Hydronephrosis Following Retrograde Pyeloqraphy

“The Pelvocalyceal collecting systems are poorly visualized; advise a retrograde pyelogram.” This is a common recommendation following intravenous urography in many departments of radiology. Prior to the present study, the authors, using the renal clearance technic, had found that ureteral catheterization disturbed kidney function (1). In unilateral catheterization a greater volume of urine is formed by the catheterized kidney, but solute excretion by the two kidneys is essentially equal. When a wire stylet is required for insertion of the catheter, this difference in simultaneously formed urine by the two kidneys is exaggerated. Accordingly, ureteral trauma provokes an increase in water excretion: the greater the trauma, the larger the volume of water excreted. It occurred to us that these physiological observations might be reproduced more graphically with radiological studies. Method of Study With the above problem in mind, the authors selected 14 children for intravenous urography, to be followed by retrograde pyelography and finally by repeat intravenous urography within sixteen hours of the retrograde study (Table I). All had either a urinary tract infection or hematuria. The studies were carried out in 1953, when, for the most part, 35 per cent Diodrast was the contrast medium employed. Results In 9 of the 14 children studied, the second urogram showed ureteral abnormalities not previously present: the changes were severe in 1, moderate in 4, and minimal in 4. In 5 children no change was demonstrable after the retrograde pyelogram (Table I). The 3 illustrative case reports which follow demonstrate what is meant by severe and moderate. Case Reports Case I: A. S., a 3-year-old girl, had a normal urogram on Jan. 14, 1953 (Fig. 1, A). Except for overfilling on the left, the retrograde pyelogram two days later was also normal (Fig. 1, B). The repeat urograms on Jan. 17 (Figs. 1, C–E) show severe impairment of renal function, with only a nephrogram showing up at fifteen minutes and dilatation of the pelvocalyceal collecting systems at one and two hours. It is of interest that it was on the left side that overdistention took place on the retrograde study; yet it is the right kidney in which function is most seriously impaired. The significant observation on retrograde pyelography was that the catheters could not be inserted beyond the lower third of each ureter, and considerable difficulty was encountered in passing them even to this height. Case II: J. N., a 6-year-old girl, had a normal urogram on Jan. 13, 1953 (Fig. 2, A) and, except for slight overfilling, a normal retrograde pyelogram the next day (Fig. 2, B) with the catheters in the upper pole of each kidney. The repeat urogram on Jan. 15 shows the right upper urinary tract to be unaffected by the ureteral catheterization, but on the left there is moderate dilatation of the entire urinary drainage tract (Fig. 2, C and D).