Technique and radiation

This procedure is performed in conjunction with cystoscopy and will therefore require either sedation or general regional anes-

Filling Defect Ureter
FIGURE 3.9. RPG—TCC lower ureter seen as a filling defect with caliber change (Courtesy of Dr A Bradley, Wythenshawe, Manchester)

thesia. Improved quality images are acquired if measures have been taken to minimise bowel related artifacts (e.g., avoid diet for 6-8 hours, aperients to minimize fecal loading, and patient to remain as ambulant as possible prior to surgery). The main contraindications are the presence of a UTI and pregnancy.

• All patients should receive a single prophylactic dose of a broad-spectrum intravenous antibiotic

• At cystoscopy, one or both ureters are catheterized by the urologist

• RPG can either be performed in the operating theater or later in the radiology department (better image quality)

• A 6 or 8 F ureteric catheter is positioned either in the ureter (e.g., below the area of interest) or in the collecting system

• The ureteric catheter is secured to an indwelling bladder catheter (for delayed imaging)

• If retrograde catheterization is not possible, or if lower ureteric visualization is required, a Braasch bulb catheter wedged in the ureteric orifice can be used for on-table RPG

• Before contrast injection, any air in the catheter lumen must be removed by aspiration or by flushing of the catheter with contrast

• 10-20 mL of Urografin 150 (or HOCM or LOCM 150-200-strength water-soluble media) is injected slowly

• Contrast media may be diluted to avoid obscuring of small lesions

• Care must be taken not to cause contrast extravasation or bleeding due to overenthusiastic injecting

• Supine PA and/or oblique images are taken

• The ureteric catheter can be slowly withdrawn while imaging to perform a withdrawal ureterogram, or can be left in situ for a short period to drain

Similar to other dynamic fluoroscopic procedures, radiation exposure is related to length of fluoroscopy time, and usually ranges from 1 to 5 mSv.

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