Conventional Voiding Cystourethrography Research Articles

Understanding and Addressing Vesicoureteral Reflux in Pediatric Patients: A Comprehensive Exploration of Diagnostic Strategies, Challenges, and Optimized Management Approaches

Vesicoureteral reflux (VUR) in pediatric patients poses a multifaceted challenge for clinicians, necessitating a thorough exploration of diagnostic strategies, challenges, and optimized management approaches. This article delves into the nuanced aspects of understanding VUR in the pediatric population. Diagnostic modalities, ranging from conventional voiding cystourethrography to advanced imaging techniques, are scrutinized for their efficacy in identifying reflux severity and associated complications. Challenges in the diagnostic process, including age-related variations and the impact of evolving clinical presentations, are discussed. The article also addresses the intricacies of managing pediatric VUR, emphasizing the importance of tailored treatment plans based on reflux grade, patient age, and concurrent conditions. Surgical and non-surgical interventions are appraised, highlighting their respective advantages and limitations. Additionally, the role of antibiotic prophylaxis in preventing urinary tract infections and preserving renal function is explored. Through a comprehensive examination of the diagnostic and management landscape, this article aims to provide clinicians with a nuanced understanding of pediatric VUR, enabling them to navigate the complexities of diagnosis and deliver optimized care to young patients with this urological condition.

Special diagnostics in pediatric urology-Ultrasound, VCUG, CT and MRI : Part 1: tips for the practice

The diagnostics and treatment of pediatric urology patients in the clinical routine can be extremely challenging. In comparison to adult patients, congenital diseases, more time consuming examinations and limited options in addition to the parents' expectations must be taken into account in the diagnostic work up. In this first of two parts we will delve into ultrasound diagnostics as the cornerstone in the diagnostic pathway of children with hydronephrosis ans take acloser look on contrast enhanced ultrasound (CEUS). Conventional voiding cystourethrography still plays amajor role in the diagnostic pathway of vesicoureteric reflux and will be treated in this article. Computed tomography should only be considered in pediatric patients in rare cases, always taking radiation into critical account. Magnetic resonance imaging provides an excellent anatomical overview without exposing the child to unnecessary radiation. This article provides an overview on the diagnostic imaging studies in pediatric urology and brings tips for the diagnostic evaluation.

Positioning the Instillation of Contrast Cystography: Does It Provide Any Clinical Benefit?

To outline positioning the instillation of contrast cystography (PICC)'s benefits in clinical practice. A total of 198 patients underwent PICC with the following indications: patients with positive preoperative conventional voiding cystourethrography (VCUG) for a single ureteric side, patients with urinary tract infection (UTI), and negative VCUG for both ureteric sides. Patients with positive VCUG served as the control group. Preoperative, intraoperative, and postoperative features of all patients were compared. The reflux rate for the contralateral vesicoureteric reflux (VUR) investigation group was 39.1%. Only the cystoscopic view of the anatomically deficient ureteric orifice was found to be a significant predictor of contralateral reflux (P = .002). For patients who presented with UTI, the reflux rate was 58.3%. Resolution of infection was assessed for patients who presented with UTI, and 54.1% of these patients had a complete response in the follow-up period. When the patients were classified as PICC positive and negative, infection-free rates were 58.3% and 48%, respectively (P = .296). PICC is an effective diagnostic method for revealing occult reflux. However, the clinical significance of this finding is vague. In patients with UTI, PICC was useful for diagnosing occult VUR and clearing the symptoms in more than half of the patients. Further, the symptom-free state in the follow up period was slightly higher but not more significant than it was in those with no VUR diagnosed.

Voiding urosonography with second-generation contrast as a main tool for examining the upper and lower urinary tract in children. Pilot study

IntroductionIn this series, we analyze the diagnostic efficacy of serial voiding urosonography (VUS) with second-generation contrast, combined harmoniously and specifically with contrast technology, in the examination of the urinary tract in children. This examination includes the diagnosis and follow-up for vesicoureteral reflux (VUR) and urethral disorders, mainly those of the posterior urethral valve (PUV). Patients and methodsAfter obtaining informed consent, a prospective study was conducted using urosonography with second-generation contrast (sulphur hexafluoride microbubbles, SonoVue®) from November 2014 to October 2015 (1 year) in pediatric patients with suspected VUR or PUV impairment. For patients with a high suspicion of VUR and in cases of PUV, we also conducted simultaneous voiding cystourethrography (VCUG). ResultsWe studied 40 patients (80 renal units) between the ages of 2 months and 13 years (median age, 14 months). The indication for the test was a suspected VUR (36 patients, group A) and PUV follow-up (4 patients, group B). The test was correlated with VCUG in 16 patients (12 cases with high suspicion of VUR in group A and with 4 cases of PUV in group B). The visualization of the urethra was appropriate in cases of dilation or urethral stricture. For 3 of these patients with bilateral VUR demonstrated in the serial VUS, the VCUG showed only unilateral VUR in 2 of the patients and no VUR in 1 of the patients (κ=.73). DiscussionWe have shown that the visualization of the urethra is no longer a limitation and that serial VUS can be superior to conventional VCUG in diagnosing VUR.

Urosonografía miccional con contraste de segunda generación como herramienta primaria en el estudio de la vía urinaria superior e inferior en pediatría. Estudio Piloto

IntroductionIn this series, we analyse the diagnostic efficacy of serial voiding urosonography (VUS) with second-generation contrast, combined harmoniously and specifically with contrast technology, in the examination of the urinary tract in children. This examination includes the diagnosis and follow-up for vesicoureteral reflux (VUR) and urethral disorders, mainly those of the posterior urethral valve (PUV). Patients and methodsAfter obtaining informed consent, a prospective study was conducted using urosonography with second-generation contrast (sulphur hexafluoride microbubbles, SonoVue®) from November 2014 to October 2015 (1 year) in paediatric patients with suspected VUR or PUV impairment. For patients with a high suspicion of VUR and in cases of PUV, we also conducted simultaneous voiding cystourethrography (VCUG). ResultsWe studied 40 patients (80 renal units) between the ages of 2 months and 13 years (median age, 14 months). The indication for the test was a suspected VUR (36 patients, group A) and PUV follow-up (4 patients, group B). The test was correlated with VCUG in 16 patients (12 cases with high suspicion of VUR in group A and with 4 cases of PUV in group B). The visualisation of the urethra was appropriate in cases of dilation or urethral stricture. For 3 of these patients with bilateral VUR demonstrated in the serial VUS, the VCUG showed only unilateral VUR in 2 of the patients and no VUR in 1 of the patients (κ=.73). DiscussionWe have shown that the visualisation of the urethra is no longer a limitation and that serial VUS can be superior to conventional VCUG in diagnosing VUR.

Magnetic resonance voiding cystourethrography (MRVCUG): A potential alternative to standard VCUG

To evaluate the accuracy and feasibility of magnetic resonance voiding cystourethrography (MRVCUG), with or without contrast medium, in detecting vesicoureteral reflux (VUR) by comparison with conventional voiding cystourethrography (VCUG). Seventy-five patients underwent a series of 55 indirect MRVCUG (I-MRVCUG) and 61 direct MRVCUG (D-MRVCUG) between 2003 and 2009. We retrospectively compared the results from I-MRVCUG and D-MRVCUG with those from VCUG on 150 kidney-ureter units. Ratios of successful completion of the two types of MRVCUG were analyzed in 116 examinations according to sex, age, and among the two groups, with or without sedation. D-MRVCUG was superior to I-MRVCUG in detecting VUR (sensitivity: 96.8% vs. 76.9%; specificity: 96.3% vs. 88.7%; agreement: 96.6% vs. 83.7%; kappa: 0.83 [95% confidence interval (CI): 0.72, 0.94] vs. 0.55 [95% CI: 0.41, 0.69]). The overall ratio of successful completion of the two types of MRVCUG was 76.7% (89/116): there was no significant difference between I-MRVCUG and D-MRVCUG. The successful completion rate was significantly lower in MRVCUG in toddlers compared with preschoolers, infants, schoolchildren, and adults (P < 0.001). The two types of MRVCUG (I-MRVCUG and D-MRVCUG) are promising tests without radiation exposure. Both I-MRVCUG and D-MRVCUG are feasible for children except for toddlers.

Positioning the instillation of contrast at the ureteral orifice cystography can be useful to predict postoperative contralateral reflux in children with unilateral vesicoureteral reflux

The aim of the present study was to evaluate the usefulness of positioning the instillation of contrast at the ureteral orifice (PIC) cystography in prediction of postoperative contralateral reflux in patients with unilateral vesicoureteral reflux (VUR) undergoing ureteral reimplantation. Between January 2007 and March 2009, 34 children (20 boys and 14 girls) had antireflux surgery for unilateral primary VUR. This was diagnosed by conventional fluoroscopic voiding cystourethrography (VCUG) in all patients. After induction of general anesthesia, PIC cystography was carried out immediately before ureteral reimplantation by instilling contrast material at the ureteral orifice. Patients with positive PIC cystogram on the contralateral side underwent bilateral ureteral reimplantation via the Cohen technique. VCUG was repeated at 6-12 months postoperatively. Of the 34 patients, 16 (47%) showed VUR on the contralateral side on PIC cystography and underwent bilateral reimplantation. The remaining 18 patients (53%) with negative PIC cystogram underwent unilateral reimplantation, and no VUR was detected by postoperative VCUG in all ureters. None of the 34 patients had surgical complications or recurrent urinary tract infections. In conclusion, PIC cystography represents a useful tool to predict new onset contralateral VUR in patients with unilateral VUR on conventional VCUG.

Voiding urosonography: the study of the urethra is no longer a limitation of the technique

Voiding urosonography (VUS) has proved to be a reliable method for the study of vesicoureteric reflux (VUR). Early reports considered it inadequate for imaging the male urethra. To determine the usefulness of contrast-enhanced VUS for the study of the urethra. A total of 208 children aged 2 days to 10 years underwent VUS to confirm or exclude VUR for different reasons (n = 150) or for follow-up (n = 58). Patients with unconfirmed suspicion of VUR (99 boys and 51 girls) also underwent VUS for the study of the urethra. Examinations were performed using a harmonic imaging mode specific for contrast (Levovist) enhancement. We used a 6-4-MHz convex probe and a transperineal and/or a transpelvic approach. The neck of the bladder and the entire urethra were visualized in all patients (n = 150). The male urethra was considered normal in 95 boys (95.95%). We diagnosed posterior urethral valves in two patients, diverticulum of the prostatic utricle in one, and diverticulum of the anterior urethra in one. All abnormal cases were confirmed using conventional voiding cystourethrography. VUS can replace voiding cystourethrography as the method of choice for the initial study of suspected VUR in children.

Gray Scale and Color Doppler Sonography With Extended Field of View Technique for the Diagnostic Evaluation of Anterior Urethral Strictures

We compared the clinical relevance of radio urethrography with that of sonourethrography for evaluating male urethral strictures. From 2002 to 2004, 93 men were referred to our institution for urethral strictures. Patients were evaluated by conventional voiding cystourethrography, retrograde urethrography, and gray scale and color Doppler sonourethrography. For sonourethrography the extended field of view technique was used to obtain 1 image of the whole anterior urethra. In all cases the urethra was evaluated cystoscopically or at open surgery. Radio urethrography and sonourethrography findings were compared with cystoscopy or surgery findings. All strictures were evaluated and treated cystoscopically with visual internal urethrotomy (34%) or at open operation (66%), which allowed comparison of the ability of each study to predict operative stricture length. Sonourethrography correctly identified the stricture and its site in all cases, whereas radio urethrography yielded 2 false-negative results. There was a significant difference between stricture length measured by radio urethrography compared to that measured by sonourethrography (correlation coefficient 0.72 vs 0.92, p<0.005). Mean+/-SD stricture length measured by radio urethrography was 1.5+/-1.3 cm and by sonourethrography it was 2.1+/-0.9 cm. Comparison of radio urethrography and sonourethrography stricture length with operative lengths demonstrated a good correlation in the penile urethra (correlation coefficient 0.91 vs 0.98), whereas a poor correlation was found in the bulbar urethra (correlation coefficient 0.65 vs 0.92). Gray scale and color Doppler sonourethrography using the extended field of view technique with a Siemens Sonoline Elegra is a promising tool for defining male urethral strictures. It seems to be superior to radio urethrography for treatment planning.

CT Voiding Cystourethrography Using 16-MDCT for the Evaluation of Female Urethral Diverticula: Initial Experience

CT Voiding Cystourethrography Using 16-MDCT for the Evaluation of Female Urethral Diverticula: Initial ExperienceSun Ho Kim1, Seung Hyup Kim1, Byung Kwan Park1, Se Young Jung1, Sung Il Hwang1, Jae-Seung Paick2 and Soo Woong Kim2Audio Available | Share

Direct radionuclide cystography by supra-pubic puncture: comparison with conventional voiding cystourethrography.

Vesicoureteric reflux (VUR) and its complications are common problems encountered in paediatric practice. Voiding cystourethrography (VCU) is the primary investigation of choice. Direct radionuclide cystography (DRC) is utilized in the follow-up evaluation of children diagnosed with VUR. However, VCU and DRC both require catheterization, which children do not tolerate well. In this prospective study we evaluated radionuclide cystography by direct supra-pubic puncture (SDRC) and instillation of the radiotracer into the bladder, avoiding catheterization. The results of this procedure were then compared with those of VCU. A total of 43 children (eight females and 35 males; mean age, 5.73+/-3.28 years; range, 1.5-12 years) were studied. Out of the total 86 renal units, SDRC showed VUR in 22, whereas VCU showed VUR in 29. The SDRC and VCU results were concordant in 77 (90%) out of 86 renal units in the detection of VUR. The sensitivity, specificity, positive predictive value, and negative predictive value of SDRC when compared to VCU were 75.86%, 100%, 100% and 89%, respectively. The overall accuracy of SDRC was 91.86%. The supra-pubic direct radionuclide cystography is a simple technique for detecting as well as grading VUR. The technique avoids catheterization, is well tolerated by children and is without significant side effects.

Videourodynamics in the diagnosis of urinary tract abnormalities in a single center.

The lower urinary tract is a complicated structure and there has been some controversy regarding the biomechanics and dynamics of bladder and sphincter function. Investigation of the function and morphological anomalies is very important. Videourodynamics (VUD) combined with conventional voiding cystourethrography (VCUG) seems to be the most appropriate method. Over a 12-year study period (January 1990 to December 2001), 422 children (aged 5 days to 20 years) prospectively underwent VUD to further define their urinary tract abnormalities. In all children the history was recorded, clinical examination, urinalysis, culture, and ultrasonography performed, and serum creatinine determined before VUD. The selection criteria included a history of recurrent urinary tract infections (UTI) in 310 patients (74%), urinary tract dilatation without UTI in 31 patients (7%), suspected neurogenic bladder dysfunction in 42 patients (10%), and voiding difficulties in 39 patients (9%). VUD consists of cystometry (CM), which is the measurement of detrusor pressure during controlled bladder filling and subsequent voiding, and was combined with VCUG using X-ray contrast material. CM is used to assess detrusor activity, sensation, capacity, and compliance. CM measurements were recorded on a computer and vesicoureteric reflux (VUR) was documented at the same time with plain films and later in a PACS system. The VUD diagnosis was of normal bladder function in 46 patients (9%), VUR in 212 (43%), unstable bladder dysfunction in 152 (31%), neurogenic bladder dysfunction in 35 (7%), urine outflow obstruction in 15 (3%), wide bladder neck in 22 (4%), and vaginal reflux in 9 (2%). Neurogenic bladder dysfunction was excluded in 7 patients (1%). VUD is useful for the investigation of the lower urinary tract function together with X-ray morphology. The advantage of these studies is that they combine the objectivity of urodynamics with the visual radiographic image, leading to lower radiation doses and a more logical interpretation of the results.

Contrast-enhanced sonography of vesicoureterorenal reflux in children: preliminary results.

The aim of our study was to evaluate contrast-enhanced sonography as an alternative to radiographic voiding cystourethrography in the detection of vesicoureteral reflux. A total of 46 children, ranging in age from 3 weeks to 14 years (median: 4 years, 6 months) with 92 ureterorenal units were investigated for reflux using radiographic voiding cystourethrography and contrast-enhanced sonography in one session. After sonography of the urinary tract, the bladder was filled with saline solution via a catheter. Later, a contrast-enhancing agent was instilled and sonography was repeated. Documentation was done using S-VHS video and a laser camera. Reflux was diagnosed when microbubbles were observed in the ureter or in the renal pelvis. In addition, conventional voiding cystourethrography was performed. Patients without micturition during either sonography or radiographic examination were excluded (eight ureterorenal units). The findings obtained by contrast-enhanced sonography and voiding cystourethrography were concordant in 78 ureterorenal units (92.9%). No reflux was detected in 67 units (79.8%) by either method. With voiding cystourethrography as the standard of reference, the sensitivity of contrast-enhanced sonography was 91.7%; the specificity, 93.1%; and the accuracy, 92.9%. The positive predictive value was 68.8%, and the negative predictive value was 98.5%. Contrast-enhanced sonography is highly sensitive for the detection of vesicoureteral reflux. Therefore, it may reduce the number of radiographic investigations.

The reliability of cysto-urethrographic signs in the diagnosis of detrusor instability in children.

To assess whether the signs associated with detrusor instability (DI), as assessed by video-urodynamic studies, can be evaluated by conventional voiding cysto-urethrography (VCUG). Fifty-nine children who underwent cystometry and VCUG were reviewed and divided into two groups; group 1 comprised 51 neurologically normal children who had DI (47 girls and four boys, mean age 7.9 years, range 4-14), with no malformations or previous surgery. Most had mixed symptoms, including urinary tract infections (44) and nocturnal enuresis with daytime symptoms (20); group 2 (control) comprised eight children (seven girls, mean age 9.7 years, range 6-15) with a stable bladder and the same clinical presentation. The interval between VCUG and cystometry ranged from 1 day to 5 months (mean 47 days) and was similar in both groups. Signs considered suspicious of DI were sought in the findings of VCUG. In group 1, VCUG was normal or showed no specific signs (only vesico-ureteric reflux or vaginal voiding) in 25 (49%) of patients, whereas 26 (51%) had some signs suspicious of DI. Suspicious signs were urethral ballooning (in 11), bladder trabeculation or a constricting ring (eight), a 'spinning-top' urethra (three), urethral notching (two) and Mercier's bar (one). In group 2, five patients had no abnormal findings on VCUG and three had suspicious signs. The positive predictive value of VCUG was high (0.89) but the diagnostic yield of suspicious signs was low, because the sensitivity (0.5), specificity (0.62) and overall accuracy (0.52) were low. Radiological signs suspicious of DI cannot be regarded as such in conventional VCUG, as although they were detected in half the patients with DI, they also occurred in three of eight children with a stable bladder.