Micturating Cystourethrography Research Articles

Role of MCU in the Management of Posterior Urethral Valves

Objective: In infancy, the most common cause of bladder outlet obstruction is Posterior urethral valves (PUV), which impair renal and bladder function. This study was planned to evaluate and record the role of MCU in the various clinical presentations and management, complications, surgical management, and long-term outcomes of PUV. Methods: In this study, 49 patients treated for PUV were evaluated at the Bangladesh Shishu Hospital and Institute from May 2018 to April 2021. Complete data were taken, paraclinical examinations were performed on each patient, and the diagnosis was confirmed by micturating-cysto-urethrography (MCU). Posterior urethral valves were ablated in all patients using an electric hook. Results: A total of 49 patients with a mean age at diagnosis of 42(±21) days were included in this study. Catheterization was done within one to 5 days of life in 29 patients. PUV was ablated by an electric hook in all 49 patients. The most common symptoms in our group were dribbling, poor stream (71%), and urinary tract infection (UTI) (46%). There was vesico-ureteral-reflux (VUR) in 52% and hydronephrosis in 92.5%. The most common associated anomaly was kidney anomalies (Renal agenesis/dysplasia and multicystic kidney disease) in 4(8.2%) patients. About ten patients had prenatal diagnosis of PUV. Complications occurred in two (4.2%) patients. Mortality occurred in 3 (6.4%) patients. The mean follow-up period was 3.2±0.8 years (1.5 months to 4 years). Conclusion: MCU is the gold-standard imaging modality for documenting PUV and Postoperative follow-up to assess the condition of the posterior urethra urinary drainage by catheter in the early days of infancy. The factors like renal dysplasia and UTI have their role in the outcome.

Comparative study of sonourethrography and conventional urethrography in determining the length of anterior urethral strictures

Background: Conventional urethrography has been the “Gold standard” in the evaluation of anterior urethral strictures. Sonourethrography (SUG) is less invasive, more readily available, and cheaper and does not use ionizing radiation.
 Objective: To determine the length of anterior urethral strictures diagnosed on conventional urethrography using SUG and compare findings on SUG with conventional urethrography in adult male patients
 Methodology: This was a prospective cross-sectional study carried out over a period of twelve months, whereby 66 male patients with clinically suspected anterior urethral strictures and confirmed on retrograde urethrography (RUG)/ Micturatingcystourethrography (MCUG) were examined using SUG. The length of anterior urethral strictures from both procedures were compared. The data analysis was done using statistical package for social sciences (SPSS) version 23(SPSS Inc, IL, USA). At 95% confidence interval, P-value ≤ 0.05 was considered statistically significant.
 Result: Sixty six patients were studied. The mean age of the participants was 56.7±13.7years with an age range of 20 – 78 years. The stricture lengths and diameters were consistently higher on SUG compared to conventional urethrography. The mean length of stricture on RUG/MCUG and SUG were 19.4 ± 6.0mm and 21.3± 6.7 mm respectfully. The mean difference for the stricture lengths on RUG/MCUG and SUG was 1.9 mm and this was statistically significant (CI = 0.983 – 2.761, p < 0.001). The mean diameter of the stricture on RUG/MCUG and SUG were 2.2± 0.7mm and 5.6± 1.2mm and the mean difference for the stricture diameter on both techniques was 3.4mm (CI= 3.158 – 3.577, p<0.001), which was statistically significant.
 Conclusion: Significantly higher mean stricture length and diameter were found on SUG compared with RUG/MCUG.

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux.

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Vesicoureteral reflux by contrast ultrasound, comparison with voiding and retrograde urethrocystography: A prospective accuracy study

Diagnosis of vesicoureteral reflux (VUR) plays an important role in the management and follow-up of children presenting with urinary tract infection. This study compared voiding uronosography (VUS) as a diagnostic method for the diagnosis of VUR with the "gold standard", voiding or micturating cystourethrography (MCU). The objective of the study is not only to compare the effectiveness of both methods, but also to assess the feasibility of implementing VUS technically and economically in a large tertiary radiology center in South America. This was a prospective accuracy study that include 41 patients (a total of 85 ureteral units) aged between 1 month and 16 years. VUS was performed in an alternative form as regular MCU, by injecting microbubble contrast solution (SonoVue©) into the bladder through an intermittent catheter and evaluating the presence of reflux with ultrasound. MCU was always performed immediately after VUS. One pediatric radiologist evaluated all VUS exams, while a second independent pediatric radiologist evaluated all MCU exams, with both blinded to each other's assessments. Comparing VUS with MCU in the diagnosis of VUR, we observed a sensitivity of 92.3% (95% CI 74.9-99.1%), specificity of 98.3% (95% CI 90.9-100%), positive predictive value of 96.0% (95% CI 79.6-99.9%), negative predictive value of 96.7% (95% CI 88.5-99.6%) and a Kappa of 0.916 (0.822-1.000). When comparing the VUR grading between VUS and MCU the agreement between the two methods was high with a Kendall's Tau-b > 0.9. VUS failed to diagnose two grade 1 VUR reflux cases in teenagers while diagnosing one grade 4 VUR in a very dilated kidney-ureter unit, which was missed on MCU. VUS and MCU had similar costs when considering the price of the ultrasound contrast agent. VUS is a reliable alternative method to MCU for the diagnosis of VUR with the advantages of not exposing the child to ionizing radiation and potentially being more accessible due to the greater availability of ultrasound equipment. Limitations to this study include the usage of a single ultrasound equipment, which limits its generalizability and not evaluating the interobserver variability. Consideration should be given to implementing VUS for the diagnosis of VUR, particularly in centers without fluoroscopy equipment available, since the exam's performance and cost are comparable to those of the MCU.

Clinical, uropathogenic, and radiological profile of culture-positive urinary tract infections in children below 18 months of age

Background: Urinary tract infections (UTIs) are common in children and have the risk of renal scarring. To better identify this at risk group, the following study was carried out to analyze the clinical profile of children below 18 months of age with culture-positive UTI and the outcome of radiological investigations. The primary objective was to assess the clinical profile of culture-positive UTI children and diagnostic yield and correlation between radiological tests. The secondary objectives were to assess the prevalent uropathogens and their antibiogram. Materials and Methods: For this retrospective study, clinical details regarding radiological investigations, prevalent uropathogens and antibiograms, common antibiotics used in treatment, and uroprophylaxis were obtained through electronic medical records in children <18 months of age admitted with culture-positive UTI. Results: In 225 children seen over a period of 36 months, a slight male predominance (56%) was observed. Ultrasonography (USG) was done in nearly all children, micturating cystourethrography (MCU) was performed in only 40% of patients, dimercaptosuccinic acid (DMSA), performed after 6 months of the index UTI, in one-fifths of the patients. All three investigations were performed in one out of six children. USG and MCU used in combination detected the highest number of significant abnormalities (39%) compared to USG and DMSA (32%). Escherichia coli was the predominant uropathogen identified. Significant meropenem resistance (52%) was observed in the community-acquired UTI. Conclusion: The evaluation and follow-up of infants and young children with UTI show inadequate radiological evaluation, which could increase the risk of undetected and untreated renal sequelae.

Clinical Evaluation and Standardization of Image Quality and Technical Protocols for Special Radiological Procedures

This work aimed to standardize and state” the insufficiencies outlined and variation in image quality, among some hospitals in Sudan for a common in specific radiologic examinations. A subjective evaluation of 1,103 image reproductions from “363 special radiologic procedures including Intravenous Urography (IVU), Hysterosalpingography (HSG), GIT barium studies” and Micturating Cystourethrography (MCUG), and the Entrance Air Surface Kerma (ESAK) values recorded for each procedur

Congenital anterior urethral valves and diverticulum: A case series and association with posterior urethral valves

There is limited data regarding long-term results and associated complications in patients with anterior urethral valve (AUV) and diverticulum (AUD). We retrospectively reviewed AUV/AUD cases managed by us between the year 2002-2020. Presentation, investigations, management, concomitant posterior urethral valves (PUV) and pre-operative characteristics predisposing to long-term poor renal outcome were assessed. There were 27 patients [AUV (n=11); AUD (n=16)] with 5 having concomitant PUV. All presented with poor urinary stream and dribbling at a median age of 1-year (5 days-12 years). More patients with AUD (9 of 16, 56.3%) especially with concomitant PUV presented at ≤1-year-age as compared to those with AUV (4 of 11, 36.4%). Concomitant PUV and AUD cases (n=3) had characteristic micturating cystourethrography (MCUG) features. (Fig. 1A) Retrograde urethrography delineated the valve and distal urethra dimensions better (Fig.1B, C). Urethral hypoplasia distal to the valve (n=4) urethral duplication (n=1) were associated (Fig.1D). Syringocele was ruled out in proximal AUD by absence of filling defect on MCUG and appearance of urethral walls on urethrocystoscopy. Serum creatinine > 1mg/dL (n=5), trabeculated bladder (n=12), and vesicoureteral reflux (VUR) (n=12) was noted at presentation. Diverticulum/valve excision (n=13, 48.2%), fulguration alone (n=12, 44.4%) and primary urinary diversion (n=2, 7.4%) were performed. Follow up (range:3 mo-19 years), showed deranged renal function tests (n=6), VUR (n=4), impaired renal function on scans (n=8), and lower urinary tract dysfunction (n=7). Outcome with and without associated PUV was similar. Long term results were better in AUV compared to AUD. Pre-operative raised serum creatinine (>1mg/dL), trabeculated bladder, non-dilated posterior urethra on MCUG and bilateral impaired renal function on scans had significant association with follow up eGFR less than 60ml/kg/min. Co-existing PUV and AUD present earlier and have specific imaging findings. In proximal AUD, possibility of syringocele should be kept in mind, as they have similar presentation and imaging. Concomitant PUV did not alter prognosis. Secondary effects on bladder and renal function were more with AUD. Follow up eGFR less than 60ml/kg/min was associated with pre-operative elevated serum creatinine, trabeculated bladder, non-dilated posterior urethra, and bilateral impaired renal function on scans.

A Case of Congenital Urethrovaginal Fistula in a Female Child with Suspected Imperforate Hymen: A Case Report

Urethrovaginal fistula is an abnormal communication between the urethra and vagina. Urethrovaginal fistula results in urinary incontinence with urine continually leaking from the vagina. In children congenital anomaly may also be the cause. Congenital Urethrovaginal fistula is an extremely rare genitourinary anomaly. The reported five cases in the literature are all associated with urogenital abnormalities like vaginal septum, vaginal agenesis and imperforate hymen. We present a case of a 7-year-old female that was referred from a peripheral hospital for micturating cystourethrography (MCUG) on account of urinary incontinence and passage of urine from vaginal orifice. Following MCUG the urethra, proximal fistula between the urethra and vagina, distended urinary bladder, contrast opacified uterus and a fallopian tube were all demonstrated. We report this case because of its rarity in the literature.

Urinary tract abnormalities in children with first urinary tract infection

Background: Pediatric urinary tract infections (UTIs) are a major health-care issue. UTI may be a harbinger of variety of underlying urinary tract abnormalities. The long-term complications of recurrent UTI are kidney scarring, hypertension, and chronic kidney disease. Aim: The present study aims to determine the prevalence of urinary tract abnormalities in children with first episode of UTI. Materials and Methods: This study was a hospital-based prospective observational study carried out in the department of pediatrics over a period of 15 months from January 2015 to March 2016. A total of 100 children with culture-positive first UTI who fulfilled the inclusion criteria were enrolled in the study. Ultrasonography (USG) abdomen, micturating cystourethrography (MCU), and dimercaptosuccinic acid (DMSA) kidney scan were done. Results: Among 100 children with culture-proven UTI, USG was abnormal in 16% with the majority (31.7%) having hydroureteronephrosis. MCU was abnormal in 14% and DMSA in 13%. About 9% had kidney scarring. Overall prevalence of urinary tract abnormalities was 14%. About 42.8% of urinary tract abnormalities were detected in children between 1 and 5 years and 35.7% below 1 year. Vesicoureteral reflux was the most common abnormality (8.0%). Conclusion: UTI in young children serves as marker for abnormalities of the urinary tract. Early diagnosis is of considerable significance to preserve kidney function and prevent complications.

Early primary endoscopic realignment in children with posterior urethral and bladder neck injury

The management of bladder neck and posterior urethral injuries is controversial and debate continues in regarding the advisability of immediate versus delayed management. The aim of present study is to present our experience of immediate endoscopic realignment of posterior urethral and bladder neck injuries in children. From June 2016 to July 2019, immediate primary endoscopic realignment was done in children with bladder neck and posterior urethral injuries. Injuries were classified according to Goldman classification of urethral injury. After stabilization, retrograde cystourethrography was performed and endoscopic realignment was done within first 10 h of presentation. Per urethral catheter was left in for 4 weeks. Peri-catheter retrograde urethrocystogram and micturating cystourethrography (MCU) was done 4 weeks after primary realignment. Two patients with type-II injury are continent and have good urinary stream. One patient with type-III injury had stricture at the injury site. Dilatation was done once and child is voiding with good urinary stream. All the three patients with type-IVa injury healed well without any complication and are voiding with good urine flow. One patient with type IV injury is continent and is voiding with good urine flow. Early primary realignment in children with posterior urethral injury and bladder neck injury is safe and effective.

Current Management of Urinary Tract Infection and Vesicoureteral Reflux.

Urinary tract infection (UTI) is defined as the growth of a significant number of microorganisms of a single species in the urine, in the presence of symptoms. Symptoms in young children are non-specific such as fever without focus; young infants may manifest with irritability, failure to thrive, jaundice, vomiting and diarrhea. Older children usually have symptoms of cystitis or pyelonephritis. Symptoms of cystitis are dysuria, frequency, new onset incontinence and malodorous urine while symptoms of pyelonephritis are high grade fever, flank pain and vomiting. Rapid urine testing by microscopy for pus cells, dipstick testing for leukocyte esterase and nitrite, and enhanced urinalysis are supportive tests. Urine culture samples should be collected with proper technique and results interpreted for significant growth accordingly. Antibiotic therapy for 7-14 d for complicated UTI and 3-4d for uncomplicated UTI is adequate. Further evaluation is recommended clinically for bladder-bowel dysfunction and obvious anatomical defects and by imaging for vesicoureteral reflux (VUR), usually by micturating cystourethrography (MCU). Since MCU involves exposure to radiation and urethral catheterization, it is now reserved for children with parenchymal involvement or recurrent UTI. VUR is the backward flow of urine into one or both ureters. Clinical manifestations other than UTI include incidental diagnosis on antenatal ultrasonography. Reflux nephropathy, the renal scarring associated with VUR may manifest clinically as hypertension, proteinuria and renal failure. The management of VUR is primarily with antibiotic prophylaxis. Anatomical correction is indicated in case of breakthrough febrile UTI. No intervention has been shown to reduce renal scarring.

Correlation of ultrasonographical findings of hydronephrosis/atrophy with 99m technetium-dimercaptosuccinic acid in childhood: A single-center experience from Turkey.

Introduction:To assess the association of frequently detected abnormalities (hydronephrosis and/or atrophy) on renal ultrasound with dimercaptosuccinic acid (DMSA) scan and the impact of vesicoureteral reflux (VUR) on these abnormalities to find new perspectives in pediatric age group.Materials and Methods:We retrospectively reviewed the DMSA, ultrasonography (US), micturating cystourethrography (MCUG) findings, and medical records of pediatric patients with hydronephrosis and/or atrophy who were at follow-up between January 2013 and December 2016 in our center which is located in the southeast region of Turkey.Results:Among 148 pediatric patients (male/female = 60/88), 66 had hydronephrosis, 72 had atrophy, and 10 patients had both. MCUG study detected VUR in 66 patients. Patients with atrophy were significantly older than patients with hydronephrosis (77.8 ± 58.6 vs. 39.3 ± 38.9 months, P = 0.002). Only 19.4% of our patients with atrophy had VUR. The rate of VUR was higher in the high-grade group than the mild-to-moderate-grade group although the difference was not statistically significant (80% vs. 61%, P = 0.199). Patients with high-grade hydronephrosis had more severe DMSA findings (73% vs. 39%). On the other side, 79% of the patients with high-grade VUR had severe DMSA findings. A total of 10 patients had both atrophy and hydronephrosis all affecting the left side. Six of them had VUR. Severe DMSA findings were more likely in toddlers (age 24–72 months) (48%). This finding was abruptly lowered after 72 months of age.Conclusions:The presence of atrophy and cases of left-sided hydronephrosis should be closely monitored, and DMSA may not be necessary in cases with high-grade hydronephrosis before MCUG.

Frequency of Urinary Tract Abnormalities on MCUG of Spina Bifida Occulta Patients with Urinary Complaints

AbstractSpina bifida occulta (SBO) is usually considered as benign entity without having any clinical significance. In Pakistan, there is a lack of studies on spina bifida. Clinicians usually ignore the mild urinary complaints and do not look with the perspective of SBO background. Micturating cystourethrography (MCUG) of the 71 children with SBO having urinary complaints was done. Analysis was done via SPSS version 20. A total of 70.4% of the patients had urinary tract abnormalities on MCUG. Vesicoureteric reflux was the most common finding. SBO is a clinically significant disorder. Especially in patients with urinary complaints, MCUG must be done to look for underlying pathologies.

Clinical profile of infantile pelviureteric junction obstruction

Background: Pelviureteric junction obstruction commonly present with antenatal hydronephrosis. The aim was to report and analyze the clinical spectrum of infantile pelviureteric junction obstruction.Methods: Retrospective descriptive study of infants operated for pelviureteric junction obstruction (PUJO) during 2013- 2016. Clinical presentations, management and follow up were analyzed.Results: There were 44 infants involving 48 PUJO renal units of who were nine girls. The sex distribution was 1:3.8. Mean age of the presentation was three months. PUJO was bilateral in four patients. Two patients had unilateral PUJO of lower moiety of duplex system. Median of anteroposterior diameter (APD) and differential function of kidney on EC was 2.5cms and 28% respectively. Three patients had poorly functioning kidneys (PFK) (<10%).Conclusions: Good antenatal counselling and appropriate postnatal evaluation detects PUJO early. Early infantile pyeloplasty is safe and effective. Routine micturating cystourethrography is debatable in pelviureteric junction obstruction.

Diagnostic reference levels for common paediatric fluoroscopic examinations performed at a dedicated paediatric Australian hospital

Diagnostic reference levels (DRL) of procedures involving ionising radiation are important tools for optimising radiation doses delivered to patients and to identify cases where the levels of dose are unusually high. This is particularly important for paediatric patients undergoing fluoroscopic examinations as these examinations can be associated with a high radiation dose. In this study, a large amount of paediatric fluoroscopic data has been analysed to: establish local DRL, identify the most significant factors determining radiation dose to patients, and modify fluoroscopic techniques to optimise the examination protocols. Paediatric fluoroscopic studies performed at our institution from April 2010 to May 2015 have been retrospectively analysed to determine range, mean, 75th and 95th percentiles of Dose-Area Product (DAP) and fluoroscopic screening time for Micturating Cystourethrography (MCU), Airway, Airway and Swallow, Barium Swallow and Meal, Barium Follow Through and Barium Enema studies. Currently, no Australian paediatric fluoroscopic DRL data are available for comparison and thus our data can only be compared with international published data. No major changes to examination protocols or modification to fluoroscopic techniques were found necessary as our data compared well with the international published values. The dose delivered to patients depend on a number of factors particularly the experience of the operators. However, DRL are also important, as shown in this study, as they enable best practice by providing feedback to the operators on their performance and benchmarking the institution with other institutions.

Radiation exposure in pediatric patients during micturating cystourethrography procedures

The objectives of this study were to measure the entrance surface air kerma (ESAK) and the effective doses in pediatric patients undergoing micturating cystourethrography (MCU) procedures. The ESAK was determined using calibrated thermoluminescent dosimeters (TLD- GR 200 A) in 167 pediatric patients. The patient population was categorized into three groups according to age (0–5 years (group 1), 6–10 years (group 2) and 11–15 years (group 3)). The mean ESAK±SD and range (mGy) resulting from a MCU procedure was estimated to be 2.2±0.5 (0.8–9.2), 2.48±0.6 (0.9–8.1) and 3.90±0.6 (1.1–10.3) for group 1, 2 and 3, respectively. The mean effective dose was between 0.03 and 0.4 mSv per procedure for the pediatric population. Pediatric patients were exposed to avoidable radiation doses because no gonad shields were used.

Profile of urinary tract infections in paediatric patients.

Background & objectives:This cross-sectional study was conducted at a tertiary care centre in Puducherry, south India, with the aim of finding the profile of the paediatric urinary tract infection (UTI), bacterial pathogens involved, and also to observe vesicoureteric reflux (VUR) and renal scarring in these patients.Methods:A total of 524 paediatric patients ≤13 yr, suspected to have UTI, were included in the study. Urine samples were collected, processed for uropathogen isolation and antibiotic susceptibility test was performed as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Thirty two culture proven children with UTI underwent micturating cysto-urethrography (MCU) and dimercaptosuccinic acid (DMSA) scanning was done for 69 children.Results:of the 524 children, 186 (35.4%) had culture proven UTI with 105 (56.4%) being infants, 50 (27.4%) between 1-5 yr, 30 (16.12%) between 5-13 yr and 129 (69.35%) males. Posterior urethral valve (PUV) was noted in three, hydronephrosis in one, VUR in 18 and renal scarring in 33. VUR as well as renal scarring were more in males >1 yr of age. A significant association (P=0.0054) was noted with a combined sensitivity and specificity of these investigations being 83 and 90 per cent, respectively of the MCU and DMSA scans for detecting VUR. Escherichia coli was the most common pathogen isolated, sensitive to nitrofurantoin, followed by cefoperazone-sulbactam, aminoglycosides and meropenem.Interpretation & conclusions:Our results indicate that UTI varies with age and gender and extensive evaluation is required in boys under one year of age with UTI. This study also highlights the better efficacy of aminoglycosides, cefoperazone-sulbactam and nitrofurantoin in vitro compared with meropenem in Gram–negative uropathogens.

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.

Evaluation of Congenital Upper Urinary Tract Anomalies in Hypospadias

Background: Hypospadias may be associated with other congenital upper urinary tract anomalies. Literature showed various opinions to evaluate or not to evaluate upper urinary tract in hypospadias patient. Frequency of upper urinary tract anomalies also varies. This study was carried out on this background to avoid confusion.Objectives: Morphological evaluation of upper urinary tract to find out the frequency of upper urinary tract anomalies associated with uncomplicated hypospadias patients and give a guideline for investigation of such patients. Methods: This prospective study was designed and accomplished in the Departments of Paediatric Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka; Dhaka Medical College Hospital (DMCH), Dhaka and Chittagong Medical College Hospital (CMCH), Chittagong; Bangladesh from October 2004 to June 2006. Eighty five (85) patient with hypospadias having neither any congenital anomalies, nor other genital ambiguity, nor any secondary vesicoureteric reflux (VUR) or meatal stenosis were selected for the study. Detailed history and examination were carried out. Upper urinary tract of all patients were evaluated by Ultrasonography (USG), Intravenous Urography (IVU), and Micturating Cystourethrography (MCU).To exclude genital ambiguity in perineal hypospadias, karyotype were done to ascertain male sex. Results were analyzed by SPSS with the help of Chi-square and Z approximation test . Result : Eighty five (85) patients were taken. All patients were evaluated by USG, IVU and MCU to detect congenital upper urinary tract anomalies.Results: Four (4) patients had had upper urinary tract anomalies. One (1) patient found to have left sided pelviureteric junction obstruction (PUJO) while one (1) patient had right sided pelviureteric junction obstruction (PUJO). One (1) patient was found to have left sided pelviureteric duplication and the last patient with left renal agenesis. USG detected three (3) anomalies in 85 patients (3.53%) and IVU detected all four (4) anomalies in 85 patients (4.7%), but no primary reflux was detected by MCU. Overall frequency of upper urinary tract anomalies was 4.7%. Eighty one (81) patients (95.3%) had no anomalies. USG detected 3 (three) anomalies out of 4 (four) patients (75%) & IVU detected all four anomalies (100%). Absence of upper urinary tract anomaly was statistically significant.Conclusion: Frequency of upper urinary tract anomalies are significantly low (4.7%) in uncomplicated hypospadias. USG can detect 75% congenital upper urinary tract anomalies in hypospadias patients. So USG is good enough and recommended to evaluate upper urinary tract anomalies in uncomplicated hypospadias patients. There is no need to evaluate upper urinary tract by IVU or MCU in such patients, if asymptomatic otherwise.DOI: http://dx.doi.org/10.3329/jpsb.v2i2.19547

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

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