Retrograde Ureteropyelography


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Retrograde Ureteropyelography

 

Definition

A retrograde ureteropyelogram provides x-ray visualization of the bladder, ureters, and the kidney (renal) pelvis by injection of sterile dye into the renal collecting system.

Purpose

A retrograde ureteropyelogram is performed to determine the exact location of a ureteral obstruction when it cannot be visualized on an intravenous pyelogram (a dye is injected and an x ray taken of the kidneys and the tubes that carry urine to the bladder). This may occur due to poor renal function and inadequate excretion of the contrast medium (dye).

Precautions

The doctor should be made aware of any previous history of reactions to shellfish, iodine, or any iodinecontaining foods or dyes. Allergic reactions during previous dye studies is not necessarily a contraindication, as dye is not infused into the bloodstream for this study. Other conditions to be considered by the physician prior to proceeding with the test include pregnancy and active urinary tract infection.

Description

After administration of anesthesia, the doctor will insert a thin, tubelike instrument (catheter) through the patient's urethra and into the bladder. A catheter is then placed into the affected ureter to instill the contrast medium. X-ray pictures are taken to visualize the ureter. If complete obstruction is found, a ureteral catheter may be left in place and secured to an indwelling urethral catheter to facilitate drainage of urine. The procedure takes approximately one hour.

Preparation

Laxatives or enemas may be necessary before the procedure, as the bowel must be relatively empty to provide visualization of the urinary tract. When general anesthesia is used for insertion of the ureteral catheter, there should be no eating and drinking after midnight prior to the procedure.

Aftercare

Even if no catheters are left in place after the procedure, the patient may have some burning on urination for a few hours after the procedure due to the irritation of the urethra. The discomfort can be reduced by liberal fluid intake, in order to dilute the urine. The appearance and amount of urine output should be noted for 24 hours after the procedure. If a stone was found, all urine should be strained to allow chemical analysis of any stones passed spontaneously. This will allow the doctor to provide advise on measures to prevent recurrent stone formation. Antibiotics are usually given after the procedure to prevent urinary tract infection.

Normal results

A normal result would reveal no anatomical or functional abnormalities.

Abnormal results

Abnormal results may indicate:
  • congenital abnormalities
  • fistulas or false passages
  • renal stones
  • strictures
  • tumors

Resources

Organizations

American Kidney Fund (AKF). Suite 1010, 6110 Executive Boulevard, Rockville, MD 20852. (800) 638-8299. http://216.248.130.102/Default.htm.
National Kidney Foundation. 30 East 33rd St., New York, NY 10016. (800) 622-9010. http://www.kidney.org.

Retrograde Ureteropyelography

Synonym/acronym: Retrograde.

Common use

To assess the urinary tract for trauma, obstruction, stones, infection, and abscess that can interfere with function.

Area of application

Renal calyces, ureter.

Contrast

Radiopaque iodine-based contrast medium.

Description

Retrograde ureteropyelography uses a contrast medium introduced through a ureteral catheter during cystography and radiographic visualization to view the renal collecting system (calyces, renal pelvis, and urethra). During a cystoscopic examination, a catheter is advanced through the ureters and into the kidney and contrast medium is injected through the catheter into the kidney. This procedure is primarily used in patients who are known to be hypersensitive to IV injected iodine-based contrast medium and when excretory ureterography does not adequately reveal the renal collecting system. The incidence of allergic reaction to the contrast medium is reduced because there is less systemic absorption of the contrast medium when injected into the kidney than when injected IV. Retrograde ureteropyelography sometimes provides more information about the anatomy of the different parts of the collecting system than can be obtained by excretory ureteropyelography. Computed tomography (CT) and ultrasound studies are replacing retrograde pyelography because they are less invasive and the quality of the technology has significantly improved.

This procedure is contraindicated for

  • high alertPatients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alertPatients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
  • high alertPatients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs) because iodinated contrast is nephrotoxic.
  • high alertElderly and compromised patients who are chronically dehydrated before the test, because of their risk of contrast-induced renal failure.
  • high alertPatients with bleeding disorders because the puncture site may not stop bleeding.

Indications

  • Evaluate the effects of urinary system trauma
  • Evaluate known or suspected ureteral obstruction
  • Evaluate placement of a ureteral stent or catheter
  • Evaluate the presence of calculi in the kidneys, ureters, or bladder
  • Evaluate the renal collecting system when excretory urography is unsuccessful
  • Evaluate space-occupying lesions or congenital anomalies of the urinary system
  • Evaluate the structure and integrity of the renal collecting system

Potential diagnosis

Normal findings

  • Normal outline and opacification of renal pelvis and calyces
  • Normal size and uniform filling of the ureters
  • Symmetrical and bilateral outline of structures

Abnormal findings related to

  • Congenital renal or urinary tract abnormalities
  • Hydronephrosis
  • Neoplasms
  • Obstruction as a result of tumor, blood clot, stricture, or calculi
  • Obstruction of ureteropelvic junction
  • Perinephric abscess
  • Perinephric inflammation or suppuration
  • Polycystic kidney disease
  • Prostatic enlargement
  • Tumor of the kidneys or the collecting system

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
    • Retained barium from a previous radiological procedure.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
  • Other considerations

    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.
    • Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the urinary tract.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s genitourinary system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results, including examinations using barium.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • If iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that some pain may be experienced during the test, or there may be moments of discomfort. Inform the patient that the procedure is performed in a special department, usually in a radiology or vascular suite, by an HCP, with support staff, and takes approximately 30 to 60 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Inform the patient that he or she may receive a laxative the night before the test and an enema or a cathartic the morning of the test, as ordered.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications. Explain that the contrast medium will be injected, by catheter, at a separate site from the IV line.
  • Inform the patient that if a local anesthetic is used, the patient may feel (1) some pressure in the kidney area as the catheter is introduced and contrast medium injected and (2) the urgency to void.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure. Instruct the patient to avoid taking anticoagulant medication or to reduce dosage as ordered prior to the procedure. Protocols may vary among facilities.
  • This procedure may be terminated if chest pain, severe cardiac arrhythmias, or signs of a cerebrovascular accident occur.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:
  • Establishing an IV site and injecting contrast medium by catheter are invasive procedures. Complications are rare but do include risk for allergic reaction related to contrast reaction; bleeding from the puncture site related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners; hematoma related to blood leakage into the tissue following needle insertion; infection that might occur if bacteria from the skin surface is introduced at the puncture site; UTI related to insertion of cystoscope or catheter; hematuria related to insertion of cystoscope; and sepsis related to bacterial contamination from infected urine.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure that the patient has complied with dietary, fluid, and medication restrictions for 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any substance or drug. Use nonionic contrast medium for the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Record baseline vital signs and assess neurological status. Protocols may vary among facilities.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
  • Administer an antianxiety agent, as ordered, if the patient has claustrophobia. Administer a sedative to a child or to an uncooperative adult, as ordered.
  • Place electrocardiographic electrodes on the patient for cardiac monitoring. Establish baseline rhythm; determine if the patient has ventricular arrhythmias.
  • Place patient supine on the table in the lithotomy position.
  • A kidney, ureter, and bladder (KUB) or plain image is taken to ensure that no barium or stool will obscure visualization of the urinary system. The patient may be asked to hold his or her breath to facilitate visualization.
  • The patient is given a local anesthetic, and a cystoscopic examination is performed and the bladder is inspected.
  • A catheter is inserted, and the renal pelvis is emptied by gravity. Contrast medium is introduced into the catheter. Inform the patient that the contrast medium may cause a temporary flushing of the face, a feeling of warmth, or nausea.
  • X-ray images are made and the results processed. Inform the patient that additional images may be necessary to visualize the area in question.
  • Additional contrast medium is injected through the catheter to outline the ureters as the catheter is withdrawn.
  • The catheter may be kept in place and attached to a gravity drainage unit until urinary flow has returned or is corrected.
  • Additional x-ray images are taken 10 to 15 min after the catheter is removed to evaluate retention of the contrast medium, indicating urinary stasis.
  • Remove the needle or catheter and apply a pressure dressing over the puncture site.
  • Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet, fluids, medications, and activity, as directed by the HCP. Renal function should be assessed before metformin is resumed.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
  • Instruct the patient in the care and assessment of the site.
  • Instruct the patient to apply cold compresses to the puncture site as needed to reduce discomfort or edema.
  • Monitor for signs of sepsis and severe pain in the kidney area.
  • Maintain the patient on adequate hydration after the procedure. Encourage the patient to drink lots of fluids to prevent stasis and to prevent the buildup of bacteria.
  • Recognize anxiety related to test results, and be supportive of perceived loss of independent function. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include angiography renal, BUN, calculus kidney stone panel, CT abdomen, creatinine, cystoscopy, IVP, KUB, MRI abdomen, PT/INR, PSA, renogram, US kidney, UA, and voiding cystourethrography.
  • Refer to the Genitourinary System table at the end of the book for related tests by body system.