Contrast-enhanced Voiding Urosonography Research Articles

Effects of Intrarenal Reflux on Renal Growth in Children With Grades III-V Primary Vesicoureteral Reflux.

The phenomenon of intrarenal reflux (IRR) has been considered a crucial link between vesicoureteral reflux (VUR) and segmental scarring. We conducted a study on renal length in 104 children diagnosed with Grades III-V VUR, with or without IRR, using contrast-enhanced voiding urosonography (ceVUS). The patients were divided into two treatment groups: the conservative antibiotic prophylaxis (CAP) group and the operation group, which were further categorized into two subgroups: the IRR group and the non-IRR group. Our findings revealed an incidence rate of 35.96% (41/114) for IRR occurrence, with 43.42% (33/76) occurring in upper renal segments, 32.89% (25/76) in lower segments, and 23.68% (18/76) in middle segments. In the CAP group where the effects of IRR persisted, the renal growth observed was as follows: IRR group-0.19 ± 0.13 cm; non-IRR group-0.39 ± 0.23 cm; contralateral negative group-0.66 ± 0.35 cm; control group-0.46 ± 0 .25 cm respectively (P < .05). In the operation group, where the effects of IRR were eliminated, the renal growth for the IRR group, non-IRR group, contralateral negative group, and control group was 0.46 ± 0.22 cm, 0.54 ± 0.31 cm, 0.67 ± 0 .42 cm, and 0.36 ± 0.17 cm respectively (P < .005). In conclusion, the presence of IRR can impact renal growth in children diagnosed with Grades III-V primary VUR. Following surgical intervention, the IRR kidney does not exhibit catch-up growth; however, it demonstrates parallel growth alongside the unaffected kidney. Conversely, the non-IRR kidney experiences catch-up growth. Therefore, for children presenting with Grades III-V primary VUR combined with IRR, a more aggressive treatment approach such as surgery is recommended.

Update on imaging recommendations in paediatric uroradiology: the European Society of Paediatric Radiology workgroup session on voiding cystourethrography.

Voiding cystourethrography (VCUG) is a fluoroscopic technique that allows the assessment of the urinary tract, including the urethra, bladder, and-if vesicoureteral reflux (VUR) is present-the ureters and the pelvicalyceal systems. The technique also allows for the assessment of bladder filling and emptying, providing information on anatomical and functional aspects. VCUG is, together with contrast-enhanced voiding urosonography (VUS), still the gold standard test to diagnose VUR and it is one of the most performed fluoroscopic examinations in pediatric radiology departments. VCUG is also considered a follow-up examination after urinary tract surgery, and one of the most sensitive techniques for studying anatomy of the lower genitourinary tract in suspected anatomical malformations. The international reflux study in 1985 published the first reflux-protocol and graded VUR into five classes; over the following years, other papers have been published on this topic. In 2008, the European Society of Paediatric Radiology (ESPR) Uroradiology Task Force published the first proposed VCUG Guidelines with internal scientific society agreement. The purpose of our work is to create a detailed overview of VCUG indications, procedural recommendations, and to provide a structured final report, with the aim of updating the 2008 VCUG paper proposed by the European Society of Paediatric Radiology (ESPR). We have also compared VCUG with contrast-enhanced VUS as an emergent alternative. As a result of this work, the ESPR Urogenital Task Force strongly recommends the use of contrast-enhanced VUS as a non-radiating imaging technique whenever indicated and possible.

Therapeutic Management of Children with Vesicoureteral Reflux.

Contrasting data refer to therapies for vesicoureteral reflux (VUR), such as surgical treatments and continuous antibiotic prophylaxis (CAP). This study evaluated the effectiveness of these approaches in children with VUR, analyzing the recurrence of febrile urinary tract infections (UTIs) and the resolution of VUR after the treatment. A total of 350 pediatric patients underwent contrast-enhanced voiding urosonography (ceVUS) to diagnose a VUR, whereas renal scintigraphy evaluated potential scars. After 12 months from the treatment, the VUR, the relapse of febrile UTIs, and reflux-related nephropathy were analyzed. Twenty-seven children had recurrent febrile UTIs after surgical therapy, with a greater rate of relapses observed in III and V VUR grades. Thirteen patients who underwent surgery had scars, independently of VUR grades and gender, with evidence of chronic renal failure at the end of the follow-up period. A total of 140 subjects were treated with CAP, and 30% of them continued to suffer from febrile UTIs. Ninety-five patients with VUR underwent ceVUS after 12 months, with persistent reflux in fifty-two patients. All of them had severe VUR, correlating with the age at diagnosis and gender. CAP therapy prevented scarring better than surgery, especially in children with III and V grades of VUR. A late onset of VUR or VUR involving neonatal patients is rarely a reversible process. This study identified predictors of success or failure of surgical or CAP therapies, evaluating the relapse of UTIs or persistent reflux after the treatment and giving prognostic information in children with VUR.

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

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. 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. 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. 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.

Viability of contrast-enhanced voiding urosonography as an alternative to fluoroscopy during video urodynamics.

Pediatric urodynamic studies are performed to evaluate bladder function, commonly in conjunction with a voiding cystourethrogram (VCUG). Contrast-enhanced voiding urosonography (CeVUS) has been approved in the evaluation of vesicoureteral reflux and has been shown to have equal or superior diagnostic value to VCUG. In this technical innovation, we have shown that ultrasound contrast agent microbubbles are compatible with the equipment used for urodynamic evaluation. We have also shown that it is feasible to use contrast ultrasound in pediatric urodynamic examinations.The purpose of our study was to assess the technical feasibility of CeVUS during urodynamics with an in vitro test followed by a vivo evaluation.This single-center prospective study enrolled 25 patients aged 0-18years who underwent CeVUS instead of VCUG at their regularly scheduled appointment.During the in vitro saline experiment, the radiologic and urologic equipment were found to be compatible. Microbubbles were observed at flow rates of 10 and 20 ml/min.

Comparison between contrast enhanced voiding urosonography (CEVUS) with standard cystography under fluoroscopy (VCUG) for detection of vesicoureteral reflux in pediatric patients

Comparison between contrast enhanced voiding urosonography (CEVUS) with standard cystography under fluoroscopy (VCUG) for detection of vesicoureteral reflux in pediatric patients

Contrast-enhanced voiding urosonography (CEVUS) as a safe alternate means of assessing vesicoureteral reflux in pediatric kidney transplant patients.

Although voiding cystourethrogram (VCUG) is currently the gold standard in VUR evaluation, there is ionizing radiation exposure. Contrast-enhanced voiding urosonography (CEVUS) uses ultrasound contrast agents to visualize the urinary tract and has been reported to be safe and effective in VUR evaluation in children. CEVUS application has yet to be specifically described in VUR evaluation in the pediatric kidney transplant population. The purpose of this study was to report the use of CEVUS and VCUG in evaluating and managing VUR in pediatric renal transplant patients. Retrospective review was conducted for pediatric kidney transplant patients (18 years and younger) who underwent VCUG or CEVUS to assess for transplant VUR from July 2019 through June 2021. Demographic information, reason for VUR evaluation, fluoroscopy time, and postimaging complications were evaluated. Costs of imaging modalities were also considered. Eight patients were evaluated for transplant VUR during the study period. Of the 3 patients who underwent VCUG, all 3 had VUR (median grade 3). Median fluoroscopy time was 18s and dose-area product was 18.7 uGy*m2 . Of the 5 patients who underwent CEVUS, 4 had VUR (median grade 4). There were no complications for either modality. Based on clinical and radiographic findings, patients were recommended no intervention, behavioral modification, or ureteral reimplantation. The total cost of CEVUS was $800 less than that of VCUG. CEVUS can provide an alternate means of safely evaluating VUR in kidney transplant patients with similar outcomes, potentially lower costs, and no exposure to ionizing radiation.

The Spectrum of Parenchymal Changes in Kidneys Affected by Intrarenal Reflux, Diagnosed by Contrast-Enhanced Voiding Urosonography and DMSA Scan.

PurposeTo describe the parenchymal defects in kidneys with intrarenal reflux (IRR) diagnosed using contrast-enhanced voiding urosonography (ceVUS) and 99mTc-DMSA scintigraphy (DMSA scan).Materials and MethodsA group of 186 uretero-renal units (URUs) was analyzed using ceVUS and DMSA scans: 47 without vesicoureteral reflux (VUR) (group A) and 139 with VURs, comprising 73 VURs without (group B), and 66 with IRR (group C). VURs included non-dilating (grades I–II), mildly non-dilating (grade III), and non-dilating (grades IV–V) grades. The parenchymal changes were analyzed using a DMSA scan.ResultsThe median age for VUR diagnosis was 16.5 months in girls, and 8.5 months in boys (Z = 3.9; p = 0.001). IRR occurred in 51.4% of boys and in 25.9% of girls (χ2 = 12.4; p < 0.001). The non-dilating VUR occurred in 44% of boys and 24.1% of girls (χ2 = 7.7; p = 0.005). IRRs characterized upper and lower renal segments (81.8 and 63.6%) and middle segments (33.3%). Both incidence and increase in IRR correlated with the grade of VUR (p < 0.001). The incidence of reduced DMSA signal was statistically different among groups A + B and C, but not between groups A and B (χ2 = 32.2; p < 0.001). No statistically significant relationship existed between the reduced DMSA signal and the grade of VUR in group C. The reduced DMSA signal appeared in 9.9% positions in kidneys from group A, 14% from group B, and 32% from group C. Out of all 118 IRRs, 38.1% had reduced and 61.9% had normal DMSA signal. Among 11 parenchymal scars found in all three groups, 2 belonged to group B, 9 to group C, while group A had no scars.ConclusionThe parenchymal changes are the most prominent in the group with IRR, but they do not significantly differ among kidneys with different grades of VUR. VURs of higher grades are associated with a higher incidence of IRR and early clinical presentation. Scars can also appear in lower-grade VURs accompanied by IRR. Boys with VUR have earlier clinical presentation than girls, as they have significantly higher grades of VUR with a higher proportion of IRRs. Therefore, we suggest a subdivision of VURs into those with IRR and abundant parenchymal damage, and those without IRR and less parenchymal damage.

Contrast-enhanced voiding urosonography part 2: urethral imaging.

Ultrasound (US) has been increasingly used as an important imaging tool to assess the urethra in children. The earliest reports of pediatric urethral sonography involved imaging the urethra in a non-voiding state, during physiological voiding of urine, and after instillation of saline. The introduction of US contrast agents has continued to improve visualization of urethral anatomy. Contrast-enhanced US of the urethra can be performed during the voiding phase of a standard contrast-enhanced voiding urosonography (ceVUS) exam or with retrograde instillation of a contrast agent, depending on the exam indication. Both techniques are well tolerated by children and provide accurate information about urethral pathology and periurethral soft tissues. This article reviews the technical aspects and imaging findings of urethral pathologies in children using contrast-enhanced US, both by the voiding and retrograde instillation techniques.

Intrarenal Reflux Diagnosed by Contrast-enhanced Voiding Urosonography - a Case Report

Objective − Intrarenal reflux (IRR) is the main cause of renal injury in children with vesicoureteral reflux (VUR), and has an important role in the pathogenesis of scarring and reflux nephropaty (RN). Using voiding cystourethrography (VCUG) IRR is usually detected in high grades of VUR. Our case demonstrates the possibility of visualizing IRR in a child with low-grade VUR using contrast-enhanced voiding urosonography (ceVUS). Case Report − We report the case of a four-month-old girl with Klebsiella pneumoniae febrile urinary tract infection (UTI) who was diagnosed by ceVUS with VUR grade II on the right kidney, with IRR strongest in the lower pole. A 99m Tc 2.3-dimercaptosuccinic acid (DMSA) renal scan, which was performed 8 months after the UTI revealed a small scar on the lower pole of the right kidney, where IRR was found by ceVUS. Conclusion − Our case report showed that not only the grade of reflux but also the presence of IRR is important to predict the severity of the clinical picture and the development of possible scarring. It is important to find IRR because it may be connect with renal scars. VUR with IRR should be managed actively to decrease the chances of renal scarring or the development of new scars.

Assessment of distal ureteral and ureterovesical junction visualization on contrast-enhanced voiding urosonography.

Contrast-enhanced voiding urosonography (CEVUS) uses intravesically administered microbubble contrast to detect vesicoureteral reflux (VUR) and urethral anomalies with ultrasound. Multiple studies have suggested CEVUS can replace voiding cystourethrogram (VCUG) as a radiation-free alternative. Analysis of the ureterovesical junction and ureters on VCUG documenting the ureterovesical junction position, ureteral duplication, periureteral diverticula and ureteroceles is important as anatomical variations may affect management and surgical approach. Our purpose was to assess distal ureteral and ureterovesical junction region visualization in children with VUR detected on CEVUS. CEVUS studies performed between June 2018 and March 2019 with reported VUR were retrospectively reviewed by two pediatric radiologists to confirm VUR and to qualitatively assess the ureterovesical junction region for each renal moiety using a 3-point scale for clear, limited or absent visualization of the distal ureter, ureterovesical junction, ureteral duplication, periureteral diverticula and ureteroceles. Thirty-four studies with VUR on CEVUS were identified. Sixty-seven renal moieties were evaluated including a solitary kidney in one child. VUR was detected in 52 moieties by reader 1 and in 53 by reader 2. A single moiety with discrepancy between readers regarding VUR was excluded from statistical analysis. No diverticula were detected by either reader and one ureterocele was detected by both readers. Visualization of the ureterovesical junction was described as clear in 5/52, limited in 14/52 and absent in 33/52 refluxing renal moieties by reader 1 and as clear in 12/52, limited in 20/52 and absent in 20/52 by reader 2. The ureterovesical junction was clearly visualized in 5/52 (9.6%) by reader 1 and 12/52 (23.1%) by reader 2. The Kappa value of -0.29 (confidence interval [CI] -0.25, 0.21) reveals a lack of agreement between the readers for clear versus limited or absent ureterovesical junction visualization. Distal ureteral visualization was described as clear in 14/52, limited in 16/52 and absent in 22/52 refluxing renal moieties by reader 1 and as clear in 27/52, limited in 7/52 and absent in 18/52 by reader 2. The distal ureter was clearly visualized in 14/52 (26.9%) by reader 1 and 27/52 (51.9%) by reader 2. The Kappa of 0.43 (CI 0.22, 0.64) reveals moderate agreement between the readers for clear versus limited or absent distal ureteral visualization. Duplication of the renal collecting system was identified in 13/52 refluxing kidneys by reader 1 and 11/52 refluxing kidneys by reader 2. Visualization of ureteral duplication was described as clear in 9, limited in 4 and absent in 39 of 52 refluxing renal moieties by reader 1 and as clear in 9, limited in 2 and absent in 41 by reader 2. Ureteral duplication was clearly visualized in 9/52 (17.3%) by reader 1 and 9/52 (17.3%) by reader 2. Kappa of 0.87 (CI 0.68, 1) reveals high agreement between the readers for clear versus limited or absent identification of ureteral duplication. The distal ureter and ureterovesical junction region frequently are not clearly visualized in refluxing renal moieties on CEVUS. Awareness of this limitation is important as there may be implications when evaluating patients for surgical management of VUR.

Role of Contrast-Enhanced Voiding Urosonography in the Evaluation of Renal Transplant Reflux - Comparison with Voiding Cystourethrography and a New Classification.

of this study is to evaluate the performance of contrast-enhanced voiding urosonography (CEvUS) in the diagnosis and classification of reflux into the renal allograft, to evaluate and classify VUR into the allograft using voiding cystourethrography (VCUG) and CEvUS, to compare the two methods, and to propose a new classification of reflux into the allograft based on CEvUS and VCUG assessment, in line with the international reflux grading system. From January 2017 to July 2019, 84kidney transplant patients were enrolled. All patients underwent VCUG and CEvUS. In 76 cases there was agreement between VCUG and CEvUS (90 %) (Kappa = 0.7). The sensitivity of CEvUS using VCUG as the gold standard was 90 %, and the specificity was 92 %. Of the 7 cases diagnosed by VCUG and not by CEvUS, 6were grade 1 and 1 was grade 2. Transplant patients with reflux symptoms should undergo CEvUS. If the outcome is negative, VCUG should be performed. The classification that we propose is better suited to describe VUR in transplant patients, because it is simpler and takes into account whether reflux occurs not only during urination but also when the bladder is relaxed.

Feasibility of Using Contrast Enhanced Voiding Urosonography (CeVUS) During Urodynamic Studies

Feasibility of Using Contrast Enhanced Voiding Urosonography (CeVUS) During Urodynamic Studies

Contrast-enhanced voiding urosonography with intravesical administration of ultrasound contrast agent for the diagnosis of pediatric vesicoureteral reflux.

Vesicoureteral reflux (VUR) is one of the most common urinary tract anomalies in children. It has been reported that VUR may be associated with reflux nephropathy. Ultrasound contrast-enhanced voiding urosonography (CeVUS) has become a routine diagnostic method for VUR in a number of European countries; however, it is not widely used in China. The aim of the present study was to analyze the clinical application and evaluate the safety of CeVUS as a diagnostic tool for VUR in children in order to establish a standardized operating procedure for CeVUS in pediatric VUR in China. Between August 2016 and October 2017, 90 children who were susceptible to VUR were admitted into the Pediatric Nephrology Department of Tongji Hospital and underwent CeVUS. The SonoVue second-generation USA contrast agent was administered intravesically via a transurethral bladder catheter at a dose of 1 ml. The occurrence of adverse events was monitored. Urine analysis and culture were performed. A total of 90 children (47 female, 43 male; mean age, 36.6 months) with 178 Pelvi-Ureteral Units (PUUs) underwent CeVUS to screen for VUR. VUR was detected in 44/90 pediatric patients (48.89%) and 65/178 PUUs (36.52%) by CeVUS. The grade distribution of the 65 PUUs with VUS was as follows: Grade I, 3; Grade II, 9; Grade III, 14; Grade IV, 22; and Grade V, 17. The accuracy of CeVUS in the present study were consistent with previous reports. No urethral anomalies were detected and there were no adverse events. CeVUS was demonstrated to be a safe, accurate and reliable imaging technique for detecting VUR in high-risk children, including neonates. Results of the present study indicated that CeVUS can be adopted as the primary screening and follow-up method for pediatric VUR diagnoses in China.

3D/4D contrast-enhanced urosonography (ceVUS) in children - is it superior to the 2D technique?

Background: By now, two-dimensional contrast-enhanced voiding urosonography (ceVUS) has become a well-established method for the diagnosis and treatment monitoring of vesicoureteral reflux in children, particularly after the recent approval for this application in children in the USA and in Europe. The introduction of three-dimensional static (3D) and real-time (4D) techniques with ultrasound contrast agents opens up new diagnostic opportunities for this imaging modality. Objective: To analyze whether 3D and 4D ceVUS is a superior technique compared to standard 2D ceVUS in diagnosing vesicoureteral reflux in children. Material and methods: The study included 150 patients (mean age 3.7 years) who underwent 2D and 3D/4D ceVUS for the diagnosis and grading of vesicoureteral reflux. Results: 2D ceVUS and 3D/4D ceVUS diagnosed the same number of vesicoureteral refluxes, however, there was a statistically significant difference in grading between the two methods. Performing 3D/4D ceVUS resulted in changing the initial grade compared to 2D ceVUS in 19 out of 107 refluxing units (17.76%) diagnosed. The 4D technique enabled a more conspicuous visualization of vesicoureteral reflux than the 3D technique. Conclusions: 2D ceVUS and 3D/4D ceVUS diagnosed the same number of vesicoureteral refluxes, however, there was a statistically significant difference in grading between the two methods. Thus 3D/4D ceVUS appears at least a valid, if not even a more conspicuous technique compared to 2D ceVUS.

PS-237 Contrast-enhanced Voiding Urosonography With A Second-generation Ultrasound Contrast Agent For Diagnosis Of Vesicoureteric Reflux In 1350 Children: The Experience Of A Single Centre

Purpose To evaluate the diagnostic performance and safety of intravesical administration of a-second-generation ultrasound contrast-agent (UCA) for the diagnosis of vesicoureteric reflux (VUR) in children. Methods and materials 1350 children (587 boys/763 girls, mean-age 2.6y, range 15d-17y) with 2720 pelvi-ureter-units, underwent contrast-enhanced voiding urosonography (ceVUS) to rule out VUR and urethral pathology. A second-generation UCA (SonoVue ® , Bracco, Milan) was administered intravesically through 5–8F feeding-tube at a dose of 0.5 ml/bladder filling. Possible adverse-events were monitored during the examination and followed-up for 7 days after the ceVUS by phone-calls. Urine analysis and culture were performed 3–5 d before ceVUS in all children and 24–48 h in any patient reported with adverse-events. Results VUR was detected in 450/1350(33%) patients (162 boys/288 girls). This was in 653 pelvi-ureter-units (reflux-grade distribution: grade I = 1, grade II = 276, grade III = 266, grade IV = 100, grade V = 10). The urethra was normal in all children. Mean duration of examination was 14 ± 7 min, including urethral imaging. Minor adverse-events were reported in 45(3.3%) children. These included dysuria (n = 39), abdominal pain (n = 2), increased frequency of micturition (n = 1), vomiting (n = 1), perineal irritation (n = 1), and urinary-tract-infection after ceVUS (n = 1). The onset of adverse-events were subacute in 92% and delayed in 8% and were self-limited non-requiring hospitalisation. Conclusions There were no serious adverse-events with intravesical use of SonoVue ® . Only a few minor adverse-events were reported during ceVUS most likely due to catheterization process. Thus ceVUS with intravesical administration of a second generation UCA (SonoVue ® ) for VUR and urethral pathology detection is a safe and reliable diagnostic procedure in children.

Paediatric vesicoureteric reflux imaging: where are we? Novel ultrasound-based voiding urosonography.

Vesicoureteric reflux is an important association of paediatric urinary tract infection. Fluoroscopic micturating cystourethrography and radionuclide cystography have been employed for detecting and grading vesicoureteric reflux. However, both modalities involve ionising radiation, which can pose significant radiation risk to growing children. They also have a lower detection rate due to intermittent fluoroscopic technique in micturating cystourethrography, and lower spatial resolution in radionuclide cystography. Therefore, newer radiation-free ultrasound-based contrast-enhanced voiding urosonography has been developed in Europe for 15 years. This article aimed to summarise the current literature and discuss the first local pilot study in our institution on detection of vesicoureteric reflux by contrast-enhanced voiding urosonography. Contrast-enhanced voiding urosonography is a valid alternative to micturating cystourethrography in assessing vesicoureteric reflux, based on its superior diagnostic performance, reliability, safety, feasibility, and radiation safety for children. Therefore, it should be incorporated in the guideline for investigating paediatric urinary tract infection.

Voiding urosonography with second-generation ultrasound contrast versus micturating cystourethrography in the diagnosis of vesicoureteric reflux

Vesicoureteric reflux has been associated with paediatric urinary tract infection. Fluoroscopic micturating cystourethrography (MCU) has been the gold standard of diagnostic test for decades; however, it has been criticized owing to its lower detection rate and radiation dose to children. Therefore, new radiation-free reflux imaging modalities have been developed, in which ultrasound-based contrast-enhanced voiding urosonography (ceVUS) is a good example. However, ultrasonography has been considered as an operator-dependent examination. Therefore, our study aimed to examine the inter-observer agreement of this sonographic technique, which has not been evaluated before. Moreover, the second-generation ultrasound contrast SonoVue has been recently marketed, and the data on its efficacy on intravesical use in ceVUS is relatively scarce. Thus, we also aimed to investigate the diagnostic performance and safety profile of SonoVue-enhanced VUS in the diagnosis of vesicoureteric reflux. Our prospective comparative study compared the diagnostic performance of ceVUS with MCU in young children presenting with first episode of urinary tract infection. We performed sequential ceVUS and MCU examinations in 31 patients (62 pelvi-ureter units). Perfect inter-observer agreement (Cohen’s kappa statistics = 1.0, p < 0.001) was achieved in ceVUS, suggesting its good reliability in reflux detection and grading. Using MCU as reference, ceVUS had 100 % sensitivity and 84 % specificity and carried higher reflux detection rate than MCU (p < 0.001). There was no complication encountered. Conclusion: Voiding urosonography is a reliable, sensitive, safe and radiation-free modality in the investigation of vesicoureteric reflux in children. It should be incorporated in the diagnostic algorithm in paediatric urinary tract infection.

Contrast-enhanced voiding urosonography with intravesical administration of a second-generation ultrasound contrast agent for diagnosis of vesicoureteral reflux: prospective evaluation of contrast safety in 1,010 children

To evaluate the safety of intravesical administration of a second-generation ultrasound (US) contrast agent for the diagnosis of vesicoureteral reflux in children. One thousand and ten children (563 girls, 447 boys; mean age: 2.9 years, range: 15 days-17.6 years) with 2,043 pelvi-ureter-units underwent contrast-enhanced voiding urosonography (ce-VUS) to rule out vesicoureteral reflux. A second-generation US contrast agent (SonoVue®, Bracco, Milan) was administered intravesically through transurethral bladder catheterization at a dose of 0.5 ml/bladder filling. Possible adverse events were monitored during the examination and followed up for 7 days after ce-VUS by phone calls. Urine analysis and culture were performed 3-5 days before ce-VUS in all children and 24-48 h in any patient who reported with adverse events. No case of serious adverse event was recorded. Minor events were reported in 37 children (3.66% of the study population). These included dysuria (n = 26, 2.57%), urinary retention (n = 2, 0.2%), abdominal pain (n = 2, 0.2%), anxiety (n = 1, 0.1%) and crying (n = 1, 0.1%) during micturition, blood and mucous discharge (n = 1, 0.1%), increased frequency of micturition (n = 1, 0.1%), vomiting (n = 1, 0.1%), perineal irritation (n = 1, 0.1%), and an episode of urinary tract infection 10 days after ce-VUS (n = 1, 0.1%). Of these adverse events, 91.9% were subacute in onset and 8.1% were delayed. All events were self-limited and none required hospitalization. There were no serious adverse events. Only a few minor events were reported, most likely due to the catheterization process. Thus, ce-VUS with intravesical administration of the second-generation US contrast agent (SonoVue®) for vesicoureteral reflux detection or exclusion had a favorable safety profile in our study group.

2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and monitoring of treatment of vesicoureteral reflux in children – can it replace voiding cystourethrography?

IntroductionVesicoureteral reflux appears in 20–50% of pediatric patients with recurrent urinary tract infections. The most common method of diagnosing this disease is voiding cystourethrography. However, contemporary pediatric radiology does not favor this method due to exposure to X-radiation.AimThe aim of this study was to assess the usefulness of 2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and treatment monitoring of vesicoureteral reflux in children and the possibility of using contrast-enhanced voiding urosonography to replace voiding cystourethrography.Material and methodsVoiding cystourethrography and contrast-enhanced voiding urosonography were conducted in 80 pediatric patients in order to assess sensitivity, specificity, positive and negative predictive values as well as the number of vesicoureteral refluxes detected by each of the two methods. The second stage of the study involved performing voiding urosonography in an extended protocol in 58 children in order to determine the usefulness of three-dimensional (3D/4D) examinations in the assessment of vesicoureteral reflux and the ability to assess the urethra.ResultsThe concordance between the two methods was 86.95%. The sensitivity of voiding urosonography was 84.51%, specificity – 90.99%, positive predictive value – 85.71% and negative predictive value – 90.17%. A 3D/4D assessment of the urinary bladder and transperineal 2D morphological assessment of the urethra were possible in all patients (100%). Assessment of the urethra during micturition with the use of 2D/3D/4D techniques was possible in all patients in whom voiding was elicited (95.83%), and 3D/4D assessment of vesicoureteral reflux was possible in all patients with reflux (100%). Although the application of 3D/4D techniques allowed accurate specification of the grade of reflux in all cases (100%), it appeared particularly useful in differentiating between grades II and III (70.97%).ConclusionsContrast-enhanced voiding urosonography allows the diagnosis and monitoring of treatment of vesicoureteral reflux in pediatric patients as well as assessment of the urethra in both girls and boys. The method is characterized by high sensitivity and specificity. Moreover, it is safe, relatively inexpensive and can replace voiding cystourethrography.