Definition:
Retrograde ureteropyelography (UPGR), also called ascending pyelography, is a useful procedure in the detailed study of ureter and kidney, if they are poorly opaque in the course of urography or if the patient could not take urography because allergic to the contrast medium.
Indications:
In addition to those already specified, other indications are the evaluation of a hematuria or a positive urinary cytology or a constant fill defect in the upper excretory pathway.
Technical Description:
It is a mini-invasive procedure, but still invasive as it requires the necessary insertion of a rigid instrument in the bladder: the cystoscope. Through this, after practicing cystoscopy in order to exclude other pathologies, the ureteral meatus (ureter-bladder connection point) is identified: within this the ureteral catheter is inserted (a small catheter with average diameter of about 2 mm) in which the contrast medium (a visible-to-X-ray substance) is injected in a quantity varying from a few cc to 10-20 cc depending on the need (very dilated ureters require higher doses).
It is a procedure to be performed in an endoscopic or operating room equipped with a radiotransparent bed and a brilliance amplifier (radioscopic instrument) with radiography printing or other image recording system support. UPGR is usually well tolerated in local anesthesia (2% carbocaine in male urethra, anesthetic lubricant by contact with the female); Sometimes (non-tolerant patients or children), it is necessary to practice it in mild sedation and, therefore, the use of an operating room is more justified.
Nowadays, UPGR is less used for diagnostic purposes, given the ever-advanced progress of image techniques (enhanced Urography, Stratigraphy, Spiral TAC, Uro-RMN); Its application becomes constant as the initial phase of endoscopic surgery on the ureter, both for simple transureteral drainage of the kidney and for diagnostic or therapeutic ureteroscopy.
Preparation for intervention:
A good preparation of the intestine (with purgatives or enema) is required, associated with an oral chemo antibiotic prophylaxis that begins the day before until 2-3 days later.
Duration of intervention:
The UPGR lasts a few minutes (5-10 minutes) if it is practiced under scopy with images recording and subsequent printing; It may take a longer time if it is necessary to proceed with radiographs and wait for their printing/visualization to show different urinary tracts.
Type and duration of hospitalization:
It can be performed in outpatient (if it is easy, practicable in local anesthesia without complications) or in Day Hospital when it is followed by placement of a stent (to follow the first drainage hours or because of anesthesia) or even as inpatient in complex patients admitted for other reasons.
Results:
This is a diagnostic procedure with almost always matching expectations.
Advantages:
They are those that can safely clarify the doubts of an urographic image.
Disadvantages:
As mini-invasive, it is still an invasive procedure with radioscopic exposure and introduction of the cystoscope and ureteral catheter.
Side Effects:
Some urinary disorders (burning, pollachiuria, mild hematuria) are quite common in the following days. The fever episode is rare: it occurs if there is a latent urinary infection.
Complications:
The complications are quite rare:
- Allergic reaction linked to contrast media resorption: it is very rare, but always possible: in case of the said allergy, a contrast medium diluted at small doses is used and the patient is prepared with desensitizing therapy;
- Extraluminal contrast medium in the location of an obstruction if this does not even allow the passage of the contrast medium; Usually associated with a slight sense of annoyance or burn experienced by the patient; It does not take much time and, in a cautionary sense, it can be treated with parenteral antibiotic therapy.
Excessive injection pressure in renal pelvis causes visualization of peripheral lymphatic circulation; it is not usually associated with additional morbidity, but may make it difficult to identify a leakage defect; - Ureteral puncture with the ureteral probe out of the ureter rarely occurs: it must be treated with ureteral drainage in case of obstruction, otherwise enough antibiotic coverage.
At discharge:
All patients who must practice UPGR should start an oral chemo antibiotic oral prophylaxis from the day before the procedure is performed up to 2-3 days later without complications.
In the case of complications, a third generation cephalosporin or a parenteral aminoglycoside may be administered.
How to behave in case of complications arising after discharge:
A persistent dysuria must not lead to particular concerns and usually resolves after a few days. A persistent fever even after parenteral therapy may suggest to contact urological center.
Checks:
There are no specific checks except those referring to the underlying disease for which the patient has consulted the urologist.