Voiding urosonography and voiding cystourethrography in primary vesicoureteral reflux associated with mild prenatal hydronephrosis: a comparative study

Determining the optimal contrast-enhanced voiding urosonography technique for vesicoureteral reflux in children and adolescents: a systematic review and network meta-analysis

Aim

To evaluate diagnostic combinations of imaging modalities and contrast agents for vesicoureteral reflux (VUR) in children.

Methods

Studies were retrieved in PubMed, EMBASE, Cochrane Library, Web of science, and China National Knowledge Infrastructure (CNKI) until March 16, 2023. We used bivariate random-effects model and a frequentist model for meta-analysis. Surface under the cumulative ranking curve (SUCRA) was used to rank ceVUS protocols.

Results

19 studies identified 4 diagnostic combinations. Contrast-harmonic ultrasound with SonoVue® (CHSV) had significantly lower sensitivity, specificity, and diagnostic accuracy than VCUG, although its negative predictive value was higher than VCUG. Contrast-harmonic ultrasound with Optison™ (CHOS) was comparable to VCUG across all diagnostic measures. SUCRA analysis favored CHOS, with probabilities of being the best for SEN, SPE, PPV, NPV, DOR, and DA at 50.9%, 16.6%, 42.6%, 57.4%, 36.2%, and 20.4%, respectively.

Conclusion

Harmonic VUS with Optison™ may be the optimal protocol for VUR detection in children.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42023424510, identifier (CRD42023424510).

Diagnostic role of contrast-enhanced voiding urosonography (ceVUS) in pediatric duplex kidneys - a comparison with voiding cystourethrography (VCUG)

Aim

The present study aimed to assess the diagnostic efficacy of contrast-enhanced voiding urosonography (ceVUS) using SonoVue for evaluating duplex kidneys, and to compare it with fluoroscopic voiding cystourethrography (VCUG).

Material and methods

Forty-six children with duplex kidneys confirmed by surgical intervention or cystoscopy were included in the study, resulting in a total of 46 duplex kidneys and 46 normal kidneys (138 pyeloureteral units).

Results

The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RBUS for diagnosing duplex kidney disease were 73.91%, 80.43%, 79.07%, and 75.51%, respectively. The diagnostic performance of RBUS and ceVUS in detecting duplex kidney yielded an overall sensitivity, specificity, PPV, and NPV of 89.13%, 84.78%, 85.42%, and 88.64%, respectively. The sensitivity, specificity, PPV, and NPV of VCUG in diagnosing duplex kidney disease were 17.31%, 86.96%, 57.14%, and 51.23%, respectively. For the 42 pyeloureteral units with VUR, Cohen's weighted kappa value for the agreement between ceVUS and VCUG in grading VUR was 0.702 (95% CI, 0.551 ~ 0.854; p <0.05).

Conclusions

RBUS effectively diagnoses duplex kidneys with renal pelvic dilation, while ceVUS can further elucidate whether reflux occurs in the upper or lower moiety in cases of duplex kidneys with VUR. Compared to VCUG, both RBUS and ceVUS provide more intuitive diagnoses for duplex kidneys with VUR and ureterocele. Additionally, there is good consistency between ceVUS and VCUG in grading VUR. CeVUS is recommended as an initial evaluation method for patients suspected of having duplex kidneys associated with urinary tract infections.

Contrast Media in Children: Ten Important Concepts on Administration, Applications, Complications, and Environmental Considerations, From the AJR Special Series on Contrast Media

Contrast media are an indispensable adjunct to pediatric imaging. The most common include iodine-based contrast media for CT and fluoroscopy, gadolinium-based contrast media and iron-oxide nanoparticles for MRI, and microbubbles for ultrasound. Although many of the considerations in the routine use of contrast media in infants and children (relating for example to renal function, allergic-like reactions, GBCM deposition, and extravasations) are similar to considerations in adult patients, some important differences exist. These variances are often age-dependent and require an appreciation of pediatric physiology for safe and effective clinical practice. This article highlights ten concepts relating to contrast media administration for diagnostic imaging in children that are important for radiologists and pediatricians to recognize and understand. We present contrast media classes and their use in children, discuss safety concerns and complications, and explore environmental impacts.

A narrative review on the applications of intracavitary contrast-enhanced ultrasonography in pediatric lower genitourinary anomalies

PURPOSE

We mainly aimed to perform a narrative review of clinical applications of the three intracavitary contrast-enhanced ultrasonography (CEUS) including contrast-enhanced voiding urosonography (ceVUS), contrast-enhanced retrograde urethrosonography (ceRUG), and contrast-enhanced genitosonography (ceGS) in pediatric lower genitourinary anomalies.

METHOD

A literature search in the PubMed and Web of Science databases was conducted up to 1 July 2022 on all studies published in English using the search terms "contrast-enhanced voiding urosonography", "contrast-enhanced retrograde urethrosonography", and "contrast-enhanced genitosonography". Trials were limited to pediatric subjects (ages ≤18 years) with no time restrictions. The inclusion criteria were studies on ceVUS, ceRUG, and ceGS to evaluate pediatric lower genitourinary anomalies. Two independent authors summarized the included articles.

RESULTS

Finally, a total of 48 original articles and 6 case reports or case series were included, of which 50 (93%) were only relevant to ceVUS, 3 (5%) articles involved ceGS, while only one (2%) article involved ceRUG, and 87% of the applications of ceVUS were focused on vesicoureteral reflux (VUR). We also searched 24 related reviews, of which 20 involved ceVUS in diagnosing VUR and 4 involved ceRUG and ceGS for other lower genitourinary anomalies.

CONCLUSION

Intracavitary CEUS including ceVUS, ceRUG, and ceGS in pediatrics has many advantages over other radiological examinations in diagnosing lower genitourinary anomalies. Although ceVUS is widely used in detecting VUR, ceRUG and ceGS have also become promising techniques for evaluating the urethral pathologies and urogenital sinus.

Contrast-enhanced voiding urosonography, a possible candidate for the diagnosis of vesicoureteral reflux in children and adolescents; a systematic review and meta-analysis

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.

Contrast-enhanced voiding urosonography, part 1: vesicoureteral reflux evaluation

Contrast-enhanced voiding urosonography (ceVUS) is a well-established, sensitive and safe ultrasound (US) modality for detecting and grading vesicoureteral reflux (VUR) and urethral imaging in children. Nearly three decades of remarkable advances in US technology and US contrast agents have refined ceVUS's diagnostic potential. The recent approval of Lumason/SonoVue in the United States, Europe and China for pediatric intravesical applications marked the beginning of a new era for this type of contrast US imaging. Consequently, the use of ceVUS in children has expanded to multiple places around the globe. In the first part of this review article, we describe the current experience in the use of ceVUS for VUR evaluation, with an emphasis on historical background, examination technique, image interpretation and diagnostic accuracy. In the second part, we will present the role of ceVUS for urethral imaging in children.

Contrast-enhanced ultrasound: a comprehensive review of safety in children

Contrast-enhanced ultrasound (CEUS) has been increasingly used in pediatric radiology practice worldwide. For nearly two decades, CEUS applications have been performed with the off-label use of gas-containing second-generation ultrasound contrast agents (UCAs). Since 2016, the United States Food and Drug Administration (FDA) has approved the UCA Lumason for three pediatric indications: the evaluation of focal liver lesions and echocardiography via intravenous administration and the assessment of vesicoureteral reflux via intravesical application (contrast-enhanced voiding urosonography, ceVUS). Prior to the FDA approval of Lumason, numerous studies with the use of second-generation UCAs had been conducted in adults and children. Comprehensive protocols for clinical safety evaluations have demonstrated the highly favorable safety profile of UCA for intravenous, intravesical and other intracavitary uses. The safety data on CEUS continue to accumulate as this imaging modality is increasingly utilized in clinical settings worldwide. As of August 2021, 57 pediatric-only original research studies encompassing a total of 4,518 children with 4,906 intravenous CEUS examinations had been published. As in adults, there were a few adverse events; the majority of these were non-serious, although very rarely serious anaphylactic reactions were reported. In the published pediatric-only intravenous CEUS studies included in our analysis, the overall incidence rate of serious adverse events was 0.22% (10/4,518) of children and 0.20% (10/4,906) of all CEUS examinations. Non-serious adverse events from the intravenous CEUS were observed in 1.20% (54/4,518) of children and 1.10% (54/4,906) of CEUS examinations. During the same time period, 31 studies with the intravesical use of UCA were conducted in 12,362 children. A few non-serious adverse events were encountered (0.31%; 38/12,362), but these were most likely attributable to the bladder catheterization rather than the UCA. Other developing clinical applications of UCA in children, including intracavitary and intralymphatic, are ongoing. To date, no serious adverse events have been reported with these applications. This article reviews the existing pediatric CEUS literature and provides an overview of safety-related information reported from UCA uses in children.

Diagnosis and grading of vesicoureteral reflux on voiding cystourethrography images in children using a deep hybrid model

BACKGROUND AND OBJECTIVE

Vesicoureteral reflux is the leakage of urine from the bladder into the ureter. As a result, urinary tract infections and kidney scarring can occur in children. Voiding cystourethrography is the primary radiological imaging method used to diagnose vesicoureteral reflux in children with a history of recurrent urinary tract infection. Besides the diagnosis of reflux, it is graded with voiding cystourethrography. In this study, we aimed to diagnose and grade vesicoureteral reflux in Voiding cystourethrography images using hybrid CNN in deep learning methods.

METHODS

Images of pediatric patients diagnosed with VUR between 2016 and 2021 in our hospital (Firat University Hospital) were graded according to the international vesicoureteral reflux radiographic grading system. VCUG images of 236 normal and 992 with vesicoureteral reflux pediatric patients were available. A total of 6 classes were created as normal and graded 1-5 patients.

RESULTS

In this study, a hybrid-based mRMR (Minimum Redundancy Maximum Relevance) using CNN (Convolutional Neural Networks) model is developed for the diagnosis and grading of vesicoureteral reflux on voiding cystourethrography images. Googlenet, MobilenetV2, and Densenet201 models are used as a part of the hybrid architecture. The obtained features from these architectures are examined in concatenating process. Then, these features are classified in machine learning classifiers after optimizing with the mRMR method. Among the models used in the study, the highest accuracy value was obtained in the proposed model with an accuracy rate of 96.9%.

CONCLUSIONS

It shows that the hybrid model developed according to the findings of our study can be used in the diagnosis and grading of vesicoureteral reflux in voiding cystourethrography images.