Detection Of Vesicoureteral Reflux Research Articles

Diagnostic Value of Technetium-99m-Dimercaptosuccinic Acid Scintigraphy in Prediction of Vesicoureteral Reflux in Children with First-time Febrile Urinary Tract Infection

Background: Imaging modalities such as voiding cystourethrography (VCUG), direct radionuclide cystography (DRNC), and renal cortical scintigraphy (RCS) with technetium-99m dimercaptosuccinic acid (Tc-99mDMSA), are helpful in detecting possible abnormalities of urinary tract such as vesicoureteral reflux (VUR). However, there are confounding data regarding the preference of these modalities. In the present study, we aimed to assess the role of Tc-99mDMSA scan in prediction of possible VUR and the subsequent need for VCUG or DRNC. Materials and Methods: Three hundred fifty seven children under 14 years old with first-time febrile urinary tract infection (UTI) who were admitted between April 2004 and February 2017 were enrolled. Data regarding to VCUG or DRNC in order to evaluate the presence of possible VUR were recorded. Finally, accuracy of Tc-99mDMSA scans in prediction of VUR were assessed. Results: Analyses showed a sensitivity and specificity of 95.65% and 14.72%, respectively for Tc-99mDMSA scan in detection of VUR. Patients with mild renal involvement in Tc-99mDMSA scans had a 3.5-fold greater risk of having VUR than those with a normal scans (odds ratio=3.5; 95% confidence interval [CI]: 1.4-8.58; p=0.007). In addition, the risk of VUR is up to 7.0-fold greater in children with moderate renal involvement (odds ratio=7.0; 95% CI: 2.6-13.2; p<0.0001) and up to 9.2-fold greater in children with severe renal involvement (odds ratio=9.2; 95% CI: 3.2-17.3; p=0.007) in the Tc-99mDMSA scans compared to those with a normal scans. Conclusion: According to the results, Tc-99mDMSA scan can be used as a screening test in prediction of VUR in infants and children with first- time febrile UTI.

Clinical implications of DMSA Scan in Childhood Acute Pyelonephritis

Purpose This study aimed to evaluate the relationships between 99mTecnicium-dimercaptosuccinic acid (DMSA) scan findings and clinical parameters including age and fever duration. Methods The positive rates for abnormal DMSA scans were analyzed according to the age of patients, fever duration prior to admission, and total fever duration. DMSA scan findings were divided into 3 categories: single defect, multifocal defects, and discrepant defects. We evaluated the detection rates of vesicoureteral reflux according to DMSA scan lesions. Results Among a total 320 cases, 141 (44.1%) had abnormal DMSA scans. The infant group (0-1 year of age) had a shorter total fever duration, and a lower C-reactive protein (CRP) value and DMSA positive rate (39.8% vs. 60.6%, P=0.002) compared to children group (2-15 years of age). Patients with abnormal scans had a longer total fever duration and higher CRP compared to those with normal scans. The positivity rate of abnormal scans did not differ between the patients with a short fever duration prior to admission of ≤2 days and those with longer fever duration of ≥3 days. However, patients with longer total fever duration had a higher rate of abnormal DMSA scans (P=0.02). Among cases with a single defect, multifocal defects, and discrepant defects, vesicoureteral reflux was observed in 22.4%, 60% and 70.6% of cases, respectively (P=0.004). Conclusion Although DMSA scan has limitations in early diagnosis, DMSA scan findings may aid in the prediction of the severity of systemic inflammation and detection of vesicoureteral reflux. Key words: Acute pyelonephritis; Urinary tract infection; Technetium 99m- dimercaptosuccinic acid; Vesicoureteral reflux; Child

Comparison of Colour Doppler Flow Imaging with Voiding Cystourethrography in the Detection of Vesicoureteric Reflux in Children

Comparison of Colour Doppler Flow Imaging with Voiding Cystourethrography in the Detection of Vesicoureteric Reflux in Children

Voiding Urosonography with Second-Generation Ultrasound Contrast Agent for Diagnosis of Vesicoureteric Reflux: First Local Pilot Study

BACKGROUND:Vesicoureteric reflux (VUR) is an important association of paediatric urinary tract infection (UTI) found in 30-50% of all children presenting with first UTI. Contrast-enhanced voiding ultrasonography (ceVUS) has become an important radiation-free method for VUR detection in children. Its sensitivity in detecting VUR has greatly improved due to the development of the contrast-specific ultrasound techniques and the introduction of the second-generation ultrasound contrast agent, superseding the diagnostic accuracy of standard radiological procedures.AIM:This article aimed to summarise the current literature and discuss the first local pilot study performed in our institution on detection of vesicoureteric reflux by contrast-enhanced voiding ultrasonography with second- generation agent (SonoVue, Bracco, Italy).MATERIAL AND METHODS:Retrospective review of the first 31 ceVUS (24 girls, 7 boys) was presented. Age range was 2 months to 18 years (mean = 6.4 ± 4.9).RESULTS:All examinations were well tolerated without any adverse incident. VUR was shown in 20 (64.5%) children in 32/62 (51.6) nephroureteral units (NUUs). In 18 NUUs, VUR was grade II/V, in 11 Grade III/V and in 3 grade IV/V, respectively. Urethra was shown in 19/31 children and in all boys, without pathological finding. In two girls spinning top urethra has been detected. Subsequent urodynamic studies revealed functional bladder problem in both.CONCLUSIONS:Contrast-enhanced voiding urosonography using intravesical second generation ultrasound contrast agent could be recommend as a valid alternative diagnostic modality for detecting vesicoureteral reflux and evaluation of the distal urinary tract in children, based on its radiation-free, highly efficacious, reliable, and safe characteristics.

Contemporary Practice Patterns of Voiding Cystourethrography Use at a Large Tertiary Care Center in a Single Payer Health Care System

Voiding cystourethrogram involves radiation exposure and is invasive. Several guidelines, including the 2011 AAP (American Academy of Pediatrics) guidelines, no longer recommend routine voiding cystourethrogram after the initial urinary tract infection in children. The recent trend in voiding cystourethrogram use remains largely unknown. We examined practice patterns of voiding cystourethrogram use and explored the impact of these guidelines in a single payer system in the past 8 years. We identified all voiding cystourethrograms performed at a large pediatric referral center between January 2008 and December 2015. Patients 2 to 24 months old who underwent an initial voiding cystourethrogram for the diagnosis of a urinary tract infection in the first 6 months of 2009 and 2014 were identified. Medical records were retrospectively reviewed. During the study period 8,422 voiding cystourethrograms were performed and the annual number declined over time. In the pre-AAP and post-AAP cohorts 233 and 95 initial voiding cystourethrograms were performed, respectively. While there was no statistically significant difference in the vesicoureteral reflux detection rate between 2009 and 2014 (37.3% vs 43.0%, p = 0.45), there was a threefold increase in high grade vesicoureteral reflux in 2014 (2.6% vs 8.4%, p = 0.03). A clear trend toward fewer voiding cystourethrograms was noted at our institution. This decrease started before 2011 and cannot be attributed to the AAP guidelines alone. While most detected vesicoureteral reflux remains low grade, there was a greater detection rate of high grade vesicoureteral reflux in 2014 compared to 2009. This may reflect a favorable impact of a more selective approach to obtaining voiding cystourethrograms.

Uroepithelial thickening improves detection of vesicoureteral reflux in infants with prenatal hydronephrosis

Postnatal evaluation of prenatal hydronephrosis (PNH) often includes a voiding cystourethrogram (VCUG) for VUR assessment. Despite limited supporting data, VCUG is currently recommended if postnatal renal and bladder ultrasound (RBUS) reveals moderate/severe hydronephrosis (HN) or hydroureter (HU). Recent studies have shown VUR is more accurately diagnosed by using certain sonographic findings as criteria for obtaining VCUG. Uroepithelial thickening (UET) of the renal pelvis is a finding associated with high-grade vesicoureteral reflux (HGVUR); however, the clinical significance of UET with PNH has not been studied. We sought to determine if the presence of UET implies increased risk for VUR, and to investigate whether UET can improve the test characteristics of RBUS for VUR. We retrospectively analyzed postnatal RBUS and VCUG findings in infants ≤30 days undergoing evaluation for "prenatal hydronephrosis" over an 11-year period. We used logistic regression to identify factors associated with VUR. Test characteristics of RBUS for HGVUR were compared based on the presence of UET and two criteria sets to define abnormal RBUS. Criteria set 1 consisted of HN SFU grade 3-4 and/or HU; criteria set 2 was defined by the presence of two of following: UET, HU, duplication, and/or renal dysmorphia. Of 135 patients, 39 (29%) had VUR, of whom 16 (41%) had HGVUR. UET was significantly associated with VUR (p<0.001), and the sensitivity for HGVUR based on UET alone was 94%. On multivariable analysis, UET, HU, duplication, and renal dysmorphia remained significant independent predictors of HGVUR. Compared to criteria 1, using criteria 2 resulted in 43 fewer VCUGs, and significant improvement in sensitivity and specificity for HGVUR (Table). Consistent with previous studies, HN alone on postnatal RBUS has little value in predicting the presence or severity of VUR. This study is the largest known series to evaluate UET in the setting of PNH, and our results demonstrate that UET, as well as HU, duplication and renal dysmorphia, are independent sonographic findings predicting HGVUR. Using our proposed criteria, the probability of HGVUR is fourfold more than the prevalence described in the literature, and importantly, when compared to the criteria recommended by the SFU and AUA, would have resulted in 53% fewer VCUGs while missing zero cases of HGVUR. In infants with PNH, the sonographic findings of UET, HU, duplication and renal dysmorphia independently indicate greater risk of HGVUR, and the sensitivity and specificity of RBUS for HGVUR is markedly improved when at least two of the four are present.

Multi-institutional Study Comparing the Height of Contrast During Performance of Voiding Cystourethrogram in Children

To assess the effect of contrast height during the voiding cystourethrogram (VCUG). The VCUG is the gold standard diagnostic test for vesicoureteral reflux (VUR). Variation in parameters may affect detection and grade of reflux. In a multicenter, prospective, nonrandomized, observational study, patients undergoing VCUG were selected. VCUG was performed per study protocol except for a change in contrast height. The initial fill was performed at 50 cm and the second at 100 cm. Data collected included presence and grade of VUR and volume filled. The actual bladder volume filled was normalized to the estimated bladder capacity (EBC) as a percentage. A Cohen's kappa coefficient of agreement was used to test for difference in the incidence of reflux and grade between contrast heights. A Wilcoxon signed-rank test was used for differences in the percent EBC filled between heights. From May 2012 to November 2013, 184 patients were enrolled. Seventy-one patients (39%) exhibited VUR at 50 cm and 80 patients (43%) at 100 cm. The kappa coefficient of agreement between 50 cm and 100 cm showed substantial agreement, with no significant difference in VUR grade. The percent of EBC filled at each height was significantly different: %EBC filled at 50 cm: 101 ± 46 (range 9.2-228.3), and %EBC filled at 100 cm: 130 ± 56 (range 37.8-280.6) (P < .0001). No significant difference was noted in the detection of VUR with different contrast heights. A significantly larger bladder volume was instilled at 100 cm.

Renal ultrasound and DMSA screening for high-grade vesicoureteral reflux.

Selection of the appropriate radiologic investigation in a child after first febrile urinary tract infection (UTI) remains a contentious issue. This report investigated the effectiveness of renal bladder ultrasound (RBUS) and late 6 month dimercaptosuccinic acid (DMSA) renal scan in the detection of high-grade vesicoureteral reflux (VUR) after first febrile UTI in infants aged <1 year. A total of 387 infants aged <1 year with first febrile UTI who completed diagnostic follow up consisting of RBUS, voiding cystourethrogram (VCUG) and late 6 month DMSA scan were enrolled in the study. The effectiveness of RBUS and DMSA scan in the detection of high-grade VUR, including cost and benefit were assessed. Abnormal RBUS was identified in 95 infants (24.5%). VUR was identified on VCUG in 79 (20.4%), of whom eight (2.1%) had high-grade VUR (grade IV-V). Abnormal renal parenchyma was identified on late 6 month DMSA scan in 22 infants (5.7%). The sensitivity of abnormal RBUS and of late 6 month DMSA scan in the prediction of high-grade VUR was 50% and 87.5%, and the proportion of infants who avoided unnecessary VCUG was 75.5% and 94.3%, respectively. Fifty percent of high-grade VUR was not identified on RBUS screening after first febrile UTI. Although late 6 month DMSA scan had higher sensitivity in the detection of high-grade VUR, with the added benefit of detection of renal scars, the practical application of this method was limited due to its high cost, radiation exposure and the associated delay in decision making.

Contrast-enhanced voiding urosonography: in vitro evaluation of a second-generation ultrasound contrast agent for in vivo optimization.

Pediatric contrast-enhanced ultrasound (CEUS) is primarily performed outside the United States where a track record for safety in intravenous and intravesical applications has been established. Contrast-enhanced voiding urosonography (ceVUS) has also been shown to have a much higher rate of vesicoureteral reflux detection compared to voiding cystourethrography. US contrast agents available in the United States differ from those abroad. Optison® (GE Healthcare, Princeton, NJ) is such an US contrast agent. While Optison® has similar characteristics to other second-generation agents, it has never been used for ceVUS. In vitro optimization of dose and imaging parameters as well as assessment of contrast visualization when delivered in conditions similar to ceVUS are necessary starting points prior to in vivo applications. To optimize the intravesical use of Optison® in vitro for ceVUS before its use in pediatric studies. The experimental design simulated intravesical use. Using 9- and 12-MHz linear transducers, we scanned 20-mL syringes varying mechanical index, US contrast agent concentration (0.25%, 0.5%, 1.0%), solvent (saline, urine, radiographic contrast agent) and time out of refrigeration. We evaluated mechanical index settings and contrast duration, optimized the contrast dose, measured the effect of urine and radiographic contrast agent, and the impact of length of time of contrast outside of the refrigerator on US contrast appearance. We scanned 50-ml saline bags to assess the appearance and duration of US contrast with different delivery systems (injection vs. infusion). Consistent contrast visualization was achieved at a mechanical index of 0.06-0.17 and 0.11-0.48 for the L9 and L12 MHz transducers (P < 0.01), respectively. Thus, it was necessary to increase the mechanical index for better contrast visualization of the microbubbles with a higher transducer frequency. The lowest mechanical index for earliest visible microbubble destruction was 0.21 for the 9MHz and 0.39 for the 12MHz (P < 0.01) transducers. The 0.5% US contrast agent volume to bladder filling was the most optimal. At this concentration, the mean time to visualize homogenous contrast was 2min and destruction of approximately half of the microbubbles in the field of view occurred in 7.8min using the 9-MHz transducer. During contrast infusion, the contrast dose needed to be reduced to 0.12% for maintenance of optimal visualization of microbubbles. There was no deleterious effect on the visualization of contrast in the presence of urine or radiographic contrast agent. Infusion of the US contrast agent speeded visualization of homogeneous enhancement compared with injection. Time outside refrigeration did not affect contrast performance. Transducer mechanical index settings need to be optimized. A very low dose of the US contrast agent Optison® will suffice for intravesical application, i.e. 0.12% to 0.50% of the bladder filling volume. The presence of urine or radiographic contrast agent did not compromise contrast visualization. The best mode of administration is the infusion method due to fast homogenous distribution at the lowest dose of 0.12%. Leaving the US contrast agent outside the refrigerator for an hour does not affect the microbubbles.

Can more urological deaths in spina bifida be prevented?

This commentary is on the original article by Oakeshott et al. on pages 634–638 of this issue.

Vesicoureteral reflux detection with reliable probabilistic outputs

Vesicoureteral Reflux (VUR) is a pediatric disorder in which urine flows backwards from the bladder to the upper urinary tract. Its detection is of great importance as it increases the risk of a Urinary Tract Infection, which can then lead to a kidney infection since bacteria may have direct access to the kidneys. Unfortunately the detection of VUR requires a rather painful medical examination, called voiding cysteourethrogram (VCUG), that exposes the child to radiation. In an effort to avoid the exposure to radiation required by VCUG some recent studies examined the use of machine learning techniques for the detection of VUR based on data that can be obtained without exposing the child to radiation. This work takes one step further by proposing an approach that provides lower and upper bounds for the conditional probability of a given child having VUR. The important property of these bounds is that they are guaranteed (up to statistical fluctuations) to contain well-calibrated probabilities with the only requirement that observations are independent and identically distributed (i.i.d.). Therefore they are much more informative and reliable than the plain yes/no answers provided by other techniques.

O-183 Voiding Urosonography With A Second Generation Ultrasound Contrast-agent In Vesicoureteral Reflux Detection And Grading In Children: How Reliable Is It?

Purpose The diagnostic accuracy of contrast-enhanced voiding urosonography (ce-VUS) in diagnosing vesicoureteral reflux (VUR) is high compared with voiding cystourethrography. However, its reliability has not been yet adequately evaluated. The purpose of this study is to assess the reliability of ce-VUS in VUR detection and grading by estimating the inter- and intra-observer agreement of two radiologists. Patients and methods Two hundred ten children (86 boys/124 girls, mean-age 2.7y) with 421 pelvi-ureteral-units underwent ce-VUS examination with a second-generation contrast-agent to detect possible (180) or follow-up known (30) VUR. The video-clips of all ce-VUS examinations were twice independently assessed by two paediatric radiologists 4–6 weeks apart. The inter- and intra-observer agreement was estimated by kappa statistic. Results The inter- and intra-observer agreement of both radiologists regarding the presence or grading of VUR was perfect (k=0.90–0.94). There were only two disagreements regarding the presence of VUR (grade I and II false-negative and false-positive respectively). There were 5 cases of disagreement in VUR grading: three cases of VUR grade II-III and two cases grade III-IV. VUR was detected in 123(29%) pelvi-ureteral-units of 87(41.4%) children and it was more common in completely duplicated ureters (6/7) than in single ones (p = 0.03). The rate of VUR was independent of sex/age/presence of hydronephrosis (p > 0.05). Conclusions The reliability of ce-VUS in VUR detection and grading is high. VUS with a second generation ultrasound contrast-agent could be used as a radiation-free alternative.

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.

The value of direct radionuclide cystography in the detection of vesicoureteral reflux in children with normal voiding cystourethrography.

Vesicoureteral reflux (VUR) is one of the most important risk factors for urinary tract infection (UTI). Diagnosis and treatment of VUR is important to prevent irreversible complications, such as renal scarring and chronic renal failure. This study was conducted to assess the value of direct radionuclide cystography (DRNC) in the detection of VUR in children with UTI and a normal voiding cystourethrography (VCUG). DRNC was performed in 35 children with a normal VCUG after an episode of febrile UTI who had hydronephrosis or hydroureter, abnormal acute dimercaptosuccinic acid (DMSA) scan results and/or febrile UTI recurrence. This study was conducted in the nephrology department of Mofid Children's Hospital, Tehran (Iran). The results were statistically analyzed. Among the 70 ureters studied, 33 (49.1 %) were observed to have VUR. Of these, 17 (51.5 %) had mild, 14 (42.4 %) moderate, and 2 (6.1 %) severe reflux. A significant relationship was observed between DRNC results and DMSA renal scan findings (P < 0.05). Based on our results, we suggest that DRNC may reveal VUR despite a normal VCUG in children with hydronephrosis, abnormal acute DMSA, and/or recurrent febrile UTI.

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.

Primary vesicoureteral reflux in Sudanese children.

Vesicoureteral reflux (VUR) is a common congenital renal tract anomaly in children. Reports from Sudan are scanty. We report the characteristics, presentation and outcome of primary VUR in a tertiary care hospital. The records of 30 patients (16 males; 53%) followed-up between January 2004 and December 2010 were reviewed. The mean age at the time of diagnosis was 4 ± 3.9 years and 47% were <2 years of age. Renal ultrasound scan (USS) failed to predict VUR in 17% of the patients. On voiding cysturethrogram (VCUG), VUR was bilateral in 57% and severe grade in 64%. Grades were not significantly associated with age, gender or site of VUR. Initial dimercaptosuccinic acid radionuclide scan showed renal damage in 61.5% of the patients. Renal damage was significantly associated with female gender and severe VUR, but not with age of onset or history of urinary tract infection (UTI). Thirteen patients (43.3%) presented with acute UTI, eight (26.6%) with non-specific urinary tract symptoms and nine (30%) with persistently elevated serum creatinine. Urine cultures were positive in 73% of patients, and E. coli was the most common pathogen. Renal impairment at presentation was significantly associated with bilateral severe VUR and history of UTI but not age or gender. After a mean follow-up period of 1.78 years (6 months to 5 years), 70% of patients remained with normal renal function and 30% progressed to chronic kidney disease; two of them died. In conclusion, our data is different from many studies. Features of primary VUR in Sudanese children are late age of onset, equal gender affection and predominance of severe grade. Presentation is associated with a high rate of UTI, renal damage and advanced renal impairment. Measures to improve early detection and treatment of VUR may reduce the risk of kidney damage.

Maximizing the sensitivity of the indirect radionuclide cystogram: a retrospective audit

The indirect radionuclide cystogram (IRC) has generally been reported as being less sensitive for detecting vesico-ureteric reflux (VUR) than the micturating cystourethrogram (MCUG), so we modified it in an attempt to increase its sensitivity. We altered our routine IRC protocol by including the data obtained during failed voids, adding extra imaging sequences at intervals during bladder filling, and by using simple mathematical criteria to determine if VUR was present when visual imaging results were equivocal. We then retrospectively compared the VUR detection rates using the standard and modified techniques. We assessed 707 renal units in 356 children over 3 years. We identified 91 cases of VUR using standard methodology, and 134 (47% more) with the modified technique. Of the extra 43 cases detected, 11 were noted during failed voids, ten were seen within a filling sequence, and 22 were inferred because the renal pelvic activity increased during an interval between two imaging sequences, while the bladder was filling. Mathematical evaluation was helpful in the 39 cases where the increase in activity due to VUR was ≤6 standard deviations greater than the level of background variation in activity. Additional imaging and mathematical assessment can significantly increase the sensitivity of the IRC for detecting VUR, possibly to equal that of the MCUG.

Comparison of Renal Ultrasound and Voiding Cystourethrography (VCUG) in the Detection of Vesicoureteral Reflux

Introduction: This study evaluates the accuracy of renal ultrasonography (US) in the detection of vesicoureteral reflux (VUR) compared to voiding cystourethrography (VCUG).&#x0D; Methods: We retrospectively reviewed the medical records of 131 children with urinary tract infection. Ultrasound findings were considered to be suggestive of VUR if a “pelvocalyceal dilatation”‚ “retrovesical ureteral dilatation” and/or an “increase in one or both kidneys’ size” were reported.&#x0D; Results: Ultrasound findings were positive for VUR in 5 of 24 patients with confirmed VUR on VCUG, and were negative in all of 107 patients without VUR on VCUG. Altogether, of the 131 children‚ 24 had reflux on VCUG, 19 (79%) of who had no sonographic findings suggestive for reflux. The sensitivity and specificity of ultrasound in Suggesting VUR were 20% and 100%, respectively.&#x0D; Conclusion: The results of this study showed that ultrasonography cannot accurately detect or predict vesicoureteral reflux. This outcome should be mentioned by clinicians in evaluation of patients with complaints which are suggestive for VUR.

Voiding Cystourethrography Revisited: Descriptive Statistics for the Detection of Vesicoureteral Reflux

To determine which factors might influence the detection of vesicoureteral reflux (VUR), we retrospectively reviewed factors including fluoroscopy time, number of true radiographic acquisitions, and patient characteristics from a large number of voiding cystourethrography (VCUG) examinations. Nine hundred eighty-seven VCUG examinations performed between March 2006 and March 2009 were randomly selected for review. Data recorded were presence of VUR, patient age and sex, examination indication, follow-up status, presence of a diagnostic radiology trainee, fluoroscopy time, and number of true radiographic acquisitions. For initial examinations, descriptive comparison and logistic analyses were performed. To evaluate which variables related to reflux identification, we analyzed variables by logistic regression after stratifying by patient age (≤ 1 or > 1 year) for both the full sample and cases grouped by VUR severity (grades I and II [mild] or grades III-V [moderate to severe]). Nine hundred eighty-seven VCUG examinations were evaluated for the study (65.5% female; mean age, 3 years 2 months; age range, 2 weeks-16 years), and 761 cases met the inclusion criteria. VUR was detected in 101 of 349 infants (40 mild, 61 moderate to severe) and in 107 of 412 children older than 1 year (52 mild, 55 moderate to severe). A wide range of fluoroscopy times was similar between both positive and negative cases (0.033-4.233 minutes). The number of true radiographic acquisitions differed significantly between the negative and positive cases. Descriptive statistics and logistic regression analyses for a large number of VCUG examinations in a pediatric population are summarized. Our results showed that high fluoroscopy times were not associated with a higher likelihood of VUR. There may be a small benefit to the use of true radiographic acquisitions for detecting VUR.