Detection Of Vesicoureteral Reflux Research Articles

The Effectiveness of the Surgical Correction of Vesicoureteral Reflux on Febrile Urinary Tract Infections after a Kidney Transplant: A Single-Center Retrospective Study.

Background/Objectives: Vesicoureteral reflux (VUR) is considered one of the major causes of post-renal transplant febrile urinary tract infections (UTI), leading to impaired renal function and the premature loss of the renal graft. We aimed to evaluate whether surgical VUR correction, such as open redo ureteric reimplantation, could be an option for treatment and provide better outcomes in post-transplant care for patients with UTI compared to their pre-VUR correction clinical state. Methods: Our study presents a retrospective analysis of 10 kidney transplant recipients with febrile UTI at the Renal Transplant Service of a Brazilian public hospital from 2010 to 2020. We selected patients who primarily underwent a surgical correction of post-transplant VUR, which was corrected by extravesical reimplantation without a stent in all patients by the same professional surgeon. Results: From 710 patients who received kidney transplants, 10 patients (1.4%) suffered from febrile UTI post-transplant and underwent surgical correction for VUR. Despite the study's limitations, such as its retrospective nature and limited sample size, the efficacy of open extravesical ureteral reimplantation in reducing post-operative febrile UTI in renal transplant patients was observed. Conclusions: As febrile UTI can contribute significantly to patient mortality after kidney transplantation and VUR emerges as a major cause of post-transplant febrile UTI, it is essential to treat it and consider the surgical outcome. This study emphasizes the timely detection and effective treatment of VUR via extravesical techniques to reduce febrile UTI occurrences post-transplant and it contributes insights into the role of surgical interventions in addressing VUR-related complications post-kidney transplantation.

First episode of febrile urinary tractinfection in children, detection and risk factors of kidney scarring: Aprospective cohort study.

This prospective study aimed to evaluate the characteristics and findings of children who presented with acute pyelonephritis (APN) and to determine the independent risk factors for kidney scarring. Patients who satisfied the following criteria were enrolled in the study: first known episode of APN; at least two of the following findings: fever ≥ 38.5 °C, white blood cell count ≥ 10,000/mm3, erythrocyte sedimentation rate ≥ 20 mm/h, C-reactive protein ≥ 20 mg/dL; absence of congenital abnormalities or other kidney and systemic diseases, except vesicoureteral reflux (VUR); no APN relapses until the time of kidney scar detection. 99mTc-Dimercaptosuccinic acid kidney scintigraphy (99mTc-DMSA) was performed at admission, along with a kidney ultrasound. Follow-up 99mTc-DMSA took place after 6 months. Radiographic cystourethrography for VUR detection and grading was performed 1 month after the acute infection. We enrolled 70 children in the study. The kidney ultrasound failed to diagnose more than half of the cases of APN. VUR was found in 21.5% of children. 75% had findings of APN in the acute phase through 99mTc-DMSA, while in the second 99mTc-DMSA, there was a complete remission in 68% of them. Scars were observed more frequently in older children, children with VUR grade ≥ III, and children not on antibiotic prophylaxis. VUR did not appear to be associated with the first episode of APN, and children older than 1 year of age had a higher risk of scarring. Antibiotic prophylaxis may prevent kidney scarring due to host immunomodulatory effects, but more studies are needed so that conclusions can be drawn.

Comparison of contrast-enhanced voiding urosonography using second-generation contrast agents and voiding cystourethrogram

Voiding cystourethrogram (VCUG) has been considered the gold standard for detecting and evaluating vesicoureteral reflux (VUR) among children. However, ionizing radiation exposure is a concern for this diagnostic modality. Contrast-enhanced voiding urosonography (ceVUS) is an alternative technique for the detection of vesicoureteral reflux (VUR) using ultrasound and intravesical administration of an ultrasound (US) contrast agent. ceVUS is a radiation-free, effective, and safe method for identifying and grading VUR. We performed a study specifically for our hospital. The purpose of this study was to evaluate the diagnostic accuracy of contrast-enhanced voiding urosonography (ceVUS) in the detection of vesicoureteral reflux and its grading in children, compared to voiding cystourethrogram (VCUG). If we consider VCUG as the gold standard, the sensitivity of ceVUS in our study was 83%, specificity was 100% and accuracy was 94%. Our positive cases had Grade II to V reflux on ceVUS and Grade I to V reflux on VCUG. In our small sample of 18 patients, the detection of vesicoureteral reflux by ceVUS was comparable to that of VCUG. ceVUS can be used as a radiation-free alternative to VCUG for the detection of VUR in children. A benefit of ceVUS is the ability to do cyclical assessment without the fear of increasing radiation dose, as you would with VCUG.

Comparison of voiding vesicoureteral urosonography with fluoroscopic voiding cystourethrography in children with vesicoureteral reflux.

To evaluate the value and compliance rate of voiding vesicoureteral urosonography in pediatric vesicoureteral reflux (VUR). This is a retrospective study. A total of 80 children with high-risk VUR admitted to Children's Hospital affiliated to Capital Medical University from December 2018 to December 2020 were selected. All patients underwent voiding urosonography (VUS) and fluoroscopic voiding cystourethrography (VCUG). The sensitivity and compliance of voiding vesicoureteral urosonography were compared, and its application value was evaluated. A total of 160 PUUs were examined, and all cases were normal. Among them, 56 PUUs had reflux (35.00%, 56/160), 46 PUUs had reflux under both examination methods (28.75%, 46/160), and 10 PUUs were only detected under VUS (6.25%, 10/160). Thirty-four cases of VUR (42.50%, 34/80) were diagnosed by VUS, among which 15 cases were bilateral reflux and 4 cases were unilateral reflux. Twenty-five cases (35.00%, 25/80) were diagnosed by VCUG, among which 10 cases were bilateral regurgitation and five cases were unilateral regurgitation. No significant difference was observed in the detection rate of reflux between the two methods (P=0.432). A total of 146 PUUs were found to be consistent between the two methods (91.25%, 160), including 2 Grade-I reflux, 6 Grade-II reflux, 14 Grade-III reflux, 12 Grade-IV reflux, eight Grade-V reflux, and 104 without reflux, demonstrating SATISFACTORY consistency between the two groups (Kappa=0.885). Voiding vesicoureteral urosonography has a high coincidence rate in the detection of vesicoureteral reflux in children.

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

Frequency of Urinary Tract Infection When Diagnosing Vesico Uretheral Reflux in Children in Tuzla Canton.

Vesicoureteral reflux (VUR) represents the return of urine from the bladder into the ureter and the renal canal system. Reflux can occur only on one or both kidneys. VUR most often occurs due to an incompetent ureterovesical junction, which consequently leads to hydronephrosis and dysfunction of the lower parts of the urinary system. The aim of the study was to determine the frequency of urinary infection when diagnosing vesicouretheral reflux in children in the Tuzla Canton, in the five-year period from 01.01.2016 to 01.01.2021. Through a retrospective study, we analyzed data from 256 children with vesiocouretheral reflux (VUR), examined in the Nephrology Outpatient Clinic, Clinic for Children's Diseases, University Clinical Center Tuzla, in the period from 01.01.2016 to 01.01.2021, from early neonatal to 15 years of age. The age and gender of children, the most common symptoms of urinary tract infections during the detection of VUR, and the degree of VUR were analyzed. From 256 children with VUR, 54% were male and 46% female. The highest prevalence of VUR was in the age group 0-2 years, and the lowest in the age of children > 15 years. There was no statistically significant difference between the groups of our respondents in relation to age groups, nor in relation to the gender of the children. Statistically significantly more children were without nonspecific symptoms and with asymptomatic bacteriuria in the group without UTI symptoms in children with VUR compared to the group with UTI symptoms in children with VUR. Pathological urine culture between the groups was without a statistically significant difference. Although urinary tract infection in children is common, the possibility of permanent consequences should always be kept in mind if VUR is not diagnosed and treated in time.

Accuracy of contrast-enhanced voiding urosonography using Optison™ for diagnosis of vesicoureteral reflux in children

There is limited quality of evidence regarding the accuracy of contrast-enhanced voiding urosonography (ceVUS) for diagnosis of vesicoureteral reflux (VUR) compared to fluoroscopic voiding cystourethrography (VCUG), and minimal data on the use of the ultrasound contrast agent Optison™ for this purpose. To compare the accuracy of ceVUS using Optison™ to VCUG, and to assess inter-rater agreement regarding presence and grading of VUR. In this retrospective investigation, all sequential ceVUS with Optison™ and VCUG studies performed in children between 2014 and 2017 were reviewed. Two raters independently graded all ceVUS studies using a 5-point scale. CeVUS sensitivity and specificity were estimated separately for each rater using the VCUG report as the ground truth for presence and degree of VUR. Logistic and ordinary linear regression models assessed rater-report agreement and inter-rater agreement for each kidney, Optison™ dose, and referral diagnosis. 97 children (51 females) with 101 paired studies were included. Sensitivity and specificity of ceVUS for VUR detection were identical for both raters: right kidney 75%/90.9%; left kidney 85.7%/78.9% (Figure). There was no statistically significant difference in disagreement between raters and the VCUG report for the right or left kidney. Inter-rater agreement on ceVUS grading was 90% and 88% for right and left kidneys, respectively. There was a significant negative association between fetal hydronephrosis vs urinary tract infection and disagreement between Rater 2 and the VCUG report for the left kidney. There were no other significant associations with respect to either kidney, Optison™ dose, or referral diagnosis. Our study showed that detection of VUR with ceVUS and Optison™ is comparable to fluoroscopic VCUG. Based on the VCUG reports, the incidence of VUR in our patient population was substantially lower than in the meta-analysis of Chua etal. and in the study of Kim etal. The explanation for the large discrepancy in VUR incidence may reflect differences in the patient populations, and in our reporting of VUR with respect to kidney number rather than to pelviureteral units. Study limitations include its retrospective nature and potential bias in terms of patient selection. Since VUR is an intermittent phenomenon, sequential rather than simultaneous performance of the ceVUS and fluoroscopic studies might have influenced VUR detection. A blinded comparison of ceVUS performed with Optison™ to fluoroscopic VCUG showed moderate-good sensitivity and specificity for diagnosis of VUR.

Contemporary Management of Urinary Tract Infections in Children.

Purpose of ReviewUrinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice.Recent FindingsWith recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs.SummaryThe American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.

Vesicoureteral Reflux in Children with Urinary Tract Infections in the Inpatient Setting in Taiwan.

PurposeChildren with vesicoureteral reflux (VUR) are at an increased risk of recurrent urinary tract infections (UTIs). Early detection and treatment of VUR are important to prevent renal function impairment. Therefore, the aims of this study were to determine the epidemiology of VUR and to identify clinical factors associated with VUR in Taiwanese children with a first documented UTI.Patients and MethodsWe conducted this nationwide retrospective study using the Longitudinal Health Insurance Database 2010. Children ≤6 years of age who were admitted and received intravenous antibiotics for a newly diagnosed UTI were included. Multivariate logistic regression analysis was used to identify independent factors associated with VUR.ResultsOverall, 388 (10.2%) of the children had VUR. The median (interquartile range) age at diagnosis of VUR was 0.5 (0.3–1.3) years. Among the children with VUR, the age at first UTI and the age at diagnosis of VUR were significant lower in the males than in the females. Age ≤1 year at the first UTI (odds ratio (OR), 1.3; 95% confidence interval (CI): 1.0–1.7), renal agenesis and dysgenesis (OR, 4.1; 95% CI: 1.3–13.1), hydronephrosis (OR, 2.2; 95% CI: 1.7–2.9), duplex collecting system/ectopic kidney/ectopic ureter (OR, 13.0; 95% CI: 8.1–20.8), neuropathic bladder (OR, 4.7; 95% CI: 2.0–11.1) and spina bifida (OR, 5.9; 95% CI: 1.3–27.8) were independent factors for VUR.ConclusionThe children with VUR were more likely to have small kidneys and progression to end-stage renal disease. VUR was common in the children with a UTI and who were ≤1 year of age. Clinicians should arrange ultrasound to diagnose urinary tract anomalies. Infants with urinary tract anomalies, neuropathic bladder and spina bifida should receive further voiding cystourethrography to diagnose VUR early, as this may help to prevent renal damage.

Starting a pediatric contrast ultrasound service: made simple!

The addition of contrast US to an existing pediatric US service requires several preparatory steps. This overview provides a guide to simplify the process. Initially, it is important to communicate to all stakeholders the justifications for pediatric contrast US, including (1) its comparable or better diagnostic results relative to other modalities; (2) its reduction in procedural sedation or anesthesia by avoiding MRI or CT; (3) its reduction or elimination of radiation exposure by not having to perform fluoroscopy or CT; (4) the higher safety profile of US contrast agents (UCA) compared to other contrast agents; (5) the improved exam comfort and ease inherent to US, leading to better patient and family experience, including bedside US exams for children who cannot be transported; (6) the need for another diagnostic option in light of increasing demand by parents and providers; and (7) its status as an approved and reimbursable exam. It is necessary to have an UCA incorporated into the pharmacy formulary noting that only SonoVue/Lumason is currently approved for pediatric use. In the United States this UCA is approved for intravenous administration for cardiac and liver imaging and for vesicoureteric reflux detection with intravesical application. In Europe and China it is only approved for the intravesical use in children. All other applications are off-label. The US scanner needs to be equipped with contrast-specific software. The UCA has to be prepared just before the exam and it is important to strictly follow the steps as outlined in the packaging inserts in order to prevent premature destruction of the microbubbles. The initial training in contrast US is best focused on the frontline staff actually performing the US studies; these might be sonographers, pediatric or interventional radiologists, or trainees. It is important from the outset to educate the referring physicians about contrast US. It is helpful to participate in existing contrast US courses, particularly those with hands-on components.

Radionuclide techniques for the detection of vesicoureteral reflux and their clinical significance.

We discuss and try to evaluate the detection of vesicoureteral reflux (VUR) by radionuclide techniques and especially direct radionuclide cystography (DRC). Direct radionuclide cystography is applied for more than half a century mainly in children. Vesicoureteral reflux has a complex pathology not yet completely understood and is often related to urinary tract infection (UTI) and renal parenchyma scarring that can lead to long-term renal function impairment. Since there is no consensus on the optimal imaging algorithm after the first febrile urinary tract infection, many imaging strategies have been proposed for VUR detection in the last decade, including or not DRC. Views opposing or accepting its use are also presented.

Veziko üreteral reflü hastalığında ultrasonun rolünü nasıl belirleyebiliriz?

Objectives: We aimed to explore the role and indication for the use of ultrasonography (US) in the vesico-ureteral reflux (VUR) disease and demonstrate the non – inferiority against the gold standard voiding cystourethrography (VCUG) for the screening in a certain group of patients. Material and Methods: This is a retrospective analysis of 532 simultaneous VCUG and US examinations between April 2010 and March 2019, by a single radiologist in our hospital. Demographic characteristics, pelvic stasis, pelvi – calyxeal dilatation and hydro – uretero – nephrosis in the US, and reflux in the VCUG were recorded. ROC analysis was done for comparing the two tests. Results: Among the cases between 5 months to 18 years of age, 342 (64.3 %) were female, and 190 (35.7 %) were male. The cases were divided into two groups below and after 6 years of age (N = 246 (46.2 %), and 286 (43.8%) respectively. There was a correlation between US and VCUG findings below the age of 6 (p<0.005, OR=6,977), but not in the cases over (p=0,539). In the ROC analysis of US in detection of VUR, compared to VCUG, sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) below 6 years age is 89,76 %, 47,86 %, 65,1 %, and 81,2 % (AUC= 0,688, p= 0,0001) respectively, and those above 6 years of age are 50,49 %, 53,55 %, 38,0 %, and 65,8 % (AUC=0,520, p= 0,5720). Conclusion: US is easy, reproducible, safe and effective for diagnosis, and staging of the disease. Its high sensitivity (89.7 %), and negative predictive value (81.2 %), can make it an initial screening test in the patients below 6 years of age. VCUG as a gold standard modality can be reserved for definitive diagnosis in the suspected cases below the age of 6 and all of the cases after the age of 6.

Targeted Indication of Imaging for Detection of Vesicoureteric Reflux after Pediatric Febrile Urinary Tract Infections Based on a Multiparametric Computational Tool.

Diagnostic workup after febrile urinary tract infections (fUTIs) in children remains a matter of debate. The authors aimed to evaluate multiple parameters in order to design a predictive tool enabling a targeted indication of voiding cystourethrography (VCUG). Records of 383 consecutive children who underwent a VCUG as well as a dimercaptosuccinic-acid (DMSA) scan after febrile urinary tract infections (fUTIs) at a single institution between 04/2009 and 06/2014 were reviewed. Twenty parameters were recorded. After regression analysis, 6 parameters were incorporated into a computational tool aiming at a targeted indication of an eventual VCUG. The performance of the tool was prospectively tested on 100 patients. Postpyelonephritic alterations on DMSA, duplex systems, age 1-3 y, duration of fever >3 d, >2 fUTIs before VCUG and abnormal sonography findings were identified as significant predictors (p< 0.05 each); the presence of bladder and bowel dysfunction (BBD) was negatively associated with vesicoureteric reflux (VUR). The resulting computational tool achieved an Area under the curve (AUC) of 0.686 (CI 0.633-0.740). Prospective evaluation (100 new patients) revealed a sensitivity of 85.1%, a specificity of 49.1%, a positive predictive value of 59.7% and a negative predictive value of 78.7%. The differentiated indication of a VCUG based on the use of a tool was efficient in optimizing the specificity of the diagnostic algorithm after fUTIs. The tool outperformed other common clinical approaches in terms of VUR detection and VCUG frequency. After validation and further refinement in a multicentric approach, this strategy could significantly enhance VUR detection whilst reducing the number of VCUGs.

The value of DMSA scintigraphy in the diagnostic evaluation of vesicoureteric reflux

In terms of treatment planning, the radiologic phenomenon of vesicoureteric reflux has become less important than its inherent risk of further urinary tract infections and loss of renal function. Whilst radiologic and sonographic voiding cystourethrography continues to be the gold standard in the mere detection of vesicoureteric reflux, dimercaptosuccinic acid scanning is important for risk stratification. Also it serves to confirm renal involvement in uncertain situations with urinary tract infection and fever. In older children, it is the standard in primary diagnostics. Furthermore, it enables the diagnosis of occult reflux in many cases. Therefore, dimercaptosuccinic acid scanning is an indispensable tool in the diagnostic evaluation of vesicoureteric reflux.

Evaluation of cyclic direct radionuclide cystography findings with DMSA scintigraphy results in children with a prior diagnosis of vesicoureteral reflux.

Direct radionuclide cystography (DRC) with cyclic imaging is a sensitive method used for the detection of vesicoureteral reflux (VUR). Radionuclide cystography is generally recommended for follow-up evaluation of VUR. The aim of this study was to evaluate cyclic DRC with DMSA scan results during the follow-up period in children with a prior diagnosis of VUR. DRC findings of 85 children with VUR were evaluated together with DMSA findings during follow-up. VUR grade was classified anatomically as grades I, II, and III reflux. Reflux grades of II and III were regarded as high-grade reflux. Reflux was also graded functionally as transient and continuous on the basis of the presence of reflux on either filling or voiding phases (transient) or both phases (continuous) of at least one cycle. Among 85 children, 32 (38%) exhibited reflux. In five patients, reflux was observed on both sides, and a total of 37 refluxing units (RUs) were evaluated. According to the highest grade attained in either cycle, 31 (84%) units had grade II, five had grade I and one had grade III reflux. Reflux was continuous in 23 (62%) and transient in 14 (38%) RUs. The incidence of an abnormal scan result was higher in continuous reflux group (78%) than in high-grade anatomic reflux group (59%). The addition of a second cycle resulted in the diagnosis of continuous reflux in six (26%) more RUs. DMSA scan findings correlated significantly with functional reflux classification (P<0.05), but not with anatomic reflux classification (P>0.05). Functional classification of VUR into continuous and transient reflux resulted in higher correlation with DMSA scan findings compared with anatomic reflux grading in follow-up patients with VUR. Cyclic imaging contributed to continuous reflux diagnosis. The significance of functional information obtained from cyclic DRC in initial diagnostic workup, management, and follow-up of children with urinary tract infection needs to be determined with further studies.

The role of 99mTc dimercaptosuccinic acid scintigraphy in detection of vesicoureteral reflux in pediatrics with first episode of acute pyelonephritis

Introduction: Acute pyelonephritis is a common disease in children leading to permanent renal function impairment due to renal scarring with the risk of later hypertension. Objectives: The aim of this study was to assess the role of initial 99mTc dimercaptosuccinic acid (DMSA) scintigraphy for detecting the early renal parenchymal damage in children with the first episode of acute pyelonephritis (APN). Patients and Methods: This study was conducted among 161 hospitalized children with the first clinically episode of APN from January 2008 to April 2013 in pediatric clinical research of development center in Qom, Iran. DMSA renal scintigraphy, ultrasonography (US), erythrocyte sedimentation rate (ESR), urine analysis and culture were performed in all patients. DMSA renal scan and voiding cystourethrogram(VCUG) was done within 15 days and one month after the diagnosis of APN using the standard protocol, respectively. Results: Children with the first episode of acute pyelonephritis aged 1 month to 12 years were enrolled in this study. There were no statistically significant correlations between initial decreased uptake detected by DMSA renal scan with age, gender, body temperature, CRP levels or ESR. The positive and negative predictive values (PPV, NPV) of diminished uptake on DMSA renal scans for detecting the presence of VUR on VCUG were (43.2%) and (93.3%), respectively. Conclusion: Children with a normal DMSA renal scan during their the first episode of UTI rarely have VUR. Avoidance of VCUG in children with negative DMSA renal scans could significantly eliminate the use of this potentially traumatic test.

Author Reply

We appreciate the thoughtful response to our study findings and agree that the medical community should re-evaluate the American Academy of Pediatrics guidelines for febrile urinary tract infections. While the guidelines rely on the use of renal and bladder ultrasound findings to determine the need for VCUGs, several previous investigations have shown that ultrasound findings are a poorly predictive of VCUG abnormalities. Hoberman et al determined that identification of urinary tract dilation on renal ultrasound following the first febrile urinary tract infection had only a 10% sensitivity and 40% positive predictive value for detection of vesicoureteral reflux on VCUG among 302 children. 1 Hoberman A Charron M Hickey RW Baskin M Kearney DH Wald ER Imaging studies after a first febrile urinary tract infection in young children. N. Engl. J. Med. 2003; 348: 195-202 Crossref PubMed Scopus (562) Google Scholar These results were corroborated by Juliano et al, who reported evidence of dilating vesicoureteral reflux among 23/84 children with a normal renal ultrasound. 2 Juliano TM Stephany HA Clayton DB et al. Incidence of abnormal imaging and recurrent pyelonephritis after first febrile urinary tract infection in children 2 to 24 months old. J. Urol. 2013; 190: 1505-1510 Crossref PubMed Scopus (40) Google Scholar A larger study by Logvinenko et al revealed that renal ultrasound had a sensitivity of only 32% for detecting grade 3-5 vesicoureteral reflux among nearly 4000 patients. The group concluded that ultrasound was a poor screening tool for diagnosis of high-grade vesicoureteral reflux. 3 Logvinenko T Chow JS Nelson CP Predictive value of specific ultrasound findings when used as a screening test for abnormalities on VCUG. J Pediatr Urol. 2015; 11 (e171-177): 176 Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The use of renal ultrasound findings to guide VCUG administration, therefore, should be called into question. It is perhaps for this reason that guideline adherence did not improve vesicoureteral reflux detection among children aged 2-24 months in our patient cohort.

Adherence to the 2011 American Academy of Pediatrics Urinary Tract Infection Guidelines for Voiding Cystourethrogram Ordering by Clinician Specialty

ObjectiveTo evaluate rates of guideline adherence and associations with voiding cystourethrogram result. The American Academy of Pediatrics guidelines recommend voiding cystourethrogram after abnormal renal ultrasound or 2 febrile urinary tract infections. It is unclear whether guideline adherence increases vesicoureteral reflux detection. Additionally, guidelines targeting children 2-24 months are often applied to other ages. MethodsChildren undergoing voiding cystourethrogram from January 2012 to December 2013 at 1 institution were retrospectively reviewed. Children with known genitourinary abnormalities were excluded. The primary outcome was guideline adherence. Univariate and multivariate analyses were performed. Subgroup analysis of children 2-24 months was completed. ResultsVoiding cystourethrograms from 365 children were included in the primary analysis, including 187 (51.2%) aged 2-24 months. Overall, 60.3% of voiding cystourethrograms were ordered in accordance with the guidelines. Urologists/nephrologists were more likely to adhere to ordering guidelines than pediatricians/others (76.4% vs 51.7%, odds ratio 3.0 [1.9-4.9], P <.001). Subgroup analysis in children 2-24 months revealed similar findings (76.4% vs 51.5%, odds ratio 3.0 [1.5-6.2], P = .002). Voiding cystourethrograms were abnormal in 31.8% overall and 26.2% aged 2-24 months. Guideline adherence was associated with increased likelihood of abnormal voiding cystourethrogram among all children (P = .02), but not among children 2-24 months (P = .95). Older age, white race, and guideline adherence remained significantly associated with abnormal voiding cystourethrogram in a multiple logistic regression model. ConclusionsGuideline adherence was more likely among urologists/nephrologists than pediatricians/others and was not associated with abnormal voiding cystourethrogram among children 2-24 months. Multicenter evaluation is necessary to determine if ordering recommendations should be revised.

Detection of Vesicoureteral Reflux Using Electrical Impedance Tomography.

The purpose of this study is to detect vesicoureteral reflux (VUR) noninvasively using an electrical impedance tomography (EIT). VUR is characterized by the backflow of urine from the bladder to the kidneys. Using porcine models, small quantities of a solution mimicking the electrical properties of urine were infused into each ureter. EIT measurements were taken before, during and after the infusion using electrodes positioned around the abdomen. The collected data from 116 experiments were then processed and time-difference images reconstructed. Objective VUR detection was determined through statistical analysis of the mean change in the voltage signals and EIT image pixel intensities. Unilateral VUR was successfully detected in 94.83% of all mean voltage signals and in over 98.28% of the reconstructed images. The images showed strong visual contrast between the region of interest and the background. In animal models, EIT has the capability to detect reflux in the kidneys with high accuracy. The results show promise for EIT to be used for screening of VUR in children. VUR is the most common congenital urinary tract abnormality in children. The condition predisposes children to urinary tract infections and kidney damage. The current gold standard diagnostic test, a voiding cystourethrogram, is invasive and uses ionizing radiation; therefore, there is a need for new tools for identifying VUR in children. This study presents a noninvasive method to detect VUR in animal models, illustrating the potential for EIT as a screening tool in clinical scenarios.

Diagnostic accuracy of contrast-enhanced voiding urosonogram using second-generation contrast with harmonic imaging (CEVUS-HI) study for assessment of vesicoureteral reflux in children: a meta-analysis.

To assess the diagnostic accuracy and safety of contrast-enhanced voiding urosonogram using second-generation contrast with harmonic imaging (CEVUS-HI) in detecting vesicoureteral reflux (VUR) among children. A systematic literature search was performed in March 2018. Relevant comparative studies from Medline, EMBASE, World of Science, Scopus, CENTRAL, WHO trial registry and Clinicaltrials.gov were identified and appraised using QUADAS-2. Diagnostic accuracy parameters were determined using VCUG as the reference standard. Adverse effects related to ultrasound contrast were summarized. The heterogeneity and inter-study variability were determined. After appropriate subgroup diagnostic accuracy parameters were investigated, summarizing receiver operator characteristics was constructed using the bivariate model meta-regression to determine the area under the curve (AUC). A total of 12 studies with low-high risk of bias, including 1917 ureteral units from 953 patients were assessed for this meta-analysis. The included studies reported no serious adverse events associated with the ultrasound contrast. The pooled diagnostic accuracy parameters of CEVUS-HI in detecting VUR amongst children were: sensitivity 90.43 (95% CI 90.36-90.50), specificity 92.82 (95% CI 92.76-92.87), the calculated (+) likelihood-ratio 12.59 (95% CI 12.49-12.68), (-) likelihood-ratio of 0.103 (95% CI 0.102-0.104) and extrapolated pooled diagnostic odds-ratio was 122.12 (95% CI 120.75-123.49). Heterogeneity with interstudy variability was noted (p < 0.0001, I-squared > 70%). The AUC was determined to be 0.965 for VUR detection. The pooled diagnostic accuracy parameters from low-moderate quality of evidence have illustrated that the CEVUS-HI study has an excellent safety profile and acceptable diagnostic accuracy. It may be considered as an alternative diagnostic modality for assessment of VUR among children.