsoalso useuse thatthatdecreasesdecreases patientpatient discomfortdiscomfort andand allowallowinstrumentationinstrumentation inin supinesupine positionposition thanthan routineroutinedorsaldorsal lithotomylithotomy positionposition..


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It provides :It provides :

Direct visual inspection of urethraDirect visual inspection of urethra

Direct visual inspection of bladderDirect visual inspection of bladderWe can do any ureteral instrumentationWe can do any ureteral instrumentation

We can take biopsy from bladder and ureterWe can take biopsy from bladder and ureter

For removal of ureteral stoneFor removal of ureteral stone

In case of cystourethroloplexyIn case of cystourethroloplexyWe can do transurethral surgery forWe can do transurethral surgery for

BPHBPH Transurethral resection ofprostateTransurethral resection ofprostate

CA prostateCA prostate

Bladder neck incisionBladder neck incision CA bladderCA bladder Transurethral resection of bladderTransurethral resection of bladder

tumortumor


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UretrorenoscopyUretrorenoscopy

It is endoscopy of ureter upto renal pelvis for bothIt is endoscopy of ureter upto renal pelvis for bothdiagnostic evaluation and therapeutic intervention.diagnostic evaluation and therapeutic intervention.

Rigid uretrorenoscope size 9.5Rigid uretrorenoscope size 9.5 12.5 Fr12.5 Fr

Semi rigid and flexible uretrorenoscope 7Semi rigid and flexible uretrorenoscope 7--9 Fr.9 Fr.

IndicationIndication

DiagnosticDiagnostic

Lesion of ureter and renal pelvicLesion of ureter and renal pelvic

Hematuria from upper tract.Hematuria from upper tract.

TherapeuticTherapeutic

Ureteral stone treatmentUreteral stone treatment

Direct vision internal uretrotomy of ureteral strictureDirect vision internal uretrotomy of ureteral stricture

Endiscopic resection and coagulation of ureteralEndiscopic resection and coagulation of ureteraltumor.tumor.


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AngiographyAngiography

AngionephrotomogramAngionephrotomogram (intravenous(intravenous renalrenalangiogram)angiogram).. InIn thisthis investigationinvestigation bolusbolus of ofradioopaqueradioopaque mediummedium isis injectedinjected insideinside aa veinvein(antecubital(antecubital vein)vein) rapidlyrapidly 44--66 tomogramtomogram areare takentaken..

ToTo differentiatedifferentiate cystcyst fromfrom tumortumor..

CystCyst oror abscessabscess failfail toto opecifyopecify

TumorTumor NormalNormal oror increaseincrease opacificationopacificationRenalRenal angiographyangiography

RenalRenal angiogramangiogram cancan bebe performedperformed byby directdirect lumberlumberneedleneedle puncturepuncture ofof thethe aorta,aorta, yetyet thisthis techniquetechnique hashasbeenbeen supersededsuperseded byby percutaneouspercutaneous femoralfemoral

angiographyangiography..1212--2424 mlml of of radioradio--opaqueopaque fluidfluid suitablesuitable for for

intravenousintravenous urographyurography isis injectedinjected andand 1010 exposureexposureareare takentaken inin 1010 secsec timetime.. TheyThey alsoalso differentiatedifferentiatebetweenbetween cystcyst andand rumorrumor..

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Investigations of the Urinary Tract