38
CHAPTER
The Genitourinary Tract;
Techniques and Anatomy
Plain abdominal radiographs
Intravenous urogram
Ultrasound
Computed tomography
Relevant anatomy for CT of the urinary tract
Micturating cystourethrogram
Ascending urethrogram
Combined ascending urethrogram and MCU
Magnetic resonance imaging
Antegrade pyelography
Retrograde pyelography
Percutaneous nephrostomy
Percutaneous nephrolithomy
Ureteric stent placement
Digital subtraction catheter angiography of the renal artery
Uterine artery embolization for uterine fibroids
Uroradiology remains a discipline that utilizes all imaging tech-
niques to provide answers to specific clinical questions. The
required information can be obtained most rapidly and effi-
ciently by using the correct test or tests performed in the cor-
rect order. The wealth of recent technological developments in
genitourinary imaging and interventional techniques means that
the opportunity to image or intervene has advanced beyond our
understanding of exactly when such techniques are best applied.
This introductory chapter illustrates imaging and interventional
techniques available and the type of specific information each
will give, where relevant specific anatomical points relating to
a particular clinical scenario will be emphasized. Subsequent
chapters will provide detailed examples and illustrations of dis-
ease processes and will explore further the preferred order of the
various tests and procedures under review.
PLAIN ABDOMINAL RADIOGRAPHS
A plain radiograph of the abdomen should be obtained before
any contrast examination because calcification may later be
Nigel Cowan
masked by the contrast medium (Fig. 38.1). A preliminary plain
radiograph also serves as a check of the exposure factors required
for the patient. It is important that the kV should be kept low to
increase the chance of detecting calcification in the urinary tract.
As small renal calculi may be hidden by bowel shadows, at least
two views of the renal area may be required. A simple routine
is to expose a full-length radiograph in inspiration and a coned
view of the kidneys in expiration. The change in position of the
kidneys at these different phases of respiration will show whether
a calcification is intrarenal because its position is constantly related
to the kidney, or separate from the kidney. During deep inspira-
tion, calcified costal cartilage (which may overlie the renal area
in expiration) is lifted up and at the same time the descending
diaphragm displaces the kidneys caudally. If there is doubt about
the presence of a calculus, an oblique view or tomography of the
kidneys may be required.
The perirenal fat gives a lucent outline to the kidneys and
allows an assessment to be made of their position. Any mass
related to them may be suspected by careful scrutiny of the
plain radiographs. The loss of outline of a psoas muscle may
point to retroperitoneal pathology but it is a notoriously
inaccurate sign. The full-length radiograph should include
the bladder base and, in male patients, the prostatic urethra,
particularly when there are lower tract symptoms, in order
not to miss a urethral calculus. The outline of the bladder can
be appreciated and for this reason the patient should empty
the bladder before investigation: a large bladder residue may
then be recognized. A careful examination of the bones should
be made, particularly the lumbar spine and sacrum in a child
with enuresis where a spina bifida or sacral anomaly (so easily
missed) may be the underlying problem.
INTRAVENOUS UROGRAM
The number of intravenous urograms (IVUs) performed over
the last 15 years has decreased as the use of other imaging
techniques, particularly US and CT, has increased. The IVU
is still a valuable procedure for examination of the urinary
814 SECTION 4 THE GENITOURINARY SYSTEM

Figure 38.1 Plain radiographs. (A) Plain abdominal X-ray. Bilateral large ureteric
calculi. (B) Unenhanced axial CT at the level of the stones. (C) Coronal multiplanar
reformation (MPR) sections demonstrating the same bilateral ureteric calculi with bilateral
hydronephrosis and renal atrophy.

tract. It gives excellent anatomical images of the pelvicalyceal
systems and, to some extent, an indication of renal function
(Fig. 38.2).
Patient preparation in the form of bowel preparation is
probably unnecessary as tomography can be employed when
overlying gas and faecal shadows are a problem. Overhydration
should be avoided but fluid restriction is no longer considered
necessary1. In patients with impairment of renal function it
is imperative that there should be no fluid restriction. Dehy-
drated patients are more prone to intratubal obstruction, lead-
ing to oliguria or anuria from protein precipitation in the renal
tubules which may cause even more serious renal impairment.
Patients at particular risk are those with myeloma and diabe-
tes. Other techniques should therefore be considered for this
patient population.
While patients should be allowed to drink normally, it may
be advisable to ask them to avoid solid food for 4 h before the
intravenous contrast examination as they are then less likely to
vomit should there be a reaction to the contrast medium.
Contrast media
Contrast media reactions are described elsewhere. Minor
reactions such as hot flushes and nausea are common and
should not cause undue alarm. It is likely that anxiety may
promote contrast reactions and so quiet reassurance should
be routine practice. Nonionic and low osmolar contrast
media have been shown to cause fewer serious side-effects
than ionic media, and most centres now exclusively use these
safer agents2.
The quantity of contrast medium administered should
be related to the weight of the patient (300 mg kg-1 body
weight). If the patient is well hydrated the dose may be
increased to 600 mg kg-1 body weight. The contrast medium
should be injected rapidly so that a bolus reaches the kid-
neys. This high concentration arriving at the glomeruli will
produce a high concentration in the nephrons, and thus a
denser nephrogram and subsequent pyelogram than would
otherwise be the case.

Figure 38.2 Intravenous urogram. (A) Duplex right ureters on a
15-minute full length radiograph. (B) Designated renal area radiograph
for improved visualization of duplex (right) and normal (left) collecting
system.
Sequence of imaging
In order to obtain a good demonstration of the renal outlines,
a radiograph coned to the renal area should be taken immedi-
ately after the injection of contrast medium (the 1-min film).
 CHAPTER 38
This will coincide with the highest concentration of contrast
medium in the nephrons and from this nephrogram the size
and outline of the kidneys will be seen.
An image at 5 min coned to the renal area will show early
filling of the pelvicalyceal system and the relationship of the
calyces to the renal outline. Again, tomography or oblique
images may be useful. Some advocate abandoning the imme-
diate 1-min nephrogram image, as the 5-min tomogram will
give an equally good demonstration of the renal outlines,
allowing the number of films in the IVU series to be reduced.
This decreases the total radiation dose to the patient, the
importance of which is now well understood. If there is any
doubt about the renal outlines, ultrasound is far better than
urography.
If the presence of a calculus in the lower ureter is suspected, a
full-length radiograph at 5 min will usually show the full length
of a normal ureter owing to the osmotic diuretic effect of the
contrast medium. At a later stage of the IVU the distal ureter
may be obscured by contrast medium in a full bladder. If the
immediate image shows only one normally situated kidney, the
full-length 5-min radiograph may disclose a pelvic kidney.
Provided there is no evidence of obstruction at 5 min, the
pelvicalyceal system is best demonstrated by applying abdomi-
nal compression with a special pneumatic belt and obtaining
an image coned to the renal area after 34 min of compres-
sion (the 10-min film). The pelvis and calyces then become
distended with contrast medium, helping to display abnormal
filling defects and pushing aside normal vessels which may
cause an impression upon a calyceal neck.
Recent abdominal surgery or evidence of an abdominal
aortic aneurysm are obvious contraindications to the use
of abdominal compression, and it is ineffective in the obese
patient. When calyces overlap each other, or there is a suspi-
cion of an abnormality related to them, a posterior oblique
radiograph coned to the dependent kidney can help. Abdom-
inal compression is uncomfortable for the patient so the belt
should be released as soon as the relevant images of the pel-
vicalyceal systems have been obtained. A full-length radio-
graph at this stage will best demonstrate the ureters. If there
is any hold-up of contrast medium in a ureter, further views
are indicated; either a prone view, when contrast medium
will collect in a more dependent portion of the ureter, or an
oblique view, when the relationship of the ureter to a possible
phlebolith will be seen. The bladder will be well filled at this
stage and oblique views may help to show any irregularity of
the wall of the bladder or demonstrate the relationship of a
pelvic mass to the bladder. At least two views of the ureters
are required when a urothelial abnormality is suspected, in
order to differentiate a peristaltic contraction from a stricture
or a tumour. A full-length, postmicturition radiograph will
offer a further view of the ureters and also show free drainage
of the contrast agent from the kidneys, which can be particu-
larly helpful if earlier films show rather baggy pelvicalyceal
systems and obstruction is to be excluded.
Each urogram should be tailored to answer a specific clini-
cal question. In some cases there may be a need for several
tomograms of the kidney to address a specific renal problem.
THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 815
To compensate for this and to avoid additional irradiation of
the patient, views of the bladder may be omitted; this organ
can in any case be better studied by ultrasound. In other cases
the initial 1-min image may be omitted if fine detail of the
inner urothelial lining of the upper urinary tract is required,
e.g. in the follow-up of a patient with a known urothelial
tumour. Tailoring the urogram in this way can decrease the
radiation dose given to the patient.
ULTRASOUND
Ultrasound (US) is an exceedingly useful technique for exam-
ination of the urinary tract. The advantages of using a non-
invasive test, which is painless and does not involve irradiation
to either patient or operator, are obvious. When a renal mass
is found at IVU, then an ultrasound examination will easily
and rapidly differentiate a tumour from a cyst. Combining a
limited IVU, with its ability to demonstrate the pelvicalyceal
system in detail, and ultrasound, which will show abnormali-
ties of the renal outline, is a very efficient method of imaging
the urinary tract accurately.
One of the most frequently performed urological ultra-
sound examinations is the estimation of residual urine in
the bladder of patients with outflow obstructive symptoms.
This can be combined with measurements of urinary flow
rates, giving vital information to the urologist. A normal flow
rate with no residue is reassuring to patient and clinician
alike. Slow flow with a large bladder residue, on the other
hand, may indicate a decompensated bladder due to outflow
obstruction.
US provides information about renal length which is used
to estimate renal mass and the presence or absence of hydro-
nephrosis (Fig. 38.3). The normal length in the adult ranges
between 11 and 14 cm. Women tend to have smaller kidneys
than men. The normal adult renal length approximates to the
height of three lumbar vertebral bodies (nearly four in children).
A difference in renal size of over 2 cm is usually significant.
A normal range of mobility during respiration varies from
1 to 5 cm. During inspiration the ureters may become kinked,
mimicking adhesions or obstruction (Fig. 38.4). Urograms are
best obtained in the expiratory phase. Studies correlating renal
size measurements obtained at urography with those obtained
by ultrasound have shown a 1015% discrepancy. The smaller
values determined by ultrasound are probably due to both the
elimination of magnification and diuresis-induced nephro-
megaly in urography.
The kidney grows rapidly in the first few years of life, reach-
ing maximum size in the early twenties, stabilizes between 40
and 50 years and decreases thereafter. Renal mass in old age
may decrease by over 20%, while renal length decreases by
approximately 10%. The more significant decrease in renal
mass is related to the replacement of parenchyma by fat. In
the healthy adult, renal cortex contributes approximately 50%,
medulla 35% and sinus fat 15% to the overall volume of the
kidney. The cortex consists by volume of 80% tubules, 10%
glomeruli and 10% interstitial tissue.
816 SECTION 4 THE GENITOURINARY SYSTEM

Figure 38.3 Ultrasound of the

kidneys. (A) Normal right renal US.
(B) Study showing hydronephrosis
and cortical atrophy.

Kidneys with duplex systems are larger than expected for a COMPUTED TOMOGRAPHY
particular individual by as much as 10% and a duplex system
is the single most common cause of an enlarged unilateral Computed tomography (CT) has become the preferred
kidney. A solitary kidney at birth often approximates the mass investigation for acute loin pain (Fig. 38.5), renal mass
of two kidneys by the age of 1 year. (Fig. 38.6), renal arteries and, more recently, the urothelium
(CT urography) (Fig. 38.7). Multidetector CT systems allow
Transrectal and transvaginal ultrasound
The bladder neck can be imaged by transrectal or
transvaginal ultrasound and a urodynamic assessment of the
bladder may include ultrasound studies to show an open or
closed bladder neck. Transrectal ultrasound of the prostate,
combined with transrectal biopsy, is widely applied in the
detection of early carcinoma of the prostate. The early
detection of prostatic carcinoma is possible, but it is still
not yet fully understood whether such detection and subse-
quent aggressive therapy leads to decreased mortality from
this disease3. This remains a controversial area of medical
practice. Transrectal or transvaginal ultrasound is useful in
women with dysuria and suspected urethral diverticula. The
fluid-filled diverticulum is better shown with ultrasound
than with a micturating cystourethrogram.
Figure 38.5 Unenhanced CT of kidneys, ureters and bladder for acute
loin pain. (A) Axial section showing a small stone in the upper left ureter
with surrounding oedema. (B) Coronal multiplanar reformation (MPR) image
showing a small stone lying in the left ureter just above the point where the
ureter crosses the left gonadal vein. Minor left hydronephrosis.

Figure 38.6 CT for diagnosis of the renal mass. (A) Multiplanar

reformation (MPR) image of abdominal CT after intravenous contrast
Figure 38.4 Respiratory-induced changes in the ureter. medium showing a large right renal cell cancer with invasion into
(A) Retrograde ureteropyelogram showing a straight ureter in expiration. the inferior vena cava and pulmonary metastases. (B) Axial CT of a
(B) A markedly kinked ureter in inspiration. multilocular cystic renal cancer.

Figure 38.7 CT urography. Coronal maximum intensity projection
(MIP) acquired 1012 minutes following intravenous contrast
medium masking the location of a stone in the upper left ureter but
demonstrating there is no obstruction and normal in all other respects.
thin slices to be acquired for large body areas in a single
breath hold. The large datasets of isotropic or near isotropic
voxels allow multiplanar interrogation. A variety of post-
processing techniques may be utilized for image analysis and
display.
CT urography (CTU) has become so refined that some
centres have now abandoned the IVU, particularly in patients
with macroscopic haematuria, as CT has high sensitivity for
detection of small renal cell carcinoma, urinary tract stones
and transitional cell carcinoma4,5 (Fig. 38.8).
CT is the best investigation for the depiction of calculi
causing acute loin pain6. Calculi that are lucent on plain radi-
ography are readily detected, and secondary signs of obstruc-
tion such as hydronephrosis, hydroureter, nephromegaly, and
perirenal and periureter streaking are also apparent. CT is
also the preferred investigation for detecting renal masses and
recent evidence supports its use for the detection of urothelial
tumours7 (Fig. 38.9).
CHAPTER 38 THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 817
Figure 38.8 CT urography and intravenous urography (IVU)
compared. (A) CT urogram showing a transitional cell carcinoma of the
left lower pole. (B) IVU of the same case illustrating the subtle signs of
the left lower pole cancer which is a greater diagnostic challenge.
CTU may also be useful for the detection of ureteric leaks or
fistulae (Fig. 38.10). For investigation of living related donors
before renal transplantation, multislice CT enables a compre-
hensive single test evaluation for the presence of stones or
renal masses, assessment of the urothelium, renal parenchyma,
renal arterial and venous configurations, and the anatomy of
the ureters. The spatial resolution and speed of acquisition
currently greatly exceed that of MR imaging. Catheter angi-
ography is now rarely performed in this patient population8.
RELEVANT ANATOMY FOR CT OF THE
URINARY TRACT
Anatomical relationships of the kidney
The kidneys lie in the retroperitoneum, surrounded by the
perinephric fat between the anterior and posterior layers of
the renal fascia (Fig. 38.11). They lie lateral to and roughly
parallel with the lateral border of the psoas. The renal fossa is
bounded medially by the psoas muscle, posteriorly by the qua-
dratus lumborum muscle, laterally by the transversus abdomi-
nis muscles, and superiorly by the diaphragm. Anteromedially,
the kidneys are covered by peritoneum; posteriorly the twelfth
rib crosses the left kidney at a 45 angle, with approximately
one third or more of the left kidney superior to the inferior
margin of the thoracic cage. Organs related to the kidney
Figure 38.9 CT urography (CTU)
and ultrasound compared. (A) Axial
CTU section showing an anterior wall
soft tissue mass in the right renal
pelvis, diagnosed as a transitional
cell cancer. (B) Coronal multiplanar
reformation (MPR) image showing
tumour extension down the ureter.
(C) US of the right kidney showing the
corresponding mass in the collecting
system. The tumour was most clearly
identified with the patient in the prone
oblique position.
818 SECTION 4 THE GENITOURINARY SYSTEM
Figure 38.10 CT urography for ureteric leaks and fistulas. Bilateral
lower ureteric leaks following laparoscopic myomectomy.
include the adrenal glands, which are directly superior to the
kidney on the right side and anteromedial to the kidney on
the left. The upper poles of both kidneys approximate the dia-
phragm, and the posterior aspect from the medial to the lat-
eral borders is related to the psoas, quadratus lumborum and
the transversus abdominis muscle or fascia. Depending on the
amount of retroperitoneal fat, the anterior surface of the right
kidney may be in contact with the right adrenal gland, the
right lobe of the liver, the second portion of the duodenum
and the hepatic flexure of the colon. The organs related to the
anterior aspect of the left kidney are, from above downwards,
the left adrenal gland, the stomach, the pancreas and (on the
extreme lateral margin) the spleen and splenic flexure of the
colon9. In thin subjects the spleen may affect the contour of
the left kidney (splenic hump).
Renal capsule
The renal capsule is a fibrous envelope covering the kidney
that is firmly adherent to the renal substance. A potential space
exists between the kidney and its capsule, which in abnormal
situations may contain blood, pus, or urine. The capsule con-
tains both elastic tissue and nerves.
Figure 38.11 The renal fascia.
(A) Axial CT section showing anterior
and posterior layers of the renal fascia.
(B) CT peritoneogram clearly depicting
the outline of the layers of the anterior
and posterior renal fascia on the right
and the location of the perirenal space.
(C) Coronal multiplanar reformation
(MPR) CT image showing the location
of the kidneys in the perirenal space
surrounded by the renal fascia.
Renal sinus
The renal sinus contains fat and areolar tissue, as well as
the renal arteries, nerves and lymphatics. The sinus extends
around the renal pelvis, infundibula and calyces and may be
continuous with the perinephric fat.
Perinephric space and renal fascia
The perinephric space lies between the anterior (Gerotas) and
the posterior (Zuckerkandl) renal fascia. It is closed superiorly,
medially and laterally but may open into the iliac fossa infe-
riorly, communicating with the anterior and posterior para-
nephric spaces. The normal perinephric space contains the
kidney and copious fat. Almost all lesions occurring here are
secondary to renal disease. Renal abscesses may rupture into
the perinephric space. Renal trauma may lead to haemorrhage
within the space, and renal neoplasms may extend into it. Uri-
nomaseither spontaneous or traumaticfrequently occupy
the inferior medial aspect of the perinephric space. Knowledge
of the retroperitoneal fascia and retroperitoneal spaces helps in
understanding the localization and spread of fluid and infec-
tion around the kidney. These fascial relationships form well-
demarcated spaces.The renal fascia is clearly visible by CT and
is occasionally seen on urography in the normal patient. This
observation is made much more frequently in the presence of
perinephric disease, when the fascia becomes thickened.
Anterior paranephric space
The anterior paranephric space is delineated by the posterior
parietal peritoneum anteriorly and Gerotas fascia posteriorly.
This space is only partially closed, medially by fusion of the fas-
cial planes along the course of the aorta and inferior vena cava,
and laterally by the lateroconal fascia. It opens inferiorly into
the iliac fossa and there communicates with the posterior para-
nephric space. The anterior paranephric space contains para-
nephric fat, the duodenal loop, the pancreas and, on the right,
the ascending and, on the left, the descending colon. Infection
of the colon, pancreas, duodenum, or retrocaecal appendix may
produce abscesses in the anterior paranephric space. If this space
enlarges with fluid collections, pressure effects may be seen on
the colon and on the proximal ureter, which runs through the
paranephric space. Infections in this space may communicate
with the posterior paranephric space in the pelvis.
 CHAPTER 38
Posterior paranephric space
The posterior paranephric space lies between the posterior
renal fascia anteriorly and the transversalis fascia posteriorly.
Laterally, the posterior renal fascia joins the anterior renal fas-
cia to form the lateroconal fascia. The medial aspect of the
posterior paranephric space is closed by fusion of the pos-
terior renal fascia with the psoas fascia. This space continues
laterally as the properitoneal fat. Inferiorly, it communicates
with the anterior paranephric space and contains no organs.
Abscesses and haematomas may occur here, and fluid collec-
tions from the anterior paranephric or perinephric space may
communicate freely with it.
There are variations to the idealized anatomy of the renal
and lateroconal fascias. In some individuals the lateroconal fas-
cia may be partially absent, possibly explaining the presence of
fluid in acute pancreatitis in the posterior paranephric space
or retrorenal position of the colon. Peritoneal recesses may
extend deeply in the retrorenal area and intraperitoneal organs
such as spleen and liver may partially extend posterior to the
kidney, which may complicate nephrostomy placement.
Ureter
The ureter is the tubular extension of the renal collecting
system which passes inferiorly and medially to connect the
kidney with the bladder. Each is 2530 cm long with a lumen
approximately 24 mm in diameter (Fig. 38.12). The ureter is
conveniently divided into two parts, an upper abdominal ure-
ter and a lower pelvic ureter. The abdominal portion begins at
the junction with the renal pelvis and runs over the anterior
surface of the psoas muscle in the anterior paranephric space.
In anteroposterior (AP) projections it is usually described as
running over the lateral third of the lumbar transverse processes
Figure 38.12 The pathway of the ureter. Sagittal maximum intensity
projection (MIP) CT image. The straight upper ureter turns into the pelvis
over the common iliac artery to pass around the side wall of the pelvis to
the bladder.
THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 819
(L35), covered by and adherent to peritoneum. A ureter that
lies more than 1.5 cm lateral to the transverse process is sus-
pected of being laterally deviated; a ureter that crosses over the
pedicle is suspected of being medially deviated. In prone or
inspiratory imaging, kinking of the proximal ureter is com-
mon.The inner surface of the ureter, like that of the collecting
system in the kidney, consists of a layer of transitional epithe-
lium. The outer surface is surrounded by loose areolar tissue.
The ureter lies in a fairly constant position in the retroperito-
neum; however, as it is not firmly fixed, pathological processes
may alter its position.
The abdominal ureter crosses the bifurcation of the com-
mon iliac artery to enter the pelvis and becomes the pelvic
ureter.The pelvic ureter runs abruptly posteriorly and laterally
in the retroperitoneal space and passes along the posterolateral
wall of the pelvis. In the region of the ischial spine the ureter
turns medially, anteriorly and inferiorly to the bladder. There
is no true ureterovesical sphincter but the passage through the
muscular wall of the bladder at a shallow angle impedes reflux.
The ureteral orifices in the bladder are approximately 2.5 cm
apart.
There are three normal areas of narrowing in the ureter: at
the pelviureteric junction, where the ureter crosses the com-
mon iliac artery at the pelvic brim, and at its entrance to the
bladder where it is narrowest.
Blood supply is by longitudinal anastomosis between renal,
gonadal and inferior vesical arteries.
Lymphatic drainage of the superior ureter is the same as
that of the kidney, draining preferentially to the renal hilar and
lateral aortic nodes. The mid portion of the ureter drains infe-
riorly to the common iliac nodes. The pelvic ureter may drain
to the external, internal, or common iliac nodes.
Ureteral peristalsis is nearly always recognizable on the IVU.
A wave of electrical depolarization extends from the focus of
a rudimentary pacemaker in the renal pelvis inferiorly along
the ureter and is followed by a muscular contraction wave that
propels a bolus of urine. In the normal ureter, the contrac-
tion wave causes the ureter walls to come together, so that the
ureter lumen is obliterated for a length of several centimetres.
Active contraction means that it is normal in urography to
see only portions of the ureter. If a bolus of opacified ureteric
urine enters a relatively unopacified bladder, it may be seen as
well-defined ureteric jet.
Congenital variations of the ureter
Duplication of the ureter may be partial or complete. Dupli-
cation occurs in approximately 3% of individuals and is more
common in women. Unilateral duplication is more common
than bilateral and complete duplication more common than
incomplete. The ureter from the superior pelvis ends inferior
to that from the inferior pelvis.
In a complete duplication the upper moiety ureter inserts
ectopically low in the bladder, in the bladder neck, or in the
posterior urethra. It may enter the seminal vesicle or ejacula-
tory duct in men or the vagina in women. Female patients
may experience urinary wetting as the result of an ectopic
ureter inserting in the urethra distal to the external sphincter
820 SECTION 4 THE GENITOURINARY SYSTEM
or into the vagina. Wetting does not occur in men, since the
ectopic ureteral insertion is always proximal to the external
sphincter. Ectopic ureter insertions are seen less commonly in
single (nonduplicated) systems. As the distance of the ectopic
ureteric orifice from the trigone increases, so does the likelihood
of renal dysplasia.
Classically, calyceal dilatation due to distal ureteric obstruc-
tion occurs in the superior moiety. The inferior moiety ureter
with a more horizontal path through the bladder wall has an
increased tendency for vesicoureteric reflux.
The upper moiety ureter, which inserts in the bladder, passes
through the bladder wall to an orifice below the normal site in
the trigone. The ectopic ureteral orifice is often stenotic, caus-
ing dilatation of the intramural portion of the upper moiety
ureter. This ectopic ureterocele will appear as a filling defect
along the posterior lateral wall of the bladder and can grow so
large that it obstructs or distorts the ipsilateral lower moiety
ureter. The ectopic ureterocele may also prolapse into the ure-
thra, causing bladder outlet obstruction, and, in women, present
as a labial and interlabial mass. A bladder filled with high-density
contrast medium can hide or flatten a ureterocele.
Recognition of an obstructed upper moiety of a duplicated
system is sometimes difficult.The upper moiety may only drain
a single calyx. Such a system, even when obstructed, may cause
no or minimal downward displacement of the lower moiety
collecting system. Radiological clues to a poorly functioning
upper moiety include lateral displacement (often subtle) of the
lower moiety ureter, apparent increased thickness of the upper
pole, fewer visible calyces than normal and a partial duplica-
tion or bifid pelvis in the contralateral kidney. Clinical clues to
an ectopic ureter are continuous urinary dribbling in a girl or
epididymitis in a prepubertal boy9.
Other congenital abnormalities such as mega-ureter may
predispose to recurrent urinary tract infections (Fig. 38.13).
Figure 38.13 Mega-ureter predisposes to recurrent urinary tract
infections.
MICTURATING CYSTOURETHROGRAM
The micturating cystourethrogram (MCU) is the most accu-
rate method of demonstrating vesicoureteric reflux, and is
important in children with urinary tract infection and reflux
nephropathy. It is an uncomfortable investigation for both
adults and children and the catheterization should be carried
out gently but confidently with anaesthetic jelly and an appro-
priately sized catheter, using a sterile nontouch technique.
Dilute water-soluble contrast medium (1520%) should be
used and the bladder filled to capacity. After removal of the
catheter the patient is tilted with the table to the erect posi-
tion and asked to empty the bladder into a plastic jug. Images
during filling and during micturition should be obtained to
document any vesicoureteric reflux. Micturating radiographs
taken with the patient slightly oblique will demonstrate the
posterior urethra. This part of the study is especially impor-
tant in children suspected of having posterior urethral valves,
which will only fill out and cause obstruction during mic-
turition. Contrast medium injected retrogradely will fail to
show valves. When catheterization is not possible because of
a urethral stricture, the bladder can be filled in the retrograde
manner using an ascending urethrogram.
ASCENDING URETHROGRAM
The ascending urethrogram gives excellent anatomical infor-
mation concerning the distal urethra as far as the distal sphinc-
ter mechanism (Fig. 38.14). Water-soluble contrast medium
should be introduced by means of either a clamp and nozzle
(Knutssons clamp) or a Foley balloon catheter gently inflated
in the fossa navicularis just proximal to the urethral meatus.
For a simple ascending urethrogram to demonstrate a penile
or bulbar urethral stricture, the clamp is easy and quick to
use, the whole investigation taking just a few moments. As
soon as the urethra is filled and contrast medium is seen to
be trickling past the distal sphincter, images are taken in two
oblique projections. Several workers are now using ultrasound
techniques to demonstrate the adult male urethra; the patient
merely pinches off the distal urethra during micturition and
the urethra can be imaged as a fluid-filled tube.
Figure 38.14 Ascending urethrogram. Study delineating all parts of
the urethra. A stricture is present in the bulbous urethra.
 CHAPTER 38
COMBINED ASCENDING URETHROGRAM
AND MCU
When both an ascending urethrogram and a descending (mic-
turating) study are required to show the posterior urethra, the
bladder can be filled slowly using a 50 ml syringe for repeated
injections. After images of the anterior urethra have been
obtained in the usual way, the clamp or catheter is removed,
the patient tilted to the upright position, and oblique views
during micturition obtained to exclude vesicoureteric reflux
and to demonstrate the posterior urethra.This combined study
is of particular importance in demonstrating the anatomy of
strictures in the proximal and distal urethra after pelvic and
perineal trauma. Images of the urethra obtained during mictu-
rition at the end of an IVU are inadequate, the concentration
of contrast medium being insufficient for this purpose.
The adult male urethra
The male urethra extends from the bladder neck to the external
urethral meatus (~20 cm), passing through the body of the pros-
tate gland, the urogenital diaphragm and the penis (Fig. 38.14).
The urogenital diaphragm extends across the pubic arch,
closing the anterior aspect of the pelvic outlet.The apex of the
triangular urogenital diaphragm lies anteriorly, and is attached
anteriorly and laterally to the inferior rami of the pubic arch
and the ischia. Posteriorly, the base of the triangle is attached
to the tendinous plate of the perineum and is contiguous
with the anal fascia. The diaphragm is perforated near the
apex by the urethra, approximately 1 cm below the symphysis
pubis. The urogenital diaphragm contains the striated exter-
nal sphincter and the pea-sized glands of Cowper, and divides
the urethra into two portions: the anterior urethra, below the
inferior aspect of the urogenital diaphragm, and the posterior
urethra above the inferior aspect of the urogenital diaphragm.
The anterior urethra
The anterior urethra extends from the inferior aspect of the
urogenital diaphragm to the external meatus. It is divided into
two parts by the penoscrotal junction. Anterior to the peno-
scrotal junction is the penile urethra, which dilates distally to
form the fossa navicularis within the glans. Proximal to the
penoscrotal junction, the bulbous urethra extends proximally
to the inferior aspect of the urogenital diaphragm. The bul-
bous urethra dilates slightly in the most proximal part. It ends
proximally in a symmetrical cone shape at the inferior aspect
of the urogenital diaphragm. Along the anterior urethra are
numerous subcutaneous glands, the glands of Littre.
Cowpers glands are about the size of a pea and empty into the
dilatation in the bulbous urethra. Each has a simple duct approxi-
mately 2.5 cm long. The glands secrete a fluid that prepares the
urethra for the passage of semen during ejaculation.The anterior
urethra is surrounded by tissue covering the corpus spongiosum
and corpora cavernosa. The bulbocavernosus muscle empties the
anterior urethra of urine at the end of micturition.
The posterior urethra
The posterior urethra extends proximally from the inferior aspect
of the urogenital diaphragm to the bladder neck and has two
THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 821
parts. The membranous urethra within the urogenital diaphragm
is 11.5 cm long and 57 mm wide.The prostatic urethra contin-
ues proximally through the prostate gland to the bladder neck.
The verumontanum is a mound of smooth muscle on the
posterior wall of the prostatic urethra. The superior aspect of
the verumontanum is clearly defined and rises abruptly a lit-
tle above the middle of the prostatic urethra. The bulk of the
verumontanum extends inferiorly into the dorsal third of the
prostatic urethra, tapering to form the urethral crest, which
extends into the membranous urethra. The verumontanum
contains three small orifices. The superior orifice is the open-
ing to the prostatic utricle which is a blind end, extending into
the median lobe of the prostate.
The prostatic utricle is a vestigial remnant of the Mllerian
duct and homologous with the female uterus and vagina.
A little below and to the side of the prostatic utricle orifice
are the two small orifices of the ejaculatory ducts.The ejacula-
tory duct is formed by the junction of the duct of the seminal
vesicle and the ampulla of the vas deferens. Each duct passes
inferiorly and anteriorly through the prostate gland to empty
into the urethra at the verumontanum. Each duct is approxi-
mately 2 cm long. On each of the verumontanum and urethral
crest is a shallow sulcusthe prostatic sinusinto which the
prostatic ducts empty. The urethra passes through the prostatic
sinus slightly anterior to the midline.
MAGNETIC RESONANCE IMAGING
MR imaging now plays an important role in the staging of
pelvic malignancy10. Functional techniques, new contrast
agents such as lymphotrophic superparamagnetic nanoparticle
(LSN)11 and 3 Tesla magnets will further improve MR imag-
ing of prostate cancer12.
The internal anatomy of the prostate gland is best dem-
onstrated on T2-weighted images (T2WI) (Fig. 38.15). The
normal peripheral zone demonstrates higher signal intensity
Figure 38.15 T2-weighted fast spin-echo (FSE) sequence of the
prostate gland showing low signal bulge in the right peripheral zone
corresponding to prostate cancer.
822 SECTION 4 THE GENITOURINARY SYSTEM

than the central zone because of its high water content and
the loose acinar structure of the glands.Tumour appears as low
signal on T2WI and T1WI whereas blood appears to be of low
signal on T2WI and high signal intensity on T1WI.
MR imaging is increasingly being used for staging and
evaluating endometrial, cervical and ovarian cancers, and the
appearance of bladder and ureters is critical. MR imaging has
proved to be superior to other techniques for staging of cer-
vical and endometrial cancers and should be used for preop-
erative staging of these tumours13. MR imaging is also being
used increasingly in the investigation of benign disease of the
female pelvis, including pelvic floor imaging and assessment of
endometriosis and uterine fibroids (Fig. 38.16).
MR urography
The unique advantage of MR urography (MRU) is the absence
of ionizing radiation. The exact clinical role of MRU has not
yet been defined and remains under evaluation. There are two
basic methods for modern MRU. The first technique uses
unenhanced, heavily T2-weighted turbo spin-echo sequences
to obtain static-water images of the urinary tract. It is used in
poorly functioning hydronephrotic kidneys. The second tech-
nique is similar to conventional intravenous urography and is
known as excretory MR urography. A gadolinium-containing
contrast agent is given intravenously. Following renal excre-
tion, the gadolinium-enhanced urine is visualized using fast
T1-weighted gradient echo sequences. Furosemide (0.1 mmol
per kg body weight) intravenously is often given to improve
image quality14.
MR angiography
Gadolinium-enhanced MR angiography may be used for
assessment of renal artery stenosis (Fig. 38.17) and for preas-
sessment of patients undergoing uterine artery embolization
(Fig. 38.18). It also has a role in the diagnosis of arteriove-
nous malformations, either congenital or secondary to trauma,
including iatrogenic injury from renal biopsy or percutaneous
nephrostomy15.
ANTEGRADE PYELOGRAPHY
Antegrade pyelography is an accurate method of demonstrat-
ing precisely the site of an obstruction to the upper urinary

Figure 38.16 T2-weighted fast

spin-echo (FSE) images of the uterus.
(A) Clear depiction of the zonal
anatomy of the uterus. A small fibroid
is present in the posterior fundal
region. (B) Sagittal section of the uterus
containing a pedunculated submucosal
fibroid. (C) Sagittal section of the
uterus post-uterine artery embolization
following spontaneous passage of the
fibroid per vaginum.

Figure 38.17 3D contrast-enhanced MR angiography (MRA) for renal artery stenosis. (A) Gadolinium-enhanced MRA of the renal arteries showing
bilateral renal artery stenosis. (B) Corresponding digital subtraction angiography (DSA) study confirming bilateral renal artery stenosis. (C) Flush DSA
study following bilateral renal artery stent placement.
 CHAPTER 38
tract. The IVU with delayed films may outline the obstruc-
tion, but the concentration of contrast medium may be poor
and the final diagnosis only made at 24 h. Multidetector-row
CT is a more rapid and accurate method of demonstrating
the site (and possible cause) of obstruction.
Ultrasound will rapidly confirm the presence of dilatation
in the pelvicalyceal system, allowing the clinician to proceed
directly to antegrade pyelography. With the patient prone, a
fine 2022 gauge Chiba needle is inserted under ultrasound
guidance or fluoroscopic control beneath the twelfth rib
into a lower pole calyx, under local anaesthesia. As soon as
the collecting system is punctured, trapped urine will escape
through the needle. This should be aspirated and sent for
culture and, if a urothelial tumour is suspected, for cytology.
Once some reduction of pressure has been achieved within
the system, contrast medium is injected to outline the pel-
vis and ureter down to the level of obstruction. It may be
necessary to tilt the patient into a semi-erect position to
demonstrate this.
THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 823
Figure 38.18 Gadolinium-enhanced MR
angiography (MRA) for pre-assessment
of uterine artery embolization. (A) MRA
study showing large ovarian arteries and
rudimentary uterine arteries bilaterally. (B)
Corresponding digital subtraction angiography
(DSA) study of large ovarian arteries supplying
the uterus and fibroid as well as the ovaries.
RETROGRADE PYELOGRAPHY
Retrograde ureteropyelography is indicated mainly in those
patients suspected of having a urothelial tumour of the upper
urinary tract and in whom excretion urography is normal or
equivocal. The catheter may be placed using a flexible cysto-
scope under sedoanalgesia and may be left in a selective position
for some hours to collect urine for cytological examina-
tion16. Images of exquisite detail may be obtained (Fig. 38.19).
Although it is important to ensure that anterior calyces are filled
with contrast medium for a complete examination (Fig. 38.20),
too much contrast medium may cause a tear of the calyx.
PERCUTANEOUS NEPHROSTOMY
Indications
Relief of obstruction
Collecting system and ureter access for percutaneous proce-
dures
Figure 38.19 Normal retrograde pyelogram.
(A) Normal study of the collecting system including the
renal pelvis. (B) Normal ureter. High spatial resolution
makes this test useful for investigation of subtle
urothelial lesions.
824 SECTION 4 THE GENITOURINARY SYSTEM
Figure 38.20 Pitfalls of retrograde
ureteropyelography. (A) Underfilling
of the inferior anterior calyces is a
pitfall to be aware of. (B) The anterior
calyces are shown clearly following
careful repositioning of the patient
and slight overfilling.
Palliation of ureteric leaks and fistulas
Functional assessment of the kidneys
Relative contraindications
Uncorrectable bleeding disorder
Severe electrolyte imbalance causing tachypnoea
Solitary kidney without prior retrograde attempt
Patients with no subsequent treatment option1719
When one procedure from below may avoid multiple pro-
cedures from above
Anatomy for intrarenal access
Access should be through a calyx to minimize the risk of
haemorrhage2023. Upper, mid, or lower zone calyceal punc-
tures are equally acceptable.
Since major segmental branches of the renal artery and
vein are related to the anterior surface of the renal pelvis, life-
threatening haemorrhage may occur as a result of an anterior
perforation (through-and-through puncture)24.
Patient positioning
The patient is placed in the 30 prone oblique position with
a pillow under the abdomen in order to decrease the lumbar
lordosis.
Imaging techniques for collecting system
localization
A combination of ultrasound25 and digital C-arm fluoroscopy
currently provide the most suitable imaging combination for
image-guided access26. CT is usually reserved for only the
most challenging of cases.
Access technique
Using real-time ultrasound for guidance25,27, a calyx is entered
using a 22g 15 cm Chiba needle. Contrast medium is injected
into the collecting system and sometimes a small amount of
air to assist with visualization of posterior lying calyces. If the
entry site is via the calyx, then the track is dilated over fine
guidewire. Should the entry point have missed a calyx, a sec-
ond puncture is made either with another 22g Chiba needle
or with a 19g diamond-pointed sheathed needle. The selected
calyx for entry is positioned at the isocentre of the C-arm.
This is achieved by putting the calyx in the centre of the TV
monitor with the C-arm in the AP position. The C-arm is
moved 1520 RPO (right posterior oblique). If the calyx
is at the isocentre it will remain in the centre of the screen.
If it moves to the left or right of the TV screen the calyx is
not at the isocentre. Raising or lowering the table so that the
calyx is returned to the centre of the screen will achieve the
required isocentre. During nephrostomy placement the radiol-
ogist should have control of the table and C-arm movements
for maximum accuracy and convenience and also to keep the
radiation dose to a minimum.
Fixation of the catheter
Displacement of catheter position is an exceedingly frustrating
complication. Secure fixation is mandatory and usually involves
a skin disc loosely sutured to the skin and tightly secured
around the catheter. The ideal catheter position is where the
pigtail lies in the upper pole from a lower pole access.
Results
The technical success rate for nephrostomy is high (98%), even
in the emergency situation28.
Complications
The complication rate of percutaneous nephrostomy (PCN) is
low28,29. In a survey published in 1978 of 516 nephrostomies,
serious major complications were reported in 21 patients (4%)29.
In a more recent series of emergency PCN performed on 160
patients, the overall complication rate was reported to be 34%:
6% were major and 28% were minor28. Major complications
included septicaemia (3.6%) and haematuria needing transfu-
sion (2.4%). Minor complications included catheter displace-
ment or malposition (4.8%), pelvic perforation (4.3%), paralytic
ileus (2.4%), pneumonia/atelectasis (1.8%) and pleural effusion

(1.2%). No deaths or serious morbidity resulted from any com-
plication28.
The mortality rate of 0.2% for percutaneous nephrostomy
compares favourably with the 6% reported for surgical neph-
rostomy. Patient death related to PCN is most commonly due
to an unanticipated cardiovascular event or rare cases of over-
whelming sepsis or massive haemorrhage.
Haemorrhage
In PCN, serious arterial injuries requiring embolization or
surgery are rare (12%)29,30. However, clinically silent sub-
capsular or extrarenal haematomas are much more common
and were found in 13% of cases following PCN as detected
by CT 12 days after the procedure31. A transparenchymal
needle puncture directed immediately into a calyx will
avoid the interlobar arteries and veins that traverse the renal
medulla. Approaches that are too medial may miss the renal
parenchyma completely and may even injure the main renal
artery or vein24.
Puncture of adjacent structures
Accidental puncture of neighbouring organs may follow
PCN placement if due care and attention are not given to
the relevant anatomy. Inadvertent puncture of the colon,
liver, or spleen has been reported3235. Ultrasound imme-
diately before PCN placement will help avoid these way-
ward punctures. If the kidney is located in an anomalous
position (e.g. horseshoe kidney) or the patient has signifi-
cant physical deformities (e.g. scoliosis), it may be helpful
to localize the kidney using CT and hence map out a safe
approach.
Infection
Special care should be taken when puncturing an infected
system. All patients should be placed on the appropriate anti-
biotics before PCN is started. Intraoperative manipulation
should be kept to a minimum. Overdistension of the renal
pelvis should be avoided and a diagnostic nephrostogram
should be deferred until the patient is afebrile. Aspirated urine
should be sent for culture and sensitivity testing.
PERCUTANEOUS NEPHROLITHOMY
Nowadays, extracorporeal shock wave lithotripsy (ESWL)
has replaced percutaneous nephrolithomy (PCNL) as the pri-
mary treatment of upper urinary tract stones. However, not
all stones respond well to ESWL, and therefore PCNL alone
or in combination with ESWL is still of value under specific
conditions.
Indications for PCNL
Large stone volume (> 2.0 cm diameter)
Complicated renal anatomypelviureteric junction
obstruction (PUJO), calyceal diverticulum
Suboptimal results with ESWLcystine stones
Special casespyonephrosis, xanthogranulomatous pyelo-
nephritis, large body habitus
CHAPTER 38 THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 825
Surgical techniques are now seldom performed in most
large stone treatment centres
Contraindications to PCNL
Untreated urinary tract infection
Uncontrolled bleeding diathesis
Method
PCNL is most commonly performed as a one-stage procedure
under general anaesthetic (Fig. 38.21). With the patient in the
supine position and using a cystoscope, the ureteric orifice
is cannulated with a straight hydrophilic-coated guidewire. A
retrograde 4 F general-purpose vascular catheter is passed up
the ureter. Using C-arm fluoroscopy, a retrograde ureterogram
is performed and images are stored for future reference. The
end of the 4 F catheter is left above the pelviureteric junction
(PUJ) to allow for opacification and distension of the system
immediately before nephrostomy. A Foley catheter should be
placed into the bladder and fixed independently to drain fluid
which passes down the ureter. The patient is then turned into
the prone oblique position and supported by padding on pres-
sure points, and the lumbar lordosis obliterated by radiolucent
pillows. The patient is draped using special PCNL drainage
bags. A watertight seal around the track is important to pre-
vent saline from seeping around the patient and lowering body
temperature, as well as providing an electrical hazard if water
enters the table mechanism.
The most appropriate calyx is selected and access achieved
as described previously. An intercostal space nephrostomy is
sometimes performed in: (A) those with ureteric stones that
cannot be flushed as they have been pushed back into the kid-
ney; (B) those with staghorn calculi (the upper pole approach
results in a track that is more nearly parallel to the long axis
of the kidney and allows smoother passage of the rigid US
probe); and (C) those with large upper pole calculi.
A safety wire may be left down the ureter and track dilata-
tion performed over a second wire introduced via a vascular
sheath.
Track dilatation
Teflon-coated plastic dilators are used initially over an Amplatz
guidewire followed by a high-pressure balloon catheter (10 mm
diameter). This is faster and less traumatic than the commonly
used alternative of metal telescopic dilators. Once a track has
been dilated, an Amplatz Teflon sheath is introduced to pro-
tect the track through which intrarenal manipulations can be
performed.
The rigid nephroscope is advanced into the calyceal system
through the sheath until the stone is visualized. Fragmenta-
tion of the stone mass is performed using ultrasonic, electro-
hydraulic, or laser lithotripsy, all performed under endoscopic
visualization and control. Large stone fragments are retrieved
with graspers and smaller ones with a sucker device. At the
end of the procedure the patient is left with a nephrostomy
(2026 F) with or without a ureteric stent that allows urinary
drainage and provides for further access should it be required. A
nephrostogram is performed 2472 h following the procedure
826 SECTION 4 THE GENITOURINARY SYSTEM

Figure 38.21 Percutaneous nephrostomy and percutaneous nephrolithotomy. (A) Plain abdominal X-ray to show the size and position of the lower
pole stone. (B) Retrograde injection of contrast medium delineates the position of the stone in relation to the calyces. (C) C-arm fluoroscopic guidance is
used for percutaneous access to a lower posterior calyx. (D, E) The exact location of the tip of the needle may be determined by views in oblique planes.
(F) The working guidewire and a safety wire are placed down the ureter before track dilatation. (G) The balloon is inflated and a sheath inserted over the
balloon into the collecting system. (H) Following stone treatment a plain radiograph is taken to see if all the stone fragments have been removed.

for assessment of ureteric drainage and possible nephrostomy
removal.
The same technique of access to the kidney may be used
for other procedures, including biopsy, removal of urothelial
tumours36, removal of retained foreign bodies37, percutaneous
endopyelotomy for PUJO38 and treatment and dilatation of
infundibular stenosis of stones39.
Complications of PCNL
Renal haemorrhage requiring transfusion (~3%)40.
Arteriovenous fistula requiring embolization (0.51%)41.
Pseudoaneurysms.
Sepsis post-procedure (12%)42, more common in patients
with infected urinary obstruction (pyonephrosis) or infected
stones (struvite).
Pneumothorax: An intercostal approach causes a higher risk
of pneumothorax (0.1%)41. Other series using a predomi-
nantly intercostal approach to the kidneys report an inci-
dence of pneumothorax and hydrothorax in the range of
412%43,44.
Colonic perforation: If the colon lies in a retrorenal posi-
tion, it may be perforated during puncture (0.002%). Signs
suggesting colonic perforation include rectal haemor-
rhage, shock and the passage of gas through the nephros-
tomy tract3234. Prior CT examination may identify at-risk
patients. A more posterior approach minimizes the risk of
colonic perforation.
Injury to anterior structures: Through-and-through punc-
ture of the kidney should be avoided as it may injure the
duodenum, jejunum, gallbladder, or pancreas35. Injuries to
the liver and spleen are very rare.
Other complications: Rarely stricture of the PUJ may
be secondary to perforations caused by the endoscopic
procedure. Early ureteric stenting may help in preventing
strictures. Foreign bodies are occasionally left in the calyceal
system or ureter during percutaneous and endoscopic inter-
ventions (e.g. pieces of wires, baskets, graspers, catheter tips,
lithotrodes, or fibres). Endoscopic or surgical intervention is
needed to remove them. Final inspection at the end of the
procedure may result in their detection and removal before
the track closes.
URETERIC STENT PLACEMENT
Indications for ureteric stent placement
Ureteric obstructionstone, tumours and strictures
Ureteric fistula
Before or after ESWL
Post-ureteric surgery/dilatation
 CHAPTER 38
Contraindications to ureteric stent placement
Distal obstruction (e.g. bladder outflow obstruction)
Irritable or intolerant bladder
Untreated urinary tract infections
Nonfunctioning bladder (noncompliant)
Bladder fistula
Small volume bladder (e.g. secondary to radiotherapy)
Approach: antegrade or retrograde?
The two principal routes used for ureteric stent placement
are the antegrade (percutaneous) approach and the retro-
grade (transurethral) approach. The choice is influenced by
several clinical factors45 as well as operator preference. Often
one approach is successful when the other has failed. Both
approaches may be reliably performed in the interventional
radiology suite under light sedation and intravenous analge-
sia46. Use of the retrograde approach means that stent place-
ment can be carried out as a one-stage procedure and the
patient is spared the inconvenience of the multiple proce-
dures usually required by the antegrade approach as well as
the potential complications of nephrostomy. Theoretically, the
retrograde approach should be attempted in nearly all cases
before considering the antegrade route. It should be regarded
as mandatory to attempt the retrograde approach first in all
cases of solitary kidney. In patients with acute renal failure and
tumour involving the ureteric orifices, it may be pertinent to
go straight to nephrostomy to reliably establish renal drainage.
Antegrade ureteric stent placement
Basic technique
Crossing the stricture The patient is prepared and draped in
the supine oblique position and the nephrostomy catheter cut
3 cm above the skin surface. A nephrostogram is performed
using dilute contrast to permit visualization of guidewires and
catheters in the collecting system and ureter.The nephrostomy
catheter is exchanged over a suitable guidewire (Bentson or
Amplatz) for a special intrarenal manipulation catheter and a
straight hydrophilic guidewire. A nephrostogram of the distal
ureter is performed (Fig. 38.22), the ureteric stricture is crossed
with the straight hydrophilic wire and the catheter is passed
into the bladder. Contrast medium is injected into the blad-
der together with a small quantity of local anaesthetic. If the
patient has an indwelling catheter it should now be clamped.
Measuring the length of the ureter Ureteric length is mea-
sured by positioning the tip of the guidewire at the uretero-
vesical junction (UVJ) and placing a clip on the guidewire at
the skin surface. The same guidewire is then withdrawn to
the PUJ and a second clip applied, again at the skin surface.
The length of the ureter may be determined by measuring
the distance between the two towel clips using a sterile ruler.
Placing the stent An Amplatz super-stiff guidewire is placed
into the bladder and the track dilated to 10 F. A 9 F 45 cm
peel-away sheath is placed over the guidewire47,48. Over the
Amplatz guidewire and through the peel-away sheath, an 8 F
double pigtail stent is placed. When the radio-opaque marker
THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 827
on the stent pusher is located within the renal pelvis above
the PUJ, the inner stiffener and the Amplatz guidewire are
completely withdrawn.The sheath is gradually withdrawn and
peeled-away while maintaining the position of the proximal
pigtail above the PUJ, but still within the renal pelvis, by a
combination of tension on the drawstrings and pressure on
the pusher until the stent is delivered into the renal pelvis
(Fig. 38.22). The stent may be finally positioned by pulling
the strings while maintaining the position of the sheath. The
strings are then cut and removed48.
Following stent placement
A covering nephrostomy catheter is placed through the peel-
away sheath into the kidney and left in place for 2448 h
until the draining urine turns clear and any residual debris or
clot is passed. Patency of the stent should be confirmed by a
nephrostogram before nephrostomy removal. An appointment
should be given to the patient to attend for routine retrograde
replacement in 6 months and the patient entered in the stent
registry or database.
Antegrade ureteric stent placement is often technically
challenging, requiring modifications of the basic technique47.
Suboptimal percutaneous access
Much has been made of selecting an upper or mid calyx for
access before stent placement but invariably a lower posterior
calyx will suffice if stiff guidewires and sheaths are subsequently
used for stent delivery49.This is important as it means the easi-
est calyx for nephrostomy access should always be selected for
renal drainage in the emergency situation.
Ureteric S-bends
Inability to negotiate an S-bend in the obstructed ureter may
lead to failure of stent placement. Rarely passage of the guide-
wire and catheter through the ureteric S-bend leads to forma-
tion of a complete loop, rendering stent placement impossible.
Rotation of the ureteric catheter at its hub in one direction
causes the loop to unfold, whereas the other direction causes
it to tighten. Once untwisted, the path for stent placement is
rendered straightforward.
Stricture dilatation
Dilatation of a ureteric stricture may allow the passage of a
stent. A 5 mm diameter, 4 cm long angioplasty balloon is usually
effective50.
Difficult strictures
Difficult strictures may be crossed using a 6 F/4 F coaxial
catheter system passed over a straight hydrophilic guide-
wire. If the 6 F supporting catheter is placed close to the
site of the stricture, the stricture may be crossed with the
guidewire and immediately followed by the 4 F inner
catheter.
Impassable strictures
A number of methods for making new channels have
been reported. The simplest involves reversing the straight
828 SECTION 4 THE GENITOURINARY SYSTEM

Figure 38.22 Antegrade ureteric stent placement. (A) Nephrostogram showing a tight malignant stricture of the lower ureter. (B) Coaxial catheter
combinations and supporting peel-away sheaths are sometimes needed to cross tight and tortuous strictures. (C, D) Tension on the strings of the stent
allows repositioning into an ideal proximal position. (E) Final position of the stent in the bladder. Ideally it should be a little higher to avoid irritating the
trigone.

hydrophilic guidewire and pushing firmly along the line of
the stricture, aiming for the bladder. More developed methods
involve the use of electrocautery51 or a Nd:YAG laser52.
Complications of ureteric stent placement
Unfortunately, there is no such thing as the perfect stent. Com-
plications may be divided into immediate and delayed. Imme-
diate complications relate to the technique of stent placement,
whereas delayed complications are related to the presence of a
foreign body in the urinary tract.
Infection, especially when combined with low urine output,
predisposes to stent encrustation. Infection may be treatable
with antibiotics; however, if marked encrustation has occurred,
stent replacement may be required. It is important that infec-
tion should be well treated before ureteric manipulation. Pre-
procedural antibiotics are recommended even if there is no
pre-existing infection.
Some patients tolerate stents poorly. In these cases replace-
ment with a shorter or softer stent may relieve symptoms.
Complications of stent placement are listed below.
 CHAPTER 38
Immediate complications
Upper pigtail left outside the kidney in the perinephric space
Upper pigtail placed too low in the upper ureter
Perforation of the renal pelvis or ureter
Extraureteric stent placement
Bucklingobstruction
Delayed complications
Bladder irritation
Stent occlusion
Stent migration
Stent breakage
Infection
Stone formation
Ureteric erosion
Ineffective drainage
Reflux pain
Haematuria
Pyrexia
Follow-up
Stents should be regarded as urinary tract foreign bodies and
hence all stents act as a nidus for calcium deposition and will
in time obstruct. Stent occlusion due to encrustation is the
most frequent complication of ureteric stents. Occlusion is
associated with a stone-forming tendency, low urine output
and infection. A high fluid intake helps prolong stent lifespan
and should be encouraged. Follow-up is essential.
Stent patency may be confirmed with ultrasound, cystogra-
phy, radionuclide urography, or IVU53.
Poor stent function may be secondary to stent occlu-
sion, poor emptying of the bladder, or ureteric encasement
by tumour. Patients should be made aware that they have an
indwelling stent or foreign body that should be changed every
6 months. It is advisable to maintain a stent registry where the
date of insertion and type of stent is recorded for every patient,
and a reminder for stent exchange sent to the patient at the
appropriate time54,55.
THE GENITOURINARY TRACT; TECHNIQUES AND ANATOMY 829
Stent exchange is best performed on an outpatient basis using
a flexible cystoscope and C-arm fluoroscopy under light seda-
tion and intravenous analgesia46. Useful alternatives for special
cases include fluoroscopically guided perurethral exchange56,57
as well as fluoroscopically guided percutaneous retrieval37,5862.
What to do when stent placement fails
If stent placement is impossible, the remaining alternatives are
permanent nephrostomy, dialysis, some form of nephrovesical
diversion63 or autotransplantation.
DIGITAL SUBTRACTION CATHETER
ANGIOGRAPHY OF THE RENAL ARTERY
Diagnostic catheter angiography of the renal arteries has
been largely replaced by CT and MR angiography but ther-
apeutic procedures such as renal artery stent placement and
renal artery embolization are widely performed (Fig. 38.17).
Renal artery embolization may be life saving for renal artery
injury (e.g. iatrogenic post-biopsy). Arteriovenous fistu-
lae and malformations may also be treated successfully by
percutaneous embolization (Fig. 38.23).
Anatomy for angiography
Typically a single artery supplies each kidney (55.3%). The renal
arteries originate from the abdominal aorta at the level of the L1
2 disc space, just inferior to the origin of the superior mesenteric
artery (SMA), usually in an anterolateral position. Considerable
variation exists, with the levels of origin varying between T12
and L2. The calibre of single main renal arteries varies consider-
ably with kidney size. Luminal diameter as determined angio-
graphically is 6.09.5 mm (mean, 7.9 mm) in men, and 58 mm
(mean, 6.4 mm) in women. In older patients the aorta rotates so
that the right renal artery often arises from the right anterolateral
aspect, while the left arises from the posterolateral aspect. During
aortography, a slight left anterior oblique (LAO) position often
displays both renal artery origins optimally.
Figure 38.23 Renal artery
embolization. (A) Digital subtraction
angiography (DSA) flush aortography
showing an arteriovenous fistula
of the right lower pole. (B)
Superselective DSA study of the right
upper renal artery.
Continued
830 SECTION 4 THE GENITOURINARY SYSTEM

Figure 38.23 Contd (C)

Superselective DSA study of the
right lower renal artery showing
the arteriovenous fistula. (D) Post-
embolization superselective arterial
study demonstrating occlusion of the
arteriovenous fistula by embolization
coils.

Accessory arteries are found in up to 45% of patients. They
may originate from the aorta above or below the main artery
or rarely from the common iliac artery.
UTERINE ARTERY EMBOLIZATION FOR
UTERINE FIBROIDS
Uterine artery embolization (UAE) has become accepted as
a first line treatment for uterine fibroids. MR imaging very
clearly depicts the site, size and location of uterine fibroids
pre-embolization as well as the changes post-procedure
(Fig. 38.16B,C). Gadolinium-enhanced MRA shows the
blood supply to the uterus preoperatively and also allows
detection of the development of ovarian artery collater-
als which may be responsible for failure of embolization64
(Fig. 38.24).

Figure 38.24 3D Gadolinium-

enhanced MRA demonstrating
the blood supply to the uterus.
(A) Coronal maximum intensity
projection (MIP) showing no
evidence of ovarian arteries but
clear demonstration of both uterine
arteries. (B) Digital subtraction
angiography (DSA) study of a catheter
injection into the left uterine artery
showing the left uterineovarian
artery anastomosis, reflux into the
left ovarian artery and crossover
filling of the right uterine artery.

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