Does an Extra Kidney-Ureter-Bladder (KUB)

Radiography Taken at Upright Position

During Routine Intravenous Urography
Provide Any Diagnostic Benefit?
Kamil Gurel, Safiye Gurel, Melike.E. Kalfaoglu, Cigdem Gkay
Abant Izzet Baysal University, Izzet Baysal School of Medicine,
Department of Radiology
Bolu/TURKEY

Introduction
Intravenous urography (IVU) has long been
the main imaging evaluation of urinary tract
disease.
However, the use of US, CT, and MRI has
surpassed the use of IVU in the last two
decades.

Introduction
The declining use of IVU in clinical practice
presents a challenge for instruction in
urographic technique and interpretation.
Nevertheless, IVU might still be important in
the diagnosis of some urinary tract disease
among other new modalities.

Purpose
The aim of this prospective study is to
assess the value of taking a kidney-ureterbladder (KUB) radiography at upright
position during routine IVU in terms of
diagnostic benefit.

Methods and Materials

September 2003-March 2006, 164 consecutive
patients were referred for IVU exam
In our department, a basal standart IVU exam
consists of totally 5 radiographies:

Precontrast supine KUB

Post-contrast supine KUB at 7th and 15th minutes
Pelvic supine graphies for full bladder and post-voiding
When needed, additional compression and/or oblique radiographies

Methods and Materials

For all patients, an additional post-contrast
15th min. upright KUB radiography was
obtained
Two reviewers analyzed the 15th min.
upright KUB comparing to 15th min. supine
KUB radiographies together, resulting in a
consensus interpretation.

Methods and Materials

This study is approved by our institutional
review board and informed consent was
obtained from patients.

Methods and Materials

Statistical Evaluation
Evaluations were expressed in
percentages.

Results
164 patients
80 women, 84 men
Mean age 44,5 15,4 years

Results
Clinical Data:
Urolithiasis. (n=95)
Collecting system dilatation....... (n=21)
Flank pain.. (n=10)
Urinary tract infection.......... (n=10)
Hematuria...(n=6)
Renal Cyst..... (n=5)
Control after ESWL ......... (n=3)
Others (bladder ca,).. (n=14)

Results
Diagnostic benefits of 15th min. upright KUB
72 (43,9%) of 164 patients
1.
2.
3.
4.
5.

Nephroptosis (n= 40)

Better filling of collecting system (n=9)
Differentiation of pheloboliths from urolithiasis (n=10)
Emptying of collecting sistem (n=51)
Milk of calcium (n=2)

Results
1.Nephroptosis (Asymptomatic)
Downward displacement of kidney by more than two
vertebral bodies or 5 cm

40 patients (24.3%)
[bilateral (n=15), unilateral (n=25)]

57 yo, F, Right renal cyst and minimal pelvicaliectasia on US

Supine

Upright

43yo, M, Right flank pain

Supine

Upright

Results
2. Better filling of collecting system
9 patients (5.4%)
[ureteral filling (n= 8),
upper pole infindibular filling (n=1) ]

24 yo, F, nephrolitiasis

Pre-contrast

Supine

Upright

Supine

Upright

4848yo,
yo, M, M,
urinary tract infection

Supine

Upright

Results
3.Differentiation of pheloboliths from
urolithiasis
10 patients (16.4%) (lower urinary tract)

44 yo, M, ureterolithiasis suspicion

Supine

Upright

L ureter

Supine

Upright

Results
4. Emptying of collecting sistem
51 patients (31%)

10, yo, F, minimal pelvicaliectasia at right kidney on US

Supine

Upright

Results
5. Milk of calcium
2 patients (1.2%)

Discussion
Recently IVU has almost been accepted
as outdated.
On the other hand alternative modalities
have their own limitations, and despite
their increasing use, the ideal global
urinary tract examination still remains
controversial

Assessment of Selected Imaging Modalities in the Evaluation of the Urinary Tract*

Intravenous
Urography

Variable

CT

MR
Imaging

US

CystoscopyRetrograde
Pyelography

++++

++/+++

0/+

++

++++

+++

++++

++

++++

++

++++

+++

++++

++++

++++

++++

Calculi

+++

++++

++

++

Ureter

++++

+++

++

++++

++/+++

+++

0/+

+++

++++

++++

+++

++++

++++

++++

++

++++

++++

+++

Collecting system
Parenchyma
Renal masses
(cysts, solid
tumors)
Function

Bladder
Abdomenretroperitoneum
Cost
Ionizing radiation

Note.Assessment was performed with a scale from 0 to ++++, with 0 being the worst and ++++
the best. *Dyer RB, et al. Intravenous Urography: Tecnique and Interpretation. Radiographics 2006;
1(4):800-821.discussion 822-824.

Discussion

The patient effective dose,

therefore radiation risk for CT
urography was 1.5 times
greater than that for
conventional urography
Radiation risk is increased for
smaller patients in CT
urography and for larger
patients in IVU.

Nawfel RD, et al. Patient Radiation Dose at CT Urography and Conventional

Urography. Radiology 2004; 232:126-132.

 CT urography performed with multi

detector row CT may eventually replace
IVU. However, the increased radiation risk
from this examination compared with IVU
should be considered in the context of the
amount of information that is necessary for
the diagnostic task.

*Nawfel RD, et al. Patient Radiation Dose at CT Urography and Conventional

Urography. Radiology 2004; 232:126-132.

Discussion

Upright positioning seems to:

Be possible-technically- only in IVU
May be a part of routine IVU
Can supply data about verification of urine
flow
Can provide better filling
Show positional change in gravity-related
layering, nephroptosis and phleboliths

Discussion
Weak points of this study are:
There is no control grup (for comparison of
total number of films and patient radiation
dose)
Absence of interobserver variability
assessment

Conclusion:
IVU, a cornerstone in urinary system
imaging, has slowly been withdrawn from
routine clinical practice in the era of CT or
MR urography.
However, the capability of using gravitational
forces by obtaining simply an upright
radiography still provides some diagnostic
benefits, in which CT or MR urography might
easily miss.