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Contrast-enhanced voiding urosonography, a possible candidate for the diagnosis of vesicoureteral reflux in children and adolescents; a systematic review and meta-analysis. J Pediatr Urol 2022; 18:61-74. [PMID: 34801413 DOI: 10.1016/j.jpurol.2021.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/23/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The diagnostic value of contrast-enhanced voiding urosonography (ceVUS) in the diagnosis of vesicoureteral reflux (VUR) is still a subject of dispute. OBJECTIVE Assessing the diagnostic value of ceVUS in VUR, performing a systematic review and meta-analysis. METHODS An extensive search on Medline, Embase, Scopus and Web of Science databases was conducted by the end of 2020. The inclusion criteria were studies on the diagnostic value of ceVUS for VUR. Two independent researchers summarized the included articles and the findings were reported as area under the curve (AUC), sensitivity and specificity with a 95% confidence interval (95% CI). RESULTS Finally, the data of 36 articles were included in the present meta-analysis (2768 children). The VUS assessment showed that 1297 of the cases were true positives, 3661 were true negatives, 398 were false positives and 169 were false negatives. The AUC, sensitivity and specificity of ceVUS with the first-generation contrast agent in the diagnosis of VUR in children and adolescents were obtained as 0.97 (95% CI: 0.95, 0.98), 0.92 (95% CI: 0.86, 0.96) and 0.94 (95% CI: 0.95, 0.98), respectively. Moreover, AUC, sensitivity and specificity of ceVUS with the second-generation contrast agent were 0.97 (95% CI: 0.95, 0.98), 0.93 (95% CI: 0.86, 0.97) and 0.91 (95% CI: 0.86, 0.95). CONCLUSION The findings of the present study showed that diagnostic value of ceVUS with both first-generation and second-generation contrast agents for VUR, is in an excellent range. Although it seems that ceVUS may be applied as a radiation-free alternative to imaging techniques such as VCUG, the presence of 3% of false negatives in this test is a limitation. Since the lack of punctual management of VUR is associated with serious renal complications in children, future studies are recommended to be focused on the evaluation of the Benefit-risk evaluation of ceVUS.
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[Sensitivity of voiding urosonography as a function of the number of the cyclic bladder fillings]. Radiologe 2021; 61:490-496. [PMID: 33587149 DOI: 10.1007/s00117-021-00818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) can occur intermittently. Cyclic testing of VUR (observation of multiple phases of filling and micturition) increases the detection rate of VUR, as has been shown in studies which have generally used a two-cycle test period. OBJECTIVES How large is the dependence of the sensitivity in voiding urosonography (VUS) on the number of observed cycles when more than two cycles are observed in a larger number of patients? How many cycles should be observed in order to achieve sufficient sensitivity? PATIENTS AND METHODS The study population consisted of 302 patients (225 female, average age 2.5 years [range 1 month-17 years]; 77 male, average age 6 months [range 1 month-2.5 years]) with 607 kidney-ureter units (KUU), examined in a pediatrican practice from 05 January 2016 to 31 December 2019. The examinations were performed by contrast-enhanced color Doppler voiding urosonography using the ultrasound contrast agent SonoVue® (Bracco Imaging, Milan, Italy) for an average of 3.14 cycles and, in the case of undetectable VUR, for an average of 3.5 cycles (range 1-6 cycles). RESULTS In all, 118 of 302 patients were found to have VUR. In terms of KUU, 163 of 607 KUU exhibited reflux. VUR occurred intermittently in 32.5% of KUU. Depending on the number of cycles observed, there was a significant increase in sensitivity of the VUS. Using the observation of five cycles as a reference for the sensitivity, the following values are obtained: 1 cycle = 82.2%, 2 cycles = 87.7%, 3 cycles = 96.3%, 4 cycles = 98.8%, 5 cycles = 100%. CONCLUSIONS To achieve a sensitivity of 96% in detecting VUR, three cycles must be observed. If less than three cycles are observed, the sensitivity shows a marked decrease.
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Velasquez M, Emerson MG, Diaz E, Kennedy W, Rubesova E, Barth RA. The learning curve of contrast-enhanced 'microbubble' voiding urosonography-validation study. J Pediatr Urol 2019; 15:385.e1-385.e6. [PMID: 31133505 DOI: 10.1016/j.jpurol.2019.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/15/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vesicoureteral reflux (VUR) is a common pediatric urologic condition associated with urinary tract infection and pyelonephritis. It can be diagnosed via fluoroscopic voiding cystourethrogram (VCUG) and, more recently, contrast-enhanced voiding ultrasonography (ceVUS), which does not expose the patient to ionizing radiation. Voiding urosonography contrast agents used for the diagnosis of VUR have been widely available in Europe but were approved by the Food and Drug Administration for use in the United States only in 2016. OBJECTIVE The objective was to optimize a protocol and compare the diagnostic performance of ceVUS to fluoroscopic VCUG in an academic medical center naïve to previous use of contrast-enhanced voiding urosonography. STUDY DESIGN Thirty-nine patients referred for clinically indicated evaluation of VUR were enrolled between September 2016 and March 2017. Patients underwent contrast-enhanced ultrasonography with prediluted Lumason and under the same catheterization underwent fluoroscopic VCUG. Comparative grading was performed by pediatric radiologists on-site at the time of examination. RESULTS Reflux was observed in 16 of 39 patients (20 of 64 renal units) ranging from grades 1 through 5. VCUG and ceVUS were concordant for detecting reflux in 10 of 39 patients (14 of 84 renal units) and excluding reflux in 23 of 39 patients (64 of 84 renal units) (Fig. 1). Using contrast enhanced voiding urosonography, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that was not found on fluoroscopy. Using fluoroscopy, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that had not been found on ceVUS. Two of 20 renal units were upgraded from low-grade on ceVUS to high-grade on fluoroscopy. This corresponds to a Cohen's kappa of 0.72 (confidence interval [CI] 0.54-0.91) or 'moderate.' DISCUSSION During our investigation, we noted that there was a technical learning curve related to poor contrast mixing and the need to titrate the concentration of Lumason. However, over the course of the study, we were able to correct the technical aspects. Ultimately, our results showed good correlation between VCUG and Lumason ceVUS and only slightly less correlation than published studies by experienced centers. Future studies with voiding should allow for improved urethral visualization. CONCLUSION While there is a considerable learning curve to the implementation of ceVUS for the diagnosis of pediatric VUR, these technical aspects can be corrected. Even a center previously naïve to contrast-enhanced ultrasound technology can, over a short period of time, demonstrate good correlation between VCUG and ceVUS in the diagnosis of VUR. Translation of ceVUS into clinical practice is an alternative to VCUG for diagnosis of reflux, is feasible, and can eliminate the radiation exposure associated with a VCUG.
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Affiliation(s)
- M Velasquez
- Stanford Children's Health (Lucile Packard Children's Hospital), Department of Urology, Stanford University School of Medicine, 725 Welch Road - Room 1890, Stanford, CA 94304-5913, USA
| | - M G Emerson
- Radiology - Diagnostic, 677 N Wilmot Rd, Tucson, AZ 85711, USA
| | - E Diaz
- Stanford Children's Health (Lucile Packard Children's Hospital), Department of Urology, Stanford University School of Medicine, 725 Welch Road - Room 1890, Stanford, CA 94304-5913, USA
| | - W Kennedy
- Stanford Children's Health (Lucile Packard Children's Hospital), Department of Urology, Stanford University School of Medicine, 725 Welch Road - Room 1890, Stanford, CA 94304-5913, USA
| | - E Rubesova
- Stanford Children's Health (Lucile Packard Children's Hospital), Department of Radiology, Stanford University School of Medicine, 725 Welch Road - Room 1890, Stanford, CA 94304-5913, USA
| | - R A Barth
- Stanford Children's Health (Lucile Packard Children's Hospital), Department of Radiology, Stanford University School of Medicine, 725 Welch Road - Room 1890, Stanford, CA 94304-5913, USA.
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Darge K, Papadopoulou F, Ntoulia A, Bulas DI, Coley BD, Fordham LA, Paltiel HJ, McCarville B, Volberg FM, Cosgrove DO, Goldberg BB, Wilson SR, Feinstein SB. Safety of contrast-enhanced ultrasound in children for non-cardiac applications: a review by the Society for Pediatric Radiology (SPR) and the International Contrast Ultrasound Society (ICUS). Pediatr Radiol 2013; 43:1063-73. [PMID: 23843130 DOI: 10.1007/s00247-013-2746-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 05/28/2013] [Accepted: 05/28/2013] [Indexed: 12/17/2022]
Abstract
The practice of contrast-enhanced ultrasound in children is in the setting of off-label use or research. The widespread practice of pediatric contrast-enhanced US is primarily in Europe. There is ongoing effort by the Society for Pediatric Radiology (SPR) and International Contrast Ultrasound Society (ICUS) to push for pediatric contrast-enhanced US in the United States. With this in mind, the main objective of this review is to describe the status of US contrast agent safety in non-cardiac applications in children. The five published studies using pediatric intravenous contrast-enhanced US comprise 110 children. There is no mention of adverse events in these studies. From a European survey 948 children can be added. In that survey six minor adverse events were reported in five children. The intravesical administration of US contrast agents for diagnosis of vesicoureteric reflux entails the use of a bladder catheter. Fifteen studies encompassing 2,951 children have evaluated the safety of intravesical US contrast agents in children. A European survey adds 4,131 children to this group. No adverse events could be attributed to the contrast agent. They were most likely related to the bladder catheterization. The existing data on US contrast agent safety in children are encouraging in promoting the widespread use of contrast-enhanced US.
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Affiliation(s)
- Kassa Darge
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Riccabona M. Application of a second-generation US contrast agent in infants and children--a European questionnaire-based survey. Pediatr Radiol 2012; 42:1471-80. [PMID: 23052725 DOI: 10.1007/s00247-012-2472-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 06/26/2012] [Accepted: 07/10/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND No US contrast agent (US-CA) is currently licensed for use in children. OBJECTIVE To survey the off-label use in children of a second-generation US-CA. MATERIALS AND METHODS Questionnaires were e-mailed to European paediatric radiologists, who were asked about their experience with the second-generation US-CA Sonovue® (Bracco, Milan, Italy). Number of examinations per indication and adverse effects were recorded. Examinations were categorised by intravenous or intracavitary use of US-CA. RESULTS Out of 146 respondents, 88 stated that they did not perform contrast-enhanced US in children, but 36 of these (44%) would appreciate paediatric approval. Forty-five centres reported 5,079 examinations in children (age mean: 2.9 years; range: birth-18 years, M/F: 1/ 2.8). The majority (4,131 [81%] in 29 centres) were intravesical applications. The minority (948 [19%] in 30 centres) were intravenous applications. No adverse effects had been recorded from intravesical use. Six minor adverse effects (skin reaction, unusual taste, hyperventilation) had been recorded after five intravenous studies (0.52%). CONCLUSION Responses suggest a favourable safety profile of this second-generation US-CA in children. It also demonstrates a demand for such US-CA from paediatric radiologists.
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Affiliation(s)
- Michael Riccabona
- Department of Radiology, Division of Paediatric Radiology, Universitätsklinikum LKH Graz, Auenbruggerplatz 34, 8036, Graz, Austria.
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CEUS Retrograde Cystography Is Helpful in Percutaneous Drainage of Complex Posttransplant Lymphocele. Case Rep Urol 2012; 2012:919215. [PMID: 22606639 PMCID: PMC3350148 DOI: 10.1155/2012/919215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 10/02/2011] [Indexed: 11/18/2022] Open
Abstract
After monolateral dual kidney transplantation, a 69 years old male patient developed symptomatic lymphocele with mild hydroureteronephrosis, impaired renal function, and right inferior limb oedema. A percutaneous ultrasound-guided drainage of the fluid collection was planned, but the complex mutual relations between the collection and the renal hilus did not allow to identify a suitable route for a safe drainage insertion during conventional ultrasound examination. A retrograde cystography using echographic contrast agent was, therefore, performed, and it clarified the position of both ureters and the renal vessels, permitting an harmless ultrasound-guided percutaneous lymphocele drainage. In conclusion contrast-enhanced ultrasound retrograde cystography may be helpful in percutaneous drainage of complex posttransplant lymphocele.
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Fallah MM, Falahati M, Mohammadi A, Alizadeh M, Mladkova-Suchy N, Ghasemi-Rad M. Comparative study of color Doppler voiding urosonography without contrast enhancement and direct radionuclide voiding cystography for diagnosis of vesicoureteric reflux in children. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:55-61. [PMID: 22215770 DOI: 10.7863/jum.2012.31.1.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Most available studies investigating the diagnostic accuracy of color Doppler voiding urosonography in the detection of vesicoureteric reflux used an echo contrast agent. It is unknown whether echo contrast agents are necessary for diagnosis or follow-up of vesicoureteric reflux. We compared color Doppler voiding urosonography without contrast enhancement and direct radionuclide voiding cystography in the detection and grading of vesicoureteric reflux with respect to the sex and age of patients as well as the severity of reflux. METHODS In the 66 patients enrolled (56 girls and 10 boys), 132 renoureteral units were investigated. All patients under went Doppler voiding urosonography and direct radionuclide voiding cystography within 3 hours. Direct radionuclide voiding cystography was used as the reference standard. RESULTS Our results indicate good overall sensitivity (83%) and specificity (77%) for color Doppler voiding urosonography without contrast enhancement in comparison with direct radionuclide voiding cystography. As the age of the patients decreased, the sensitivity of urosonography increased, reaching 100% among patients younger than 1 year. In the comparison of different grades of reflux severity, we found that the sensitivity and specificity were elevated as the grade increased (both parameters reaching 100% in the most severe cases). Severity grading was equal between the two methods. CONCLUSIONS We have shown that Doppler voiding urosonography without contrast enhancement is a comparably reliable method versus direct radionuclide voiding cystography in the detection and grading of vesicoureteric reflux, especially at higher grades of reflux and in children younger than 1 year.
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Abstract
OBJECTIVE To evaluate non-invasive and non-ionizing methods of determining the presence of vesicoureteral reflux (VUR) and to preview upcoming ideas that have the potential of finding VUR non-invasively. MATERIALS AND METHODS We performed a PubMed search using the terms 'vesicoureteral reflux/radiography', 'vesicoureteral reflux/ultrasonography' and 'magnetic resonance imaging/urologic disease'. We also included information from a recent American Academy of Pediatrics meeting and our own research. RESULTS Voiding ultrasonography is non-radiating and has undergone significant improvements recently. Best results require instillation of contrast through invasive catheter placement, and doubts regarding sensitivity and specificity are significant. Magnetic resonance cystograms are best with catheter-instilled contrast. They are expensive, require anesthesia or sedation, and are impractical. Horizon technologies include magnetic resonance cystogram with gadolinium 'activation' within the bladder. Another promising completely non-invasive method includes warming the bladder with microwaves and measuring kidney temperatures before and after warming. Detection of a rise in kidney temperatures would indicate VUR. CONCLUSIONS Voiding cystourethrography remains the gold standard in reflux diagnosis but is invasive and submits the child to ionizing radiation. Developing technologies need improvements and further research before they may have a role in significantly decreasing voiding cystourethrography use or replacing it completely.
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Affiliation(s)
- Brent W Snow
- University of Utah, School of Medicine, Primary Children's Medical Center, Salt Lake City, UT 84113-1100, USA.
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Darge K. Voiding urosonography with ultrasound contrast agents for the diagnosis of vesicoureteric reflux in children. I. Procedure. Pediatr Radiol 2008; 38:40-53. [PMID: 17618429 PMCID: PMC2292498 DOI: 10.1007/s00247-007-0529-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Revised: 04/23/2007] [Accepted: 05/01/2007] [Indexed: 12/18/2022]
Abstract
Voiding urosonography (VUS) encompasses examination of the urinary tract with intravesical administration of US contrast agent (UCA) for diagnosis of vesicoureteric reflux (VUR). The real breakthrough for US examination of VUR came with the availability of stabilized UCAs in the mid-1990s. This article presents a comprehensive review of various procedural aspects of VUS. Different US modalities are available for detecting the echogenic microbubbles: fundamental mode, colour Doppler US, harmonic imaging and dedicated contrast imaging with multiple display options. The reflux is graded (1 to 5) in a similar manner to the system used in voiding cystourethrography (VCUG). The most commonly used UCA for VUS, Levovist, is galactose-based and contains air-filled microbubbles. The recommended concentration is 300 mg/ml at a dose of 5-10%, or less than 5%, of the bladder filling volume when using fundamental or harmonic imaging modes, respectively. There are preliminary reports of VUS using a second-generation UCA, SonoVue. Here the UCA volume is less than 1% of the bladder filling volume. There is no specific contraindication to intravesical administration of UCA. The safety profile of intravesical Levovist is very high with no reports of side effects over a decade of use in VUS.
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Affiliation(s)
- Kassa Darge
- Department of Pediatric Radiology, University Hospital Wuerzburg, Josef-Schneider Strasse 2/D31, Wuerzburg, Germany.
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Darge K. Voiding urosonography with US contrast agents for the diagnosis of vesicoureteric reflux in children. II. Comparison with radiological examinations. Pediatr Radiol 2008; 38:54-63; quiz 126-7. [PMID: 17639371 DOI: 10.1007/s00247-007-0528-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Revised: 04/23/2007] [Accepted: 05/01/2007] [Indexed: 12/18/2022]
Abstract
Studies comparing voiding urosonography (VUS) with voiding cystourethrography (VCUG) and direct radionuclide cystography (DRNC) were analyzed and detailed tables demonstrating the diagnostic values and grading of vesicoureteric reflux (VUR) are presented. Comparative studies of DRNC were too few and did not allow definite conclusions. Using VCUG as the reference, the results of VUS were as follows: sensitivity 57-100%, specificity 85-100%, positive/negative predictive values 58-100%/87-100%, respectively, and diagnostic accuracy 78-96%. With the exception of two studies the diagnostic accuracy reported was 90% and above. In 19% of pelviureteric units (PUUs) the diagnosis was made only by VUS and in 10% only by VCUG. Thus in 9% of PUUs more refluxes were detected using VUS. In 73.6% the reflux grades were concordant in VUS and VCUG. Reflux grade was found to be higher with VUS than with VCUG in 19.6% of PUUs. In 71.2% of PUUs with grade I reflux on VCUG, the reflux was found to be grade II and higher on VUS. The common selection criteria for VUS as the primary examination for VUR currently include (a) follow-up studies, (b) first examination for VUR in girls, and (c) screening high-risk patients.
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Affiliation(s)
- Kassa Darge
- Department of Pediatric Radiology, University Hospital Wuerzburg, Josef-Schneider Strasse 2/D31, Wuerzburg, Germany.
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Contrast-enhanced ultrasonography (voiding urosonography) of vesicoureteral reflux: State of the art. Radiol Med 2007; 112:1211-24. [PMID: 18074194 DOI: 10.1007/s11547-007-0218-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 03/15/2007] [Indexed: 10/22/2022]
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Ochoa Sangrador C, Formigo Rodríguez E. Pruebas diagnósticas de imagen recomendadas en la infección urinaria. An Pediatr (Barc) 2007; 67:498-516. [DOI: 10.1016/s1695-4033(07)70717-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Pediatric Urology is a surgical subspecialty that is very dependent upon radiographic imaging as the majority of the genitourinary (GU) tract is internally located. Technological advances in various imaging modalities (e.g. ultrasonography, nuclear medicine, CT and MRI) have aided in our ability to visualize and evaluate the functionality of the GU tract, enabling the diagnosis of various disease processes that affect the genitourinary system. Collectively the advances in uro-radiology have improved our understanding of the natural history of many conditions that involve the GU tract. As a result of these newer imaging modalities, some of the more traditional techniques have assumed a limited role in the diagnostic evaluation of the pediatric GU patient (e.g. intravenous urography).The purpose of this article is to review the advances in radiographic imaging, in particular the cross-sectional imaging modalities and discuss their utility (appropriate indications and application) in Pediatric Urology, so that the reader can maximize the diagnostic yield of these studies. For a thorough review of any of the imaging modalities discussed in this article and their utility in the practice of pediatric urology, I would direct the readers to articles in the radiological literature that are specific to that technology. Besides the obvious technological advances in imaging modalities, this review also discusses the attention to radiation safety for the pediatric patient that every physician who orders a diagnostic imaging study in a child should be aware of.
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Affiliation(s)
- Pramod P Reddy
- Division of Pediatric Urology, Surgical Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
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Giordano M, Marzolla R, Puteo F, Scianaro L, Caringella DA, Depalo T. Voiding urosonography as first step in the diagnosis of vesicoureteral reflux in children: a clinical experience. Pediatr Radiol 2007; 37:674-7. [PMID: 17520246 DOI: 10.1007/s00247-007-0499-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Revised: 04/05/2007] [Accepted: 04/07/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Contrast-enhanced voiding urosonography (VUS) is becoming more widely used for the diagnosis of vesicoureteric reflux (VUR), but until now its use has only been accepted for first diagnosis in females and in the follow-up of children, including boys, who have already undergone voiding cystourethrography (VCUG). OBJECTIVE To describe our 6-year experience with VUS used as a first step in the diagnosis of VUR. MATERIALS AND METHODS A total of 610 children (334 boys, 276 girls; mean age 22 months), underwent VUS as the first step in the diagnosis of VUR. In selected children, VCUG was also performed. RESULTS VUR was detected in 199 of 610 VUS examinations, and 265 refluxing kidney-ureter units were found. Children with VUR underwent antibiotic prophylaxis or surgery. Children without VUR underwent clinical follow-up. Just 60 children underwent VCUG. The criteria for VCUG were: high-grade VUR after consultation with a urologist, onset of urinary tract infection while receiving prophylaxis, nondiagnostic VUS, and other malformations with or without clinical signs. CONCLUSION Our experience suggests that we can use VUS as the first step in the diagnosis of VUR in children, boys and girls, with a significant reduction in radiation exposure.
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Affiliation(s)
- Mario Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital Giovanni XXIII, Via Amendola 207, 70126 Bari, Italy.
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Bildgebende Diagnostik bei Harnwegsinfektion. Monatsschr Kinderheilkd 2007. [DOI: 10.1007/s00112-007-1468-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
The voiding cystourethrogram (VCUG) is a widely used study to define lower urinary tract anatomy and to diagnose vesicoureteric reflux (VUR) in children. We examine the technical advances in the VCUG and other examinations for reflux that have reduced radiation exposure of children, and we give recommendations for the use of imaging studies in four groups of children: (1) children with urinary tract infection, (2) siblings of patients with VUR, (3) infants with antenatal hydronephrosis (ANH), and (4) children with a solitary functioning kidney. By performing examinations with little to no radiation, carefully selecting only the children who need imaging studies and judiciously timing follow-up examinations, we can reduce the radiation exposure of children being studied for reflux.
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Affiliation(s)
- Richard S. Lee
- Department of Urology, Children’s Hospital Boston, Boston, MA USA
| | - David A. Diamond
- Department of Urology, Children’s Hospital Boston, Boston, MA USA
| | - Jeanne S. Chow
- Department of Radiology, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115 USA
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Papadopoulou F, Tsampoulas C, Siomou E, Tzovara J, Siamopoulou A, Efremidis SC. Cyclic contrast-enhanced harmonic voiding urosonography for the evaluation of reflux. Can we keep the cost of the examination low? Eur Radiol 2006; 16:2521-6. [PMID: 16639494 DOI: 10.1007/s00330-006-0253-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 02/23/2006] [Accepted: 03/10/2006] [Indexed: 12/19/2022]
Abstract
The purpose of this study was to evaluate whether a second cycle of contrast-enhanced voiding urosonography (VUS) with no added contrast medium (CM) can increase the detection rate of vesicoureteral reflux (VUR). One hundred twelve consecutive children with a mean age of 2.9 years with 224 kidney-ureter units (KUU) underwent two cycles of contrast-enhanced harmonic VUS. The first cycle of VUS was performed with 3.5-12.5 ml of suspension 300 mg/ml SH U 508 A and was followed immediately by a second cycle with only saline without adding CM. VUR was detected in 57 KUU from 44 children (39%) at the first cycle of VUS. Eight of the remaining 68 non-refluxing children (12%) demonstrated VUR at the second cycle (P=0.045). Most cases of missed reflux at the first cycle were grade II (75%). However, in two KUU from two children missed reflux was grade III. In one child reflux (grade II) was missed on the second cycle. Comparing the second cycle of VUS with the first cycle, concordant findings regarding the presence or absence as well as the grade of reflux were found in 94% of KUU. A second cycle of contrast-enhanced harmonic VUS with no added CM discloses significantly more cases of VUR at no additional cost for the examination.
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Affiliation(s)
- Frederica Papadopoulou
- Department of Clinical Radiology and Imaging, Ioannina University Hospital, Ioannina, 45110, Greece.
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Riccabona M. Modern pediatric ultrasound: potential applications and clinical significance. A review. Clin Imaging 2006; 30:77-86. [PMID: 16500537 DOI: 10.1016/j.clinimag.2005.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 10/28/2005] [Accepted: 11/01/2005] [Indexed: 01/21/2023]
Abstract
After the introduction of ultrasound (US), the new imaging modality was first warmly welcomed, but then lost reputation and importance particularly in radiology leading to an increasing number of other -- particularly computed tomography (CT) -- investigations, which especially in pediatrics was a potentially dangerous development considering the radiation hazards. However, innovative and creative US approaches as well as new US techniques such as amplitude-coded color Doppler, harmonic and high-resolution imaging, and US contrast media or three-dimensional US have been introduced over the past decade and significantly broadened the potential of US. Thus, now, the role of US has been widened in many conditions and queries, and US today may well play a more pronounced and essential role in modern imaging algorithms at still relatively low cost, with sufficient diagnostic accuracy and conspicuity. Particularly in the pediatric setting, these new capabilities are applicable in many queries and almost all body regions and should be used to reduce the number of more invasive or radiating and relatively costly examinations that often additionally need some sedation or intravenous iodinated contrast material. To readily provide this approach for sick children, we need to promote the knowledge about modern US capabilities, to train US staff to guarantee 24-h availability of adequate pediatric US performance, and to make it known to the referring clinicians.
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Affiliation(s)
- Michael Riccabona
- Division of Pediatric Radiology, Department of Radiology, LKH Graz, University Hospital, Auenbruggenplatz, A-8036 Graz, Austria.
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Abstract
In children ultrasound plays a central role in the diagnostic imaging of the urinary tract. It is used most frequently and as a primary diagnostic option. Consequently, innovations in ultrasound technology and ultrasound contrast media have major impact on pediatric urosonography. Harmonic imaging is a modality that produces artifact-free images with high resolution. It has been shown that harmonic imaging is superior to fundamental mode in many urosonographic indications. Color Doppler is an established imaging modality, but its application for diagnosis of stones in the urinary tract, especially in children, is relatively new. The so-called twinkling sign, a color Doppler artifact at the site where one normally expects the acoustic shadow to be, enhances the conspicuity of the stone. A further development is three-dimensional (3D) ultrasound. It offers better volume measurement of the bladder and kidneys than 2D ultrasound. Contrast-enhanced voiding urosonography has already proven to be a valuable alternative in the diagnosis of vesicoureteral reflux. Thus, a significant decrease of radiation exposure has become possible as it replaces the radiological methods. With the introduction of contrast-specific ultrasound imaging modalities, further improvements in voiding urosonography are emerging.
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Affiliation(s)
- K Darge
- Abteilung für Pädiatrische Radiologie, Institut für Röntgendiagnostik der Bayerischen Julius-Maximilians-Universität Würzburg.
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Westwood ME, Whiting PF, Kleijnen J. How does study quality affect the results of a diagnostic meta-analysis? BMC Med Res Methodol 2005; 5:20. [PMID: 15943861 PMCID: PMC1180444 DOI: 10.1186/1471-2288-5-20] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Accepted: 06/08/2005] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The use of systematic literature review to inform evidence based practice in diagnostics is rapidly expanding. Although the primary diagnostic literature is extensive, studies are often of low methodological quality or poorly reported. There has been no rigorously evaluated, evidence based tool to assess the methodological quality of diagnostic studies. The primary objective of this study was to determine the extent to which variations in the quality of primary studies impact the results of a diagnostic meta-analysis and whether this differs with diagnostic test type. A secondary objective was to contribute to the evaluation of QUADAS, an evidence-based tool for the assessment of quality in diagnostic accuracy studies. METHODS This study was conducted as part of large systematic review of tests used in the diagnosis and further investigation of urinary tract infection (UTI) in children. All studies included in this review were assessed using QUADAS, an evidence-based tool for the assessment of quality in systematic reviews of diagnostic accuracy studies. The impact of individual components of QUADAS on a summary measure of diagnostic accuracy was investigated using regression analysis. The review divided the diagnosis and further investigation of UTI into the following three clinical stages: diagnosis of UTI, localisation of infection, and further investigation of the UTI. Each stage used different types of diagnostic test, which were considered to involve different quality concerns. RESULTS Many of the studies included in our review were poorly reported. The proportion of QUADAS items fulfilled was similar for studies in different sections of the review. However, as might be expected, the individual items fulfilled differed between the three clinical stages. Regression analysis found that different items showed a strong association with test performance for the different tests evaluated. These differences were observed both within and between the three clinical stages assessed by the review. The results of regression analyses were also affected by whether or not a weighting (by sample size) was applied. Our analysis was severely limited by the completeness of reporting and the differences between the index tests evaluated and the reference standards used to confirm diagnoses in the primary studies. Few tests were evaluated by sufficient studies to allow meaningful use of meta-analytic pooling and investigation of heterogeneity. This meant that further analysis to investigate heterogeneity could only be undertaken using a subset of studies, and that the findings are open to various interpretations. CONCLUSION Further work is needed to investigate the influence of methodological quality on the results of diagnostic meta-analyses. Large data sets of well-reported primary studies are needed to address this question. Without significant improvements in the completeness of reporting of primary studies, progress in this area will be limited.
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Affiliation(s)
| | - Penny F Whiting
- Centre for Reviews and Dissemination, University of York, UK
| | - Jos Kleijnen
- Centre for Reviews and Dissemination, University of York, UK
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Whiting P, Harbord R, Kleijnen J. No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Med Res Methodol 2005; 5:19. [PMID: 15918898 PMCID: PMC1184082 DOI: 10.1186/1471-2288-5-19] [Citation(s) in RCA: 230] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Accepted: 05/26/2005] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND There is a lack of consensus regarding the use of quality scores in diagnostic systematic reviews. The objective of this study was to use different methods of weighting items included in a quality assessment tool for diagnostic accuracy studies (QUADAS) to produce an overall quality score, and to examine the effects of incorporating these into a systematic review. METHODS We developed five schemes for weighting QUADAS to produce quality scores. We used three methods to investigate the effects of quality scores on test performance. We used a set of 28 studies that assessed the accuracy of ultrasound for the diagnosis of vesico-ureteral reflux in children. RESULTS The different methods of weighting individual items from the same quality assessment tool produced different quality scores. The different scoring schemes ranked different studies in different orders; this was especially evident for the intermediate quality studies. Comparing the results of studies stratified as "high" and "low" quality based on quality scores resulted in different conclusions regarding the effects of quality on estimates of diagnostic accuracy depending on the method used to produce the quality score. A similar effect was observed when quality scores were included in meta-regression analysis as continuous variables, although the differences were less apparent. CONCLUSION Quality scores should not be incorporated into diagnostic systematic reviews. Incorporation of the results of the quality assessment into the systematic review should involve investigation of the association of individual quality items with estimates of diagnostic accuracy, rather than using a combined quality score.
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Affiliation(s)
- Penny Whiting
- MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK
| | - Roger Harbord
- MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK
| | - Jos Kleijnen
- Centre for Reviews and Dissemination, University of York, York, UK
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Teh HS, Gan JSJ, Ng FC. Magnetic resonance cystography: Novel imaging technique for evaluation of vesicoureteral reflux. Urology 2005; 65:793-4. [PMID: 15833531 DOI: 10.1016/j.urology.2004.12.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Revised: 11/21/2004] [Accepted: 12/15/2004] [Indexed: 11/17/2022]
Affiliation(s)
- Hui-Seong Teh
- Department of Radiology, Changi General Hospital, Singapore, Singapore.
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Westwood ME, Whiting PF, Cooper J, Watt IS, Kleijnen J. Further investigation of confirmed urinary tract infection (UTI) in children under five years: a systematic review. BMC Pediatr 2005; 5:2. [PMID: 15769296 PMCID: PMC1079875 DOI: 10.1186/1471-2431-5-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 03/15/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Further investigation of confirmed UTI in children aims to prevent renal scarring and future complications. METHODS We conducted a systematic review to determine the most effective approach to the further investigation of confirmed urinary tract infection (UTI) in children under five years of age. RESULTS 73 studies were included. Many studies had methodological limitations or were poorly reported. Effectiveness of further investigations: One study found that routine imaging did not lead to a reduction in recurrent UTIs or renal scarring. Diagnostic accuracy: The studies do not support the use of less invasive tests such as ultrasound as an alternative to renal scintigraphy, either to rule out infection of the upper urinary tract (LR- = 0.57, 95%CI: 0.47, 0.68) and thus to exclude patients from further investigation or to detect renal scarring (LR+ = 3.5, 95% CI: 2.5, 4.8). None of the tests investigated can accurately predict the development of renal scarring. The available evidence supports the consideration of contrast-enhanced ultrasound techniques for detecting vesico-ureteric reflux (VUR), as an alternative to micturating cystourethrography (MCUG) (LR+ = 14.1, 95% CI: 9.5, 20.8; LR- = 0.20, 95%CI: 0.13, 0.29); these techniques have the advantage of not requiring exposure to ionising radiation. CONCLUSION There is no evidence to support the clinical effectiveness of routine investigation of children with confirmed UTI. Primary research on the effectiveness, in terms of improved patient outcome, of testing at all stages in the investigation of confirmed urinary tract infection is urgently required.
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Affiliation(s)
- Marie E Westwood
- Centre for Reviews and Dissemination, University of York, England
| | - Penny F Whiting
- MRC Health Services Research Collaboration, University of Bristol, England
| | - Julie Cooper
- Department of Radiology, York District Hospital, York, England
| | - Ian S Watt
- Department of Health Sciences, University of York, England
| | - Jos Kleijnen
- Centre for Reviews and Dissemination, University of York, England
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Darge K, Moeller RT, Trusen A, Butter F, Gordjani N, Riedmiller H. Diagnosis of vesicoureteric reflux with low-dose contrast-enhanced harmonic ultrasound imaging. Pediatr Radiol 2005; 35:73-8. [PMID: 15448949 DOI: 10.1007/s00247-004-1317-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2004] [Accepted: 08/06/2004] [Indexed: 11/24/2022]
Abstract
BACKGROUND Harmonic US imaging has been shown to be better than conventional US for the detection and visualisation of microbubbles in contrast-enhanced voiding urosonography (VUS). OBJECTIVE To determine the diagnostic efficacy of VUS using a reduced dose of the US contrast medium in comparison to voiding cystourethrography (VCUG). MATERIALS AND METHODS Fifty-five children (17 boys, 38 girls; mean age 4 years) were recruited. All patients underwent VUS by harmonic imaging followed by VCUG. The dose of the US contrast medium (Levovist) administered intravesically was half of the recommended dose i.e. 5% of the bladder filling volume. RESULTS A total of 114 kidney-ureter (K-U) units were available for evaluation. Vesicoureteric reflux (VUR) was detected in 29 K-U units by one or both examination modalities. There was a 91.2% concordance rate between VUS and VCUG. VUR in seven and three K-U units were detected only by VUS and VCUG, respectively. Taking VCUG as the reference method, VUS had the following diagnostic results: 86.4% sensitivity, 92.4% specificity, positive and negative predictive values of 73.1 and 96.6%, respectively. CONCLUSIONS Even when the dose of US contrast medium is halved, the diagnostic efficacy of harmonic VUS is comparable to VCUG. Consequently, we recommend an US contrast medium dose of 5% of the bladder filling volume for the diagnosis of VUR using contrast-enhanced harmonic VUS.
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Affiliation(s)
- Kassa Darge
- Department of Paediatric Radiology, University Hospital Wuerzburg, Josef-Schneider-Strasse 2/D31, 97080 Wuerzburg, Germany.
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Valentini AL, De Gaetano AM, Minordi LM, Nanni G, Citterio F, Viggiano AM, Tancioni V, Destito C. Contrast-enhanced Voiding US for Grading of Reflux in Adult Patients Prior to Antireflux Ureteral Implantation. Radiology 2004; 233:35-9. [PMID: 15317946 DOI: 10.1148/radiol.2331031803] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively assess contrast material-enhanced voiding ultrasonography (US) for grading of vesicoureteral reflux (VUR) and to compare results with those of voiding cystourethrography (VCUG) in adult patients undergoing antireflux ureteral implantation. MATERIALS AND METHODS Thirty-seven consecutive adult patients who had undergone renal transplantation with Politano-Leadbetter (18 patients) or Lich-Gregoire (19 patients) technique were included on the basis of previous urinary tract infections (UTIs) and time elapsed after renal transplantation. Exclusion criterion was current UTI. US was performed by one of two sonologists with injection of saline and microbubble suspension and was recorded on videotape. Sonologists assigned VUR diagnosis in consensus after videotape review. VCUG was performed by one of two radiologists immediately after US. Radiologists were blinded to US findings and assigned VCUG diagnoses in consensus. Contingency table was used to compare US and VCUG. Agreement between US and VCUG was determined with kappa statistics. RESULTS With VCUG, VUR was diagnosed in 15 patients and not diagnosed in 22 patients. US and VCUG results were in agreement in 14 patients with VUR and 21 patients without VUR. US sensitivity and specificity for detection of VUR were 93% (14 true-positive results in 15 abnormal cases) and 95% (21 true-negative results in 22 normal cases), respectively. Agreement between US and VCUG was 95% (kappa = 0.89, P <.001). In 11 of 14 patients, VUR grades were in agreement for US and VCUG. In three of 14 patients, US indicated a higher grade than did VCUG. VUR was diagnosed in seven of 18 Politano-Leadbetter cases and eight of 19 Lich-Gregoire cases. CONCLUSION A high rate of agreement was seen between voiding US and VCUG.
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Affiliation(s)
- Anna Lia Valentini
- Departments of Radiology and Surgery, Università Cattolica del Sacro Cuore, Policlinico A. Gemelli, L.go A. Gemelli 8, 00168 Rome, Italy.
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Darge K, Riedmiller H. Current status of vesicoureteral reflux diagnosis. World J Urol 2004; 22:88-95. [PMID: 15173954 DOI: 10.1007/s00345-004-0404-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Accepted: 04/02/2004] [Indexed: 10/26/2022] Open
Abstract
In children, diagnostic imaging for vesicoureteral reflux (VUR) encompasses both radiologic and sonographic modalities. The former comprises voiding cystourethrography (VCUG), the most widespread method for examination for reflux, and radionuclide cystography (RNC). In RNC the radiation exposure is significantly less than in VCUG with continuous fluoroscopy, but the anatomic details depicted are much inferior. With the introduction of pulsed fluoroscopy, the radiation exposure of VCUG has been markedly curtailed. VCUG is the first imaging choice for the urethra. The sonographic diagnosis of VUR with the intravesical administration of an ultrasound (US) contrast agent-voiding urosonography (VUS)-is being used increasingly in the routine diagnostic imaging work-up of reflux. Various sonographic reflux examination methods had been tried in the past. The real breakthrough came with the availability of stabilized US contrast media. Further impetus came with the introduction of harmonic US imaging. The recent release of a second generation US contrast medium promises to make a further positive impact on VUS. The diagnostic accuracy of contrast-enhanced VUS has been found to be comparable to radiologic methods. VUS is primarily performed in follow-up studies and as the primary reflux examination modality in girls.
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Affiliation(s)
- Kassa Darge
- Department of Pediatric Radiology, Institute of Radiodiagnostics, Würzburg University Hospital, Josef Schneider Strasse 2/D31, 97080 Würzburg, Germany.
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Ascenti G, Zimbaro G, Mazziotti S, Chimenz R, Fede C, Visalli C, Scribano E. Harmonic US imaging of vesicoureteric reflux in children: usefulness of a second generation US contrast agent. Pediatr Radiol 2004; 34:481-7. [PMID: 15107964 DOI: 10.1007/s00247-004-1190-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2004] [Revised: 03/09/2004] [Accepted: 03/10/2004] [Indexed: 01/18/2023]
Abstract
BACKGROUND Contrast-enhanced voiding urosonography (VUS) is largely accepted both for the diagnosis and follow-up of vesicoureteric reflux (VUR) in children. OBJECTIVE To evaluate the usefulness of contrast-enhanced second-harmonic VUS in the diagnosis and grading of VUR, using a second-generation contrast agent. MATERIALS AND METHODS Eighty consecutive children were prospectively studied with contrast-enhanced second-harmonic VUS. All children received a second-generation contrast medium, constituted by phospholipid-stabilized microbubbles of sulphur-hexafluoride (SonoVue, Bracco, Milan, Italy). US monitoring of the bladder, of the retrovesical space and of the kidneys was performed using, alternatively, both tissue-harmonic and contrast-harmonic modes. In those young boys where VUR was depicted at VUS, examination was completed with transperineal, sagittal urethral exploration during micturition. VUR was graded in five steps and diagnoses were compared with voiding cystourethrography (VCUG). RESULTS VUR was diagnosed in 52 reno-ureteral units with VUS. In 49 of these reno-ureteral units, VCUG confirmed the presence of VUR. In comparison to VUS, sensitivity and negative predictive value of VCUG were inferior. The grade of VUR detected at VUS was higher than that detected at VCUG in three units. In no case was the grade of VUR detected at VCUG higher than the one detected at VUS. The differences between VUS and VCUG in grading VUR were statistically significant (p=0.02). Imaging of the normal posterior urethra was skilfully demonstrated with US in 15 young boys with VUR. No statistically significant differences were found between tissue-harmonic and contrast-harmonic mode (p=0.102). CONCLUSIONS Contrast-enhanced second-harmonic VUS is a sensitive and easy technique for the evaluation of VUR. A second-generation US contrast medium such as SonoVue, if available, should be the first choice as the dose required for one examination is much lower and consequently significant reduction of contrast agent cost is possible.
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Affiliation(s)
- Giorgio Ascenti
- Department of Radiological Sciences, University of Messina, Via Giordano Bruno, 53, 98163 Messina, Italy.
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Abstract
Advances in the field of ultrasound technology and ultrasound contrast media over the past few years have also brought major improvements to pediatric sonography. Accordingly, contrast-enhanced voiding urosonography has become a valuable alternative in the diagnosis of vesicoureteral reflux. It is possible to achieve significant reduction in radiation exposure replacing the conventional radiologic methods used for reflux diagnosis with contrast-enhanced ultrasound. Through the introduction of harmonic imaging, an ultrasound scanning modality with high spatial and contrast resolution has become available. The modality was initially propagated as one to be applied in difficult-to-scan adults. However, initial experiences in pediatric applications are demonstrating the significant improvement it can bring in the ultrasound image quality, for example, in intestinal ultrasound. A further development is three-dimensional [3D] imaging using ultrasound. 3D-ultrasound not only offers an improvement in diagnosis but also in the acceptance of ultrasound in interdisciplinary work and teaching. The first applications of 3D-ultrasound in pediatrics are focusing on brain ultrasound and volume measurement of the kidneys.
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Affiliation(s)
- K Darge
- Abteilung für Pädiatrische Radiologie, Institut für Röntgendiagnostik der Bayerischen Julius-Maximilians-Universität Würzburg.
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Novljan G, Kenig A, Rus R, Kenda RB. Cyclic voiding urosonography in detecting vesicoureteral reflux in children. Pediatr Nephrol 2003; 18:992-5. [PMID: 12898375 DOI: 10.1007/s00467-003-1228-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2002] [Revised: 03/05/2003] [Accepted: 05/04/2003] [Indexed: 10/27/2022]
Abstract
Three methods are currently used to identify vesicoureteral reflux (VUR) in children, namely X-ray voiding cystourethrography (VCUG), radionuclide voiding cystography (RVC), and, recently, echo-enhanced voiding urosonography (VUS). It is known that the sensitivity of VCUG and RVC for detecting VUR can be improved by using cyclic procedures, such as repeated bladder filling and voiding. The purpose of our prospective study was to evaluate whether the cyclic procedure is superior to the conventional (one cycle only) procedure in VUS also. VUS was performed in 49 patients, aged 1.4-15.8 years (mean 4.1 years). After the first micturition, the catheter was left in place and the whole procedure was repeated under the same conditions. The results of the first and second cycles and the combined procedure were compared. In the initial cycle, 7 of 35 (20%) refluxing renal units that were detected in the second cycle and 4 of 26 (15%) children with at least unilateral VUR were missed. Cyclic VUS detected 25% more VURs than the conventional (one cycle only) VUS ( P=0.049) and revealed 50% more VUR III than the first cycle. Our results suggest that cyclic VUS is superior to conventional VUS.
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Affiliation(s)
- Gregor Novljan
- Department of Pediatric Nephrology, University Medical Center Ljubljana, Children's Hospital, Stare pravde 4, 1000 Ljubljana, Slovenia.
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Nakamura M, Wang Y, Shigeta K, Shinozaki T, Taniguchi N, Itoh K. Simultaneous Voiding Cystourethrography and Voiding Urosonography: An In Vitro and In Vivo Study. Clin Radiol 2002. [DOI: 10.1053/crad.2002.0974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ring E, Mache CJ, Vilits P. Future expectations--what paediatric nephrologists and urologists await from paediatric uroradiology. Eur J Radiol 2002; 43:94-9. [PMID: 12127206 DOI: 10.1016/s0720-048x(02)00117-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cooperation between paediatric nephrology/urology and paediatric radiology is essential for timely and correct diagnosis and therapy of kidney and urinary tract disorders. We need the direct contact between doctors before or after investigations, interdisciplinary discussions, and rapid access to the images. This should lead to optimal settings for investigations, a reduction of radiation burden and the number of investigations, and further improvement in the management of patients. Modern sonography including colour Doppler sonography, amplitude-coded Doppler sonography, and eventually 3D-ultrasound is and will be the method of choice as the basic, non-invasive investigation. These investigations should become the routine in all institutions. Refinement and standardisation of already established investigations are needed. Recently introduced investigations, like MRI, will have to show their impact on future diagnostic imaging. Future introduction of new non-invasive methods is welcome, e.g. to correctly diagnose vesicoureteral reflux without catheterisation/puncture of the bladder.
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Affiliation(s)
- Ekkehard Ring
- Department of Paediatrics, University Hospital of Graz, Auenbruggerplatz 30, 8036, Graz, Austria.
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Abstract
OBJECTIVE To describe the potential of modern sonographic techniques in paediatric uroradiology. METHOD Ultrasound (US)-now being the primary imaging tool-has revolutionised imaging diagnostic in the urinary tract. Constant developments and technical refinements have secured the role of US in uroradiology. Colour Doppler Sonography (CDS) and innovative applications such as the transperineal approach or application of m-mode US to the urinary tract have helped to develop US from just a basic tool to a sophisticated and respected method. The ongoing introduction of new and even more sophisticated methods further enhance the sonographic potential, which shall be demonstrated by a more detailed discussion of these methods. RESULTS Harmonic imaging, extended field of view US, amplitude coded CDS, echo-enhanced US, and three-dimensional US as the most recent new sonographic techniques are successfully applicable to paediatric urinary tract disease. They improve sonographic diagnosis in many conditions, such as detection of vesico-ureteral reflux, renal parenchymal volume assessment, comprehensive visualisation of hydronephrosis and complex pathology, evaluation of renal perfusional disturbances or defects, superior documentation with improved comparability for follow-up, or simply by offering clearer tissue delineation and differentiation. CONCLUSION Modern US techniques are successfully applicable to neonates, infants, and children, further boosting the value of US in the paediatric urinary tract. However, as handling became more sophisticated, and artefacts have to be considered, modern urosonography became not only a more powerful, but also a more demanding method, with the need for expert knowledge and dedicated training.
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Affiliation(s)
- Michael Riccabona
- Department of Radiology, Division of Paediatric Radiology, University Hospital LKH Graz, Auenbruggenplatz, A-8036, Graz, Austria.
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34
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Abstract
OBJECTIVE To briefly describe basic conventional imaging in paediatric uroradiology. METHOD The state of the art performance of standard imaging techniques (intravenous urography (IVU), voiding cystourethrography (VCU), and ultrasound (US)) is described, with emphasis on technical aspects, indications, and patient preparation such as adequate hydration. Only basic applications as used in routine clinical work are included. RESULT AND CONCLUSION Conventional imaging methods are irreplaceable. They cover the majority of daily clinical routine queries, with consecutive indication of more sophisticated modalities in those patients who need additional imaging for establishing the final diagnosis or outlining therapeutic options.
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Affiliation(s)
- M Riccabona
- Department of Radiology, Division of Paediatric Radiology, University Hospital, LKH Graz, Auenbruggerplatz, A-8036, Graz, Austria.
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35
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Abstract
INTRODUCTION AND OBJECTIVE The sonographic diagnosis of vesicoureteral reflux (VUR) with contrast-enhanced voiding urosonography (VUS) is gradually increasing. With the introduction of VUS as part of the routine diagnostic imaging modalities for reflux significant reduction in the number of voiding cystourethrographies (VCUG) was possible. Like in VCUG grading of reflux in VUS is becoming more and more relevant. The aim of this study was to find out if there are any sonomorphologic and sonomorphometric parameters that would correlate with reflux grading in VCUG. Furthermore, a reflux grading system for VUS is proposed and the correlation of this grading system tested with the one of VCUG. PATIENTS AND METHODS In one examination session a total of 186 children underwent both VUS and VCUG of whom 89 had VUR in at least one and the same kidney-ureter-unit (KUU) in both diagnostic imagings. The VUS was conducted with intravesical administration of ultrasound (US) contrast medium (Levovist). Ureteral and pelvicalyceal dilatations before administration of US contrast medium and during reflux were documented. Renal pelvic diameter was measured. The density of microbubbles in the renal pelves was scored on a scale of 1-3 (low to high). A grading system for reflux in VUS was set up similar to the international reflux grading system for VCUG with the addition of one more differentiation parameter, namely whether the reflux was primarily in a dilated or non-dilated urinary tract. Reflux grades in VUS were compared with those in VCUG. RESULTS None of the sonomorphologic and sonomorphometric parameters demonstrated any clear cut finding that would simplify reflux grading in VUS. In 59/95 (62%) KUUs the reflux grades were the same in both examinations. In 10/95 (11%) and 26/95 (27%) KUUs, the reflux was graded lower or higher, respectively, in VUS than in VCUG. Fifty-seven percent were in a primarily dilated system and the remaining 43% in a non-dilated one. Seventy percent of KUUs diagnosed as having grade I reflux in VCUG, showed as grade 2 on VUS. CONCLUSIONS A reflux grading system similar to the one used in VCUG can be applied in VUS. Adding the parameter reflux into a primarily dilated or non-dilated ureter and/or pelvicalyceal system may bring in a further dimension to the reflux grading in VUS. Most of the refluxes labelled as grade I in VCUG are actually grade II or higher.
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Affiliation(s)
- Kassa Darge
- Department of Pediatric Radiology, Institute of Radiodiagnostic, University Children's Hospital, Josef-Schneiderstrasse 27/B34, 97080, Wuerzburg, Germany.
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