Intravenous Pyelography

The IVP provides both anatomic and functional information about the kidney. It is most commonly utilized in the setting of flank pain and hematuria and has long been considered the "gold standard" for visualizing renal calculi. The disadvantages of the study include the necessity of transporting the patient to x-ray, the time demand of the study, and the administration of contrast material. Concern regarding poor images in ED patients because of the lack of bowel preparation is unwarranted. 1

Before initiation of the IVP, the patient is asked to void and the abdomen is compressed. The standard series of films taken during an IVP include the following:

1. The scout film, a plain radiograph from the level of the kidneys to the bladder prior to the administration of contrast. This allows visualization of stones that may be obscured by contrast material. The compression device is released after the scout film.

2. The nephrogram, a coned view of the kidneys 1 min after injection of contrast. This film is examined for the absence or delay in visualization, homogeneity, and duration of the nephrogram.

3. The pyelogram, two films taken 5 and 10 min after injection. Calyceal dilation or effacement, ureteral dilation, intraluminal filling defects, and the extravasation of contrast material can be seen.

4. The bladder film, taken 20 min after injection.

5. The postvoid film, used to evaluate postvoid residual bladder volume and visualize any retained contract that may have been hidden by the full bladder. Multiple views and tomograms are often used to enhance the quality of the study. When a calculus is suspected, two views are required to distinguish a peristaltic contraction from a tumor or a stricture. Delayed views are necessary in instances of obstruction or nonvisualization.

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