Fluoroscopic Voiding Cystourethrography Research Articles

Fluoroscopic Voiding Cystourethrography and Voiding Vesicoureteral Ursonography as A Comparison in Pediatric Vesicoureteral Reflux

Background: Vesicoureteral reflux (VUR) is a significant pediatric condition linked to recurrent urinary tract infections (UTIs) and can adversely affect a child's growth and development if not diagnosed promptly. Traditional diagnostic methods such as fluoroscopic voiding cystourethrography (VCUG) offer high accuracy but involve radiation risks, which are particularly concerning in pediatric populations. Objective: To compare the efficacy and safety of voiding vesicoureteral urosonography (VUS) with VCUG in the diagnosis of VUR in children, highlighting the advantages of a radiation-free method. Methods: This cross-sectional study included 208 renal ureteral units from 145 children diagnosed with VUR at the University of Lahore Teaching Hospital between July 2022 and September 2023. Patients underwent both VCUG and VUS. VUS utilized a SonoVue contrast agent, and the imaging involved real-time monitoring using a Super Sonic Imagine's Aixplorer V model with CEUS+ capability. Data were analyzed using SPSS version 25, focusing on the agreement between VUS and VCUG in diagnosing various grades of VUR. Results: VUS accurately identified no reflux in 98 of 112 cases as confirmed by VCUG. In higher grades of reflux (III to V), VUS detected 24 of 32 cases for Grade III, 7 of 13 for Grade IV, and 10 of 13 for Grade V. The overall agreement analysis revealed substantial consistency between VUS and VCUG across all grades of VUR, demonstrating that VUS can effectively identify higher grades of reflux. Conclusion: Voiding vesicoureteral urosonography is a viable and safer alternative to VCUG for the diagnosis of VUR in pediatric patients. It offers the benefits of being radiation-free, with high diagnostic accuracy, particularly in detecting severe cases of reflux. This study supports the increased adoption of VUS in clinical settings, especially for children, to reduce radiation exposure risks.

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.

An innovative diagnostic procedure in children: videourodynamics with contrast-enhanced voiding urosonography.

Contemporary videourodynamic (VUD) investigation combines voiding cystourethrography (VCUG) and urodynamics into one study, which allows simultaneous visualization of the urinary tract by ionizing radiation alongside the measurement of sensation, capacity, compliance, and detrusor pressure during bladder filling and voiding using one double lumen catheter. Today VUD is a benchmark for evaluating the lower urinary tract disorders in children because it evaluates urinary bladder and sphincter function and visualizes bladder morphology and vesicoureteral reflux (VUR) presence at the same time. Several previous studies of fluoroscopic videourodynamics issued concerns regarding radiation exposure. This technical report aims to describe a new modality of VUD in children by replacing fluoroscopic VCUG with contrast-enhanced voiding urosonography (ceVUS). ceVUS using second-generation contrast media and harmonic imaging is a radiation-free and highly sensitive imaging modality used to detect VUR in children. We simultaneously performed an infusion of ultrasound contrast through the double lumen urodynamic catheter during urodynamic evaluation. This article describes the advantages of this method compared with a conventional technique. In addition to being radiation-free, this procedure of advanced videourodynamics method can better detect vesicoureteral reflux and intrarenal reflux combined with urodynamic disorders associated with VUR.

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.

Contrast-enhanced voiding urosonography for the diagnosis of vesicoureteral reflux and intrarenal reflux: a comparison of diagnostic performance with fluoroscopic voiding cystourethrography.

PurposeThis study evaluated the diagnostic performance of contrast-enhanced voiding urosonography (ce-VUS) using a second-generation ultrasound contrast agent for the diagnosis of vesicoureteral reflux (VUR) and intrarenal reflux (IRR), and compared it with that of standard fluoroscopic voiding cystourethrography (VCUG).MethodsThirty-two consecutive children from April to October 2019 were included in this study. ce-VUS and VCUG were performed simultaneously by two operators with intravesical infusion of a mixture of ultrasound contrast medium, iodinated contrast medium and water. Two pediatric radiologists independently reviewed the ce-VUS and VCUG images and reported the presence and degree of VUR (grades I-V), and the presence and type of IRR.ResultsTwenty-seven of 63 urinary systems showed VUR. Interobserver agreement for VUR grading was very good for both examinations (κ=0.87; 95% confidence interval [CI], 0.82 to 0.92 for ce-VUS and κ=0.92; 95% CI, 0.87 to 0.96 for VCUG). The detection rate of VUR showed no significant difference between the two examinations (P=0.370). Four cases of VUR were missed on ce-VUS, while one case of VUR was missed on VCUG. All four false-negative cases on ce-VUS were grade 1 VUR. The two examinations showed very good agreement regarding VUR grading (κ =0.89; 95% CI, 0.81 to 0.96). IRR was more frequently detected with ce-VUS than with VCUG (10 cases with ce-VUS vs. 3 cases with VCUG, P=0.016).Conclusionce-VUS showed very good agreement with VCUG for detecting grade 2 VUR and above, while grade 1 VUR was sometimes missed with ce-VUS. IRR was more frequently detected with ce-VUS than with VCUG.

Voiding cystourethrography after prostatectomy: spectrum of appearances.

This article reviews current prostatectomy techniques and then techniques for fluoroscopic voiding cystourethrography (VCUG) evaluation of the prostate and bladder after prostatectomy. Both normal post-prostatectomy appearances and complications will be reviewed. VCUG is a useful evaluation for both common and uncommon post-prostatectomy complications and appropriate interpretation of the VCUG complications is important to aid the urologist's clinical decision making.

Intrarenal Reflux

Vesicoureteral reflux (VUR) is a childhood condition that is usually diagnosed by fluoroscopic voiding cystourethrography (VCUG). Intrarenal reflux (IRR) of infected urine is believed to play an important role in the pathogenesis of reflux-associated pyelonephritis and subsequent parenchymal scarring and is traditionally depicted by fluoroscopic VCUG. This case series describes the phenomenon of IRR occurring in association with VUR in 4 children as depicted by contrast-enhanced voiding urosonography. The ability of contrast-enhanced voiding urosonography to show IRR when it occurs in conjunction with VUR compares favorably to that of fluoroscopic VCUG.

Lower radiation burden in state of the art fluoroscopic cystography compared to direct isotope cystography in children

Both, fluoroscopic voiding cystourethrography (fVCUG) and direct isotope cystography (DIC) are diagnostic tools commonly used in pediatric urology. Both methods can detect vesicoureteral reflux (VUR) with a high sensitivity. Whilst the possibility to depict anatomical details and important structures as for instance the urethra in boys or the detailed calyceal anatomy are advantages of fVCUG, a lower radiation burden is thought to be the main advantage of DIC. In the last decade, however, a rapid technical evolution has occurred in fluoroscopy by implementing digital grid-controlled, variable rate, pulsed acquisition technique. As documented in literature this led to a substantial decrease in radiation burden conferred during fVCUGs. To question the common belief that direct isotope cystography confers less radiation burden compared to state of the art fluoroscopic voiding cystography. Radiation burden of direct isotope cystography in 92 children and in additional 7 children after an adaption of protocol was compared to radiation burden of fluoroscopic voiding cystourethrography in 51. The examinations were performed according to institutional protocols. For calculation of mean effective radiation dose [mSv] for either method published physical models correcting for age and sex were used. For DIC the model published by Stabin et al., 1998 was applied, for fVCUG two different physical models were used (Schultz et al., 1999, Lee et al., 2009). The radiation burden conferred by direct isotope cystography was significantly higher as for fluoroscopic voiding cystourethrography. The mean effective radiation dose for direct isotope cystography accounted to 0.23 mSv (± 0.34 m, median 0.085 mSv) compared to 0.015 mSv (± 0.013, median 0.008 mSv, model by Schultz et al.) - 0.024 mSv (± 0.018, median 0.018 mSv, model by Lee et al.) for fluoroscopic voiding cystourethrography. After a protocol adaption to correct for a longer examination time in DIC that was caused by filling until calculated bladder capacity, mean radiation burden accounted to .07 mSv (median 0.07 mSv) and the values were less scattered. As it had to be expected from literature, radiation dose from fVCUG, if modern image acquisition techniques are used, is even less than from DIC. In our protocol, according to nuclear medicine standards, bladders were filled until calculated capacity. This resulted in a longer examination time for the patients with a higher functional capacity, resulting in relatively higher radiation burden. However, also if the protocol is changed or only the patients with relatively fast bladder emptying are considered, radiation burden conferred by DIC is higher (at least × 2.9, comparing the "worst" case for fVCUG with the "best" case for DIC). Absolute radiation burden conferred by either exam is extremely low compared to other medical radiation exposures as well as to environmental radiation. Consequently it is most probably not relevant for the individual childs future risk for cancer or other radiation damage. However, because of repeated investigations with correspondingly higher radiation burden in this patient group the ALARA (as low as reasonably achievable) principle should lead to a optimized use of fVCUG rather than an uncritical use of DIC, given that modern acquisition standards are available and radiation measurement is performed. Also, fVCUG provides more information concerning anatomical details compared to DIC. Contrary to common beliefs, effective radiation dose conferred during fluoroscopic voiding cystourethrography is significantly lower than during direct isotope cystography. The prerequisite for our findings, however, is the use of modern image acquisition tools and an optimized protocol. Both exams confer low radiation doses probably only relevant to children undergoing repeated radiation exposure. Nevertheless, this findings should be considered in indication for either exam in order to reduce the radiation burden to a minimum whilst optimizing the information yield.

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 with second-generation contrast agent versus voiding cystourethrography

Contrast-enhanced voiding urosonography (VUS) is becoming more widely used for the diagnosis of vesicoureteric reflux (VUR). The purpose of this study was to evaluate the sensitivity of VUS using a second-generation ultrasound (US) contrast agent and compare it with standard fluoroscopic voiding cystourethrography (VCUG). A total of 183 children with 366 kidney-ureter units (KUUs) underwent VUS and VCUG in the same session with the same catheterization. VUS was performed after intravesical administration of 1 ml of a second-generation ultrasound contrast agent (UCA; SonoVue, Bracco, Italy). VUR was detected in 140 out of 366 cases (38%); in 89 (24.3%) by both methods, in 37 (10.1%) by VUS only, and in 14 (3.8%) by VCUG only. Although there was considerable agreement in the diagnosis of VUR by VUS and VCUG (κ=0.68, standard error [κ]=0.04), the difference in the detection rate of reflux between VUS and VCUG was significant (p<0.00001). The grade of VUR detected with VUS showed moderate agreement with grading by VCUG. Our findings suggest that contrast-enhanced harmonic VUS using a second-generation contrast agent is superior to VCUG in the detection and grading of VUR, and it should be the method of choice for this clinical indication.

Voiding Cystography Practices and Preferences of North American Pediatric Urologists

Little consensus exists regarding the choice of a specific modality of voiding cystography in the evaluation and management of vesicoureteral reflux. We hypothesized that choices of pediatric urologists are based on technical factors of the studies themselves, as well as institutional factors unique to their hospital(s). Therefore, we surveyed pediatric urologists to determine their current practices and preferences of modalities of voiding cystography. We mailed an anonymous survey of 40 questions to all fellows of the American Academy of Pediatrics Section on Urology. Surveys were returned from 186 of 301 fellows (62%). Of the respondents 57% were in academic, 30% in private and 13% in mixed practices. Given a choice of fluoroscopic voiding cystourethrography, radionuclide cystography and voiding ultrasonography, fluoroscopic voiding cystourethrography was preferred by 98% and 96% of respondents for initial evaluation of urinary tract infection in males and females, respectively, 96% for assessment of prenatal hydronephrosis, 54% for followup of vesicoureteral reflux, 59% for screening siblings, and 63% and 66%, respectively, after open and endoscopic correction of vesicoureteral reflux. Voiding ultrasonography was preferred by less than 10% of respondents in all groups, and radionuclide cystography was preferred by the remainder. Voiding images of the urethra, child-friendliness of staff, sensitivity and accuracy were factors most important in choosing a test. Of the respondents 83% reported full-time access to pediatric radiologists at their primary hospital, although a minority had full-time access to pediatric radiologists at additional institutions. Sedation was used in some or most cases by 29%, rarely by 56% and never by 15% of respondents. Pediatric urologists prefer fluoroscopic voiding cystography in all situations to evaluate vesicoureteral reflux but the proportion varies by indication. Diagnostic and patient issues are of greater concern than radiation dose. Variability in access to pediatric radiologists and ability to obtain the desired study may also alter ordering practices.

Comparison of direct radionuclide cystography and voiding cystourethrography in detecting vesicoureteral reflux

Fluoroscopic voiding cystourethrography (VCUG) is a widely used imaging test for the diagnosis of vesicoureteral reflux (VUR). However, high gonadal radiation and intermittent imaging are the main disadvantages of VCUG. Direct radionuclide cystography (DRC) has been advocated for the detection of VUR with increased sensitivity and low radiation doses, however, having the disadvantage of providing less anatomical details for urethral evaluation. In this study, DRC has been compared with standard fluoroscopic VCUG for detection of VUR. A total of 41 children (82 kidney ureter units, KUU) aged 1 month-126 months (median, 15 months) were studied sequentially using DRC and VCUG. The indications of VUR studied were urinary tract infection in 29 children, VUR follow up in eight children and antenatal dilatation history in four children. A total of 18 refluxing ureters were detected by DRC, 22 refluxing ureters by VCUG and 14 refluxing ureters by both methods. The two methods were concordant for the detection and exclusion of VUR in 85% of KUU. VUR was missed by VCUG in four KUU (three severe, one mild) whereas VUR was missed by DRC in eight KUU (four grade I, four grade III). There was a good correlation between DRC and VCUG in the evaluation of VUR. DRC provides continuous monitoring and low gonadal radiation exposure. DRC can be used in the diagnosis of VUR as an alternative to VCUG in selected cases.

Simultaneous voiding cystourethrography and voiding urosonography reveals utility of sonographic diagnosis of vesicoureteral reflux in children

Aim: To evaluate the diagnostic potential of voiding urosonography (VUS) compared with fluoroscopic voiding cystourethrography (VCUG) under identical conditions and to evaluate potential reasons for false‐negative VUS results, particularly regarding bladder concentrations of the US contrast agent, Levovist. Methods: Fifty‐six paediatric patients (M/F 34/22, mean age 2.3 y, age range 1 mo‐14 y) underwent simultaneous VUS and VCUG under identical conditions. The bladder was filled by simultaneous administration of Levovist and the X‐ray contrast medium, DIP Conray. Levovist concentrations in bladders were calculated using amounts of Levovist injected and total DIP Conray infused when reflux was first observed in either procedure. Results: Sensitivities of VUS and VCUG for detection of vesicoureteral reflux (VUR) were both 86%, assuming that VUR detected by either method represented a true‐positive, and no reflux by either method represented a true‐negative. Patients under 24‐mo of age displayed a better VUS sensitivity, of 94%. Levovist concentrations in bladders ranged from 1.8% to 23%, with older children tending to demonstrate increased bladder capacity and lower concentration. All VUS false‐negative units displayed Levovist bladder concentrations of less than 5%. Conclusion: The present simultaneous study suggests that: 1) the two techniques demonstrate similar sensitivity for detection of reflux; 2) sustained Levovist bladder concentrations of below 5% may not allow detection of reflux on VUS; and 3) VUS represents a suitable technique, particularly for small children whose bladder capacity is not so large.

Simultaneous Voiding Cystourethrography and Voiding Urosonography. Diagnostic comparison for vesicoureteral reflux

To compare the diagnostic accuracy of contrast-enhanced voiding urosonography (VUS) and voiding cystourethrography (VCUG) during simultaneous performance of both examinations. A total of 24 children, 16 girls and 8 boys, with a mean age of 3.5 years referred for reflux examination were recruited for the study. After transurethral bladder catheterization, radiographic contrast medium, followed directly by the US contrast medium, were administered. Fluoroscopic VCUG and VUS were carried out concurrently in the same patient. When 1 kidney was scanned by ultrasound, fluoroscopy was performed on the contralateral side. In 19 of the 47 kidney-ureter-units (KUU) vesicoureteral reflux (VUR) was detected. In 16 units the reflux was detected by both VCUG and VUS. In 3 KUUs the reflux was detected only at VCUG. All 3 cases were grade 1. Taking the VCUG as the reference standard, VUS had 84% sensitivity, 100% specificity, 100% and 90% positive and negative predictive values, respectively. A dependable comparison could be achieved by performing VCUG and VUS at the same time and under the same conditions. It reconfirmed that VUS is reliable in the exclusion or verification of reflux.

Assessment and Management of Fetal Hydronephrosis

After completing this article, the reader should be able to: 1. Differentiate genitourinary abnormalities associated with hydronephrosis detected on fetal ultrasonography. 2. Describe the type of fetal hydronephrosis that requires a complete uroradiologic evaluation. 3. Characterize the complete postnatal uroradiologic evaluation of significant fetal hydronephrosis. 4. Delineate the factor that sets the timetable for postnatal uroradiologic evaluation. 5. Describe the neonates for whom diuretic renography is reserved. Ultrasonographic detection of antenatal anomalies in the fetus has increased steadily since its initial widespread use in the 1970s. During these early years, antenatal ultrasonography detected structural abnormalities in approximately 1% to 3% of all pregnancies. (1) Currently, it is estimated that genitourinary anomalies comprise 20% of all antenatally detected fetal anomalies. (2) In a recent British population-based study, fetal genitourinary anomalies were identified in 2.3% of women undergoing routine obstetric ultrasonography between 18 and 23 weeks of gestation. (3) Hydronephrosis clearly has become the most commonly detected antenatal anomaly on fetal ultrasonography. Detection of antenatal dilation of the urinary tract does not always indicate postnatal urinary tract obstruction or even a significant genitourinary anomaly. (4) Among infants diagnosed as having prenatal hydronephrosis or other genitourinary anomalies, the question often is raised about the need for and extent of the postnatal evaluation to assess the magnitude of this commonly detected antenatal anomaly. The purpose of this review is to provide a framework for assessment and management of antenatally detected hydronephrosis. Fetal hydronephrosis is a nonspecific finding that can be associated with multiple congenital anomalies of the genitourinary tract. A thorough understanding of disorders that can result in hydronephrosis postnatally allows the physician to assess the need for postnatal diagnostic tests and guide treatment recommendations. The congenital anomalies that may result in hydronephrosis can be categorized as disorders of urinary reflux and disorders of urinary obstruction. It can be …

Simultaneous Voiding Cystourethrography and Voiding Urosonography: An In Vitro and In Vivo Study

AIM: To compare the diagnostic accuracy of fluoroscopic voiding cystourethrography (VCUG) and voiding urosonography (VUS) under identical conditions. We performed VUS and VCUG simultaneously with the total time for both examinations taking no longer than the time required for either examination individually. MATERIALS AND METHODS: X-ray contrast medium and echo-contrast agent were mixed together in vitro, and echogenicity of the mixture was confirmed. A clinical study was then performed on 33 children who had a history of urinary tract infection. The bladder was filled using simultaneous administration of X-ray contrast medium and echo-contrast agent. VCUG and VUS were then performed simultaneously and evaluated separately by two specialists. RESULTS: Equivalent results were obtained for the two examinations in 61 of 66 renal tracts. Sensitivities of VUS and VCUG for the detection of VUR were 86% and 79%, respectively. The average time from catheterization to the completion of the study was 9.1 minutes – approximately as long as performing VCUG alone. CONCLUSIONS: First, the present simultaneous study is superior to previous comparisons, because the two examinations were performed under identical physiologic conditions. Second, our results suggest that the two techniques demonstrate similar sensitivity in the detection of reflux. Nakamura, M. et al. (2002). Clinical Radiology57, 846–849.

Simultaneous Voiding Cystourethrography and Voiding Urosonography: An In Vitro and In Vivo Study

AIM: To compare the diagnostic accuracy of fluoroscopic voiding cystourethrography (VCUG) and voiding urosonography (VUS) under identical conditions. We performed VUS and VCUG simultaneously with the total time for both examinations taking no longer than the time required for either examination individually. MATERIALS AND METHODS: X-ray contrast medium and echo-contrast agent were mixed together in vitro, and echogenicity of the mixture was confirmed. A clinical study was then performed on 33 children who had a history of urinary tract infection. The bladder was filled using simultaneous administration of X-ray contrast medium and echo-contrast agent. VCUG and VUS were then performed simultaneously and evaluated separately by two specialists. RESULTS: Equivalent results were obtained for the two examinations in 61 of 66 renal tracts. Sensitivities of VUS and VCUG for the detection of VUR were 86% and 79%, respectively. The average time from catheterization to the completion of the study was 9.1 minutes – approximately as long as performing VCUG alone. CONCLUSIONS: First, the present simultaneous study is superior to previous comparisons, because the two examinations were performed under identical physiologic conditions. Second, our results suggest that the two techniques demonstrate similar sensitivity in the detection of reflux. Nakamura, M. et al. (2002). Clinical Radiology57, 846–849.

Cystography in infants and children: a critical appraisal of the many forms with special regard to voiding cystourethrography.

The aim of this study was to describe and discuss the various forms of cystography and their clinical value. Conventional fluoroscopic voiding cystourethrography (VCU), radionuclide cystography and the various sonographic cystographic approaches, including echo-enhanced cystosonography (EECS), are described. Their indications, potential, benefit and setbacks/restrictions are discussed with regard to the literature and the constantly changing clinical demand. With the introduction of EECS a new and reliable tool has been established to be useful for follow-up and screening for vesico-ureteral reflux (VUR); however, with the growing importance of functional disturbances a reliable method to evaluate both function and anatomy/VUR as offered by modified VCU is mandatory, and thus VCU remains to play a major part in evaluating children with urinary tract infection, suspected VUR, hydronephrosis or functional bladder disturbances. While EECS offers a new method for certain indications, such as follow-up examinations in VUR or screening, VCU remains an irreplaceable tool for evaluating anatomy (particularly the male urethra) and bladder function (if performed using the modified technique).

Prognostic value of urodynamic testing in myelodysplastic patients

We herein describe the clinical progress of 42 myelodysplastic patients studied urodynamically and followed for a mean of 7.1 years. Urodynamic evaluation included urethral pressure profilometry, simultaneous determination of urethral pressure, intravesical pressure and external anal or external urethral sphincter electromyography with fluoroscopic voiding cystourethrography. Assessment of urethral function showed 36 patients (86 per cent) with an open vesical outlet and nonfunctional proximal urethra. Cystometrography revealed that 7 of 42 patients (17 per cent) had reflex detrusor activity: 4 with coordinated micturition and 3 with detrusorsphincter dyssynergia. Thirty-five patients (83 per cent) had areflexic detrusor dysfunction: 5 with atonic detrusor response and 30 with a progressive increase in pressure with increasing volume. The intravesical pressure at the time of urethral leakage was 40 cm. water or less in 20 patients and at pressures greater than this value in 22 patients. No patient in the low pressure group had vesicoureteral reflux and only 2 showed ureteral dilatation on excretory urography. In contrast, of the patients in the higher pressure group 15 (68 per cent) showed vesicoureteral reflux and 18 (81 per cent) showed ureteral dilatation on excretory urography. Thus, a striking relationship between the urethral closure pressure and intravesical pressure at the time of urethral leakage and the clinical course in this group of myelodysplastic patients is demonstrated. Every patient with a normally closed vesical outlet was continent on intermittent catheterization and an anticholinergic agent, while only 60 per cent of patients with open bladder outlets similarly treated achieved good urinary control and none was dry. An artificial sphincter device would seem to be a reasonable method to achieve urinary control in the latter patients but the detrusor response to filling also must be considered. Detrusor hypertonia should be controlled or controllable before a sphincter augmenting device can be used safely. Treatment options for patients with high urethral closure pressures include intermittent catheterization and anticholinergic medications or a sphincter ablative procedure to decrease the outlet resistance combined with anticholinergic therapy and implantation of an artificial sphincter. However, only longer followup will determine if these therapeutic regimens will prevent upper urinary tract deterioration.

211 VESICOURETERAL REFLUX IS NOT RELIABLY DETECTED WITH RENAL ULTRASOUND

Nowadays, clinicians rely greatly on Renal Ultrasound (RU) as a screening examination. RU seems to be less sensitive than Fluoroscopic Voiding Cystourethrography (FVCU) for the detection of Vesicoureteral Reflux (VUR), but relevant percentages in large numbers of patients with Urinary Tract Infection (UTI) are scanty. This study evaluates the potential reliability of RU as a means to detect VUR in children with UTI. The population under study consisted of 288 infants and children (101 boys and 187 girls, median age 3.8 years) with UTI. RU and FVCU were performed within the same day. For data analysis both kidneys were considered separately for a total of 576 kidneys. Of 576 kidneys, VUR documented on FVCU in 116 (20%). In 85 of these refluxing kidneys (73%), the RU was normal and in 31 (27%) was abnormal. Of 517 normal kidneys on RU 85 (16%) had VUR on FVCU. In the remaining 59 kidneys with an abnormal RU (dublex system, dilatation, pyelonephritis, small scarred kidney), VUR was documented on FVCU in 31 (53%). This study oonfirms, that RU does not reliably diagnose VUR, since only 27% of the refluxing kidneys were identified on RU. On the other hand, patients with an abnormal RU would alert the clinician and radiologist to the increased possibility of VUR (53%). It is concluded, that a) RU is not an adequate substitute for the FVCU, if the clinical question is VUR in children with UTI, b)RU should be performed prior to FVCU.