Renal Bladder Ultrasonography Research Articles

Just Get in Line: Rural-Urban Differences in Access to Pediatric Renal-Bladder Ultrasounds

IntroductionHealth-care disparities in rural and underserved areas may be exacerbated by the pandemic, personnel challenges, and supply chain limitations. This study aimed to quantify current variation in rural and urban pediatric renal ultrasound availability. MethodsWe identified all hospitals statewide and contacted radiology departments posing as a parent trying to schedule an appointment for a routine pediatric renal-bladder ultrasound. Intervals between day of contact and first available appointment were compared between rural and urban institutions. ResultsWe were able to contact 42/48 (87.5%) rural hospitals, and 20/39 (51.3%) urban hospitals. Scheduling could not be completed in 5 rural and 7 urban hospitals. The median wait time for the 37 remaining rural and 13 remaining urban hospitals was similar: 7 (range: 0-21) days in rural hospitals and 6 (range: 0-17) days in urban hospitals (P = 0.81). If contact was made, the likelihood of scheduling within 7 d was similar in rural and urban areas (odds ratio [OR] = 0.23; 95% confidence interval [CI] 0.03-1.97; P = 0.18). However, patients were much more likely to have a completed call at a rural hospital (OR = 6.65; 95% CI: 2.3-19.2; P = 0.0005), and so in reality, patients were 2.89 times as likely to be able to schedule an renal-bladder ultrasound within 7 d at a rural compared with an urban institution (95% CI: 1.19-7.03; P = 0.019). ConclusionsWhile access to pediatric renal sonograms was similar within a week at rural and urban institutions once telephone contact was made, it was significantly more difficult to schedule appointments at urban institutions.

Considerations for Percutaneous Nephrolithotomy in Transgender Female Patients

Clinical History: A 38-year-old transgender female with history of HIV, bilateral orchiectomy, bilateral breast and buttock augmentation, and kidney stones presented for surgical evaluation of right nonobstructing kidney stones. CT scan showed two nonobstructing stones in the right lower pole measuring 8 and 7 mm. She specifically requested no ureteral stent and nonprone positioning because of recent facial plastic surgery. She elected to proceed with supine minipercutaneous nephrolithotomy (PCNL). There are several special considerations that should be taken when performing PCNL on transgender patients. Physical Examination: NAD, AAOx3. Abdomen was soft, nontender, and negative for costovertebral tenderness. Diagnosis: Right lower pole nonobstructing kidney stones. Intervention: A supine mini-PCNL was performed to accommodate patient's recent facial surgery and aversion to ureteral stent placement. In the Galdakao-modified Valdivia supine position, access was obtained using combined fluoroscopic, ultrasound, and endoscopic approaches. Access site was dilated to 18F, and the stones were extracted without incident. A retrograde flexible ureteroscope was used to evaluate all calices and confirm that no additional stones were present. A 14F nephrostomy tube was placed and no ureteral stent was left. Follow-up: Patient effectively underwent surgery without complication and was sent to post-anesthesia care unit (PACU) postoperatively where she recovered well. She was observed overnight for pain control. On postoperative day 1, the nephrostomy tube was clamped and there was confirmed urinary drainage in the foley. The nephrostomy tube and foley catheter were removed. She was instructed on wound care and informed to follow-up for her postoperative visit. Follow-up renal bladder ultrasound (RBUS) confirmed that she was stone free. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure No competing financial interests exist. Runtime of video: 4 mins 51 secs

Abdomino-Pelvic Ultrasound Evaluation in Monosymptomatic Primary Nocturnal Enuresis.

Enuresis is one of the most common childhood problems. Our study aimed to evaluate children with enuresis by renal bladder ultrasound (RBUS) to detect urological abnormalities and to compare the sonographic findings with control group. Our study included 30 children with primary monosymptomatic nocturnal enuresis (PMNE). Another 30 matched children with normal continence to urine were assigned as controls. The 2 groups were subjected to urine analysis, serum creatinine, and RBUS. Ultrasound showed abnormality in 10% of case group, which was not significantly different from controls (p = 1.000). Abnormalities discovered by ultrasonography in PMNE are more than in control group but without statistical significance and do not require invasive diagnostic tests. Children with sonographic abnormalities appear to be more resistant to treatment. We concluded that ultrasound is not necessary in MPNE and should be done in patients resistant to treatment.

Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center.

Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis.Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes.Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow.Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.

Ultrasonographic evaluation of the children with candiduria for the fungal ball: Is It necessary?

Imaging of the urinary tract by ultrasonography (USG) or computerized tomography scanning is recommended for detecting structural abnormalities, hydronephrosis, abscesses, emphysematous pyelonephritis, or fungus ball formation. Limited studies on the epidemiology and the imaging results of candiduria were present in the children. This study aimed to evaluate the results of renal ultrasonography imaging in hospitalized pediatric patients with candiduria. In this descriptive study, we reviewed our ultrasonography findings with hospitalized children and infants who with candiduria. The study included the period between January 2012 and December 2019. Demographic data, the previous medical history, the clinical features of the patients, ultrasonographic findings of the urinary tract system, presence of an indwelling urinary catheter, type of urinary samplings, type of candida species were retrospectively recorded. The study was approved by Institutional Review Board with the registration number 2019/366. During the study period, 220 children with nosocomial candiduria were evaluated. The most common isolated candida species was Candida albicans (68.2%) and followed by C. tropicalis (9.1%). Among all patients, 2 (0.9%) had renal fungal balls associated with C. Albicans. Twenty-five patients (11.4%) had findings including internal echogenicity in the bladder (n=12), uroepithelial thickening of the kidney (n=10), and sediments in the renal pelvis (n=3). Candida albicans was the most prominent candida isolated from the patients. The fungal ball is an uncommon infection especially in children and predominantly caused by Candida species. Fungal ball in the kidney was reported as case reports especially in neonates, in immunosupressed patients, and in patients who had undergone surgical procedures. In our study, none of the patients with the fungal ball were in the neonatal period, however, the patients with fungus ball had underlying disease or condition. Our study has several limitations including a retrospective study, and the USG were not performed by a single radiologist. Besides these limitations, our findings are important to give information about the place of USG for diagnosis of the renal fungal ball in children adding valuable information to a topic in which data came from mainly case reports. Despite the low incidence of fungal balls reported, considering the high consequences of missing a fungal ball and elimination of it, a non-invasive method such as the renal bladder USG is still necessary for detection of fungal ball especially. More prospective studies are required for high risk groups to establish the diagnostic value of renal USG.

Prevalence of high-risk bladder categorization with prenatal and postnatal myelomeningocele repair types.

Urologic substudies of prenatal myelomeningocele (MMC) closure have focused primarily on continence without significant clinical benefit. Fetoscopic MMC repair (FMR) is a newer form of prenatal intervention and touts added benefits to the mother, but urological outcomes have yet to be analyzed. We set out to focus on bladder safety rather than continence and examined bladder outcomes with different prenatal MMC repairs (FMR and prenatal open [POMR]) and compared bladder-risk-categorization to traditional postnatal repair (PSTNR). An IRB-approved retrospective analysis of all patients undergoing all forms of MMC repairs with inclusion and exclusion criteria based on the MOMS trial was performed. Bladder safety assessment required initial urodynamic studies (UDS), renal bladder ultrasound (RBUS), and/or voiding cystourethrogram (VCUG) within the 1st year of life. Follow-up analyses within the cohorts required follow-up studies within 18 months after initial evaluations. Outcomes assessed included bladder-risk-categorization based on the CDC UMPIRE study (high, intermediate, and safe), hydronephrosis (HN), and vesicoureteral reflux (VUR). A single reader evaluated each UDS. Initial UDS in 93 patients showed that the prevalence of high-risk bladders were 35% FMR versus 36% PSTNR and 60% POMR. Follow-up UDS showed only 8% of FMR were high-risk compared to 35% POMR and 36% PSTNR. Change from initial to follow-up bladder-risk-category did not reach significance (p = .0659); however, 10% PSTNR worsened to high-risk on follow-up, compared to none in either prenatal group. Subanalysis of follow-up UDS between the prenatal cohorts also was not significant (p = .055). Only 8% of FMR worsened or stayed high-risk compared to 35% with POMR (p = .1). HN was significantly different at initial and subsequent follow up between the groups with the least in the FMR group. Early outcome UDS analyses demonstrated lower incidence of high-risk bladders in FMR patients with a trend toward clinically significant improvement compared to POMR in regard to all evaluated metrics. Larger, prospective, confirmatory studies are needed to further evaluate the potential benefits on FMR on bladder safety and health.

Crossed fused renal ectopia: Diagnosis and prognosis as a single-center experience

BackgroundCrossed fused renal ectopia (CFRE) is a rare congenital malformation. Renal bladder ultrasound (RBUS) is a good tool for establishing the diagnosis, however, additional imaging with a voiding cystourethrogram (VCUG) and dimercaptosuccinic acid scan (DMSA) might be required. We assessed the need for postnatal evaluation and the long-term consequences in patients with this diagnosis. MethodsA retrospective review of the records of all patients diagnosed with CFRE between 2004 and 2014 was done. We included all patients who underwent postnatal evaluation with RBUS, DMSA and VCUG. Long-term radiological and functional outcomes were assessed. ResultsA total of 29 patients with CFRE were identified. Majority of cases were detected antenatally (79%) and left to right crossed ectopia constituted the majority of cases (65%). RBUS revealed associated hydronephrosis (HN) in 11 patients (38%). DMSA scans confirmed the diagnosis in all patients and showed impaired renal function in 10 ectopic kidneys (34%). Vesicoureteral reflux was detected in 12 patients (41%); one third of them needed surgical intervention. Extra-urinary anomalies were present in 14 patients (48%) mainly of cardiac origin. After a mean follow-up of 4.5 years, 4 patients (14%) with extra-urinary anomalies developed chronic kidney disease and two of them died. ConclusionsCrossed fused renal ectopia is commonly associated with both urinary and extraurinary malformations. Postnatal RBUS is usually sufficient for diagnosis, however, additional imaging may aid for confirming the diagnosis and detection of associated urinary anomalies. Presence of extra-urinary malformations with crossed fused ectopia carries a higher risk of morbidity. Type of the StudyRetrospective study [diagnostic/prognostic study]. Level of EvidenceLevel IV.

Clinical Predictors for Abnormal Renal Bladder Ultrasound in Hospitalized Young Children With a First Febrile Urinary Tract Infection.

Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management. We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI. A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals. No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.

Ultrasound in Hospitalized Children With First Febrile UTI: What Exactly Are We Looking For?

Detection of genitourinary abnormalities and vesicoureteral reflux (VUR) in young children who present with a febrile urinary tract infection (UTI) is important because severe VUR may predispose to renal scar formation, which may lead to hypertension and impaired kidney function. In this issue of Hospital Pediatrics , Wallace et al1 attempt to identify clinical factors that could be used to predict which hospitalized children 0 to 24 months of age with first febrile UTI are likely to have an abnormal renal bladder ultrasound (RBUS). The authors were not able to determine any clinical factors (other than known genitourinary tract abnormalities) that could be used to guide selective RBUS screening. The authors conclude that selective screening cannot be applied and recommend screening all young children at the time of first febrile UTI. Screening for genitourinary abnormalities technically precedes UTI in most children because severe genitourinary abnormalities and clinically significant hydronephrosis may be noted on a prenatal ultrasound. One study of 4586 children revealed that a prenatal ultrasound identified severe genitourinary tract abnormalities requiring immediate intervention with a negative predictive value of 99.9%.2 In a prescreened population, we would not expect an ultrasound at the time of first UTI to detect prenatally missed posterior urethral valves or high-grade obstruction. The population in this study was a prescreened population in which all patients had a normal prenatal ultrasound, and all patients with …

Cost-Effectiveness of Screening Ultrasound after a First, Febrile Urinary Tract Infection in Children Age 2-24 Months

To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics. We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY). Among children 2-24months after a first febrile UTI, RBUS had an overall accuracy (true positives+true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incrementalcost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group. Screening RBUS after a first, febrile UTI in children age 2-24months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

Renal bladder ultrasound in children with urinary tract infection

Introduction. Urinary tract infections (UTI) are a common problem in the pediatric age patients. They can represent the first sign of congenital anomaly of the kidney or urinary tract (CAKUT) in children younger than 2 years, vesicoureteral reflux being the most frequent. Renal bladder ultrasound (RBUS) is the most utilized imaging modality in children with UTI. RBUS is a non-invasive, non-radiating and the least expensive imaging test available. Materials and methods. The present study is a retrospective analysis of patients admitted for UTI in “Grigore Alexandrescu” Clinical Emergency Hospital for Children between 1st January 2015 and 31st December 2017. Results. RBUS was performed in 310/359 cases. Urinary tract anomalies were found in 108 patients. In 67/108 cases upper urinary tract dilations were identified. 31/191 patients (16%) under 2 years of age had upper urinary tract dilations on RBUS, while 36/119 patients (30%) older than 2 years had positive RBUS for upper urinary tract dilations. In 61 cases both RBUS and VCUG were available. 11/29 patients with upper urinary tract dilations on RBUS had VUR on VCUG (8 patients with high grade VUR). 8 patients with normal RBUS had VUR on VCUG (5 patients with high grade VUR). Conclusions. Although RBUS is a non-invasive and non-radiating imaging test, its value when used alone in children with UTI is limited in diagnosing CAKUT, especially VUR.

Radiographic abnormalities, bladder interventions, and bladder surgery in the first decade of life in children with spina bifida.

Spina bifida (SB) patients are at increased risk for hydronephrosis, bladder storage and emptying problems, and renal failure that may require multiple bladder surgeries. We retrospectively reviewed patients born with SB 2005-2009, presenting to our institution within 1year of birth. Outcomes at 8-11years old included final renal/bladder ultrasound (RBUS) results, clean intermittent catheterization (CIC) use, anticholinergic use, surgical interventions, and final renal function. We excluded those without follow-up past age 8 and/or no RBUS or fluoroscopic urodynamic images (FUI) within the first year of life. Imaging was independently reviewed by four pediatric urologists blinded to radiologists' interpretation and initial findings compared with final outcomes. Of 98 children, 62 met inclusion criteria (48% male, 76% shunted). Median age at last follow-up was 9.6years. Upon initial imaging, 74% had hydronephrosis (≥ SFU grade 1), decreasing to 5% at 10years (p < 0.0001). Initially, 9% had ≥ SFU grade 3 hydronephrosis, decreasing to 2% (p = 0.13). CIC and anticholinergic use increased from 61% and 37% to 87% and 86%, respectively (p = 0.001 and p < 0.0001, respectively). With follow-up, 55% had surgical intervention and 23% had an augmentation. Of children with a serum creatinine/cystatin-C at 8-11years old, one had confirmed chronic kidney disease (stage 2). Despite initial high incidence of hydronephrosis, this was low grade and resolved in the first decade of life. Additionally, the 8-11-year incidence of kidney disease and upper tract changes was low due to aggressive medical management.

Predicting and Modifying Risk for Development of Renal Failure in Boys with Posterior Urethral Valves.

The purpose of this review is to bring the reader up to date on the current risk factors for the development of renal deterioration in the boys with posterior urethral valves (PUV) and approaches to modify this risk. Renal bladder ultrasound (RBUS) is routinely performed in boys with PUV and recent advancements allow imaging processing that can more accurately quantify renal parenchyma and correlate this with risk for renal loss. Refinement of urine studies may improve our ability to stratify patients into renal loss categories. Use of videourodynamics (VUDS) allows refined assessment of the valve bladder to identify those who might benefit from secondary procedures and/or the addition of targeted pharmacotherapy to improve bladder emptying or dangerous storage pressures. All boys with a history of PUV are at a significant long-term risk of renal deterioration. The literature suggests that several technical advances have improved our ability to predict this risk, although there needs to be further refinement and validation before widespread use. Utilization of close follow-up, VUDS, pharmacotherapy, and bladder drainage provide the best methods to improve care to this group of patients and if more studies confirm their utility, adoption of these as part of standard of care protocols may be warranted.

Unilateral Renal Agenesis: Necessity of Postnatal Evaluation in a Contemporary Series

To assess the need for postnatal evaluation and the long-term consequences in patients with prenatal diagnosis of unilateral renal agenesis (URA). A retrospective review of the records of all patients with prenatal diagnosis of URA between 2004 and 2013 was done. We included all patients who underwent postnatal evaluation with renal bladder ultrasound (RBUS), dimercaptosuccinic acid scan, and a voiding cystourethrogram. Long-term follow-up included physical examination and assessment of contralateral renal growth. A total of 46 children (24 boys and 22 girls) with URA were identified. Ultrasounds showed associated hydronephrosis in 9 patients (19%). Dimercaptosuccinic acid scans confirmed the diagnosis of URA in all patients and showed renal scars in 2 solitary kidneys (4%). Vesicoureteral reflux was diagnosed in 4 patients (12%); all were of low grade and managed conservatively. After a mean follow up of 4 years, RBUS showed compensatory hypertrophy in 31 patients (67%), 3 patients (6%) developed chronic kidney disease, and 2 patients (4%) developed hypertension. Prenatally detected cases of URA should be promptly evaluated. RBUS is found to be sufficient for diagnosis. However, additional imaging may be indicated for confirming the diagnosis and detection of other associated urinary anomalies. Serial assessment of the contralateral solitary kidney growth and serum creatinine measurement will be helpful to assess kidney function on the long term.

Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections.

There is considerable interest in detecting vesicoureteral reflux (VUR) because its presence, especially when severe, has been linked to an increased risk of urinary tract infections and renal scarring. Voiding cystourethrography (VCUG), also known as micturating cystourethrography, is the gold standard for the diagnosis of VUR, and the grading of its severity. Because VCUG requires bladder catheterisation and exposes children to radiation, there has been a growing interest in other screening strategies that could identify at-risk children without the risks and discomfort associated with VCUG. The objective of this review is to evaluate the accuracy of two alternative imaging tests - the dimercaptosuccinic acid renal scan (DMSA) and renal-bladder ultrasound (RBUS) - in diagnosing VUR and high-grade VUR (Grade III-V VUR). We searched MEDLINE, EMBASE, BIOSIS, and the Cochrane Register of Diagnostic Test Accuracy Studies from 1985 to 31 March 2016. The reference lists of relevant review articles were searched to identify additional studies not found through the electronic search. We considered published cross-sectional or cohort studies that compared the results of the index tests (DMSA scan or RBUS) with the results of radiographic VCUG in children less than 19 years of age with a culture-confirmed urinary tract infection. Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate summary sensitivity and specificity values. A total of 42 studies met our inclusion criteria. Twenty studies reported data on the test performance of RBUS in detecting VUR; the summary sensitivity and specificity estimates were 0.44 (95% CI 0.34 to 0.54) and 0.78 (95% CI 0.68 to 0.86), respectively. A total of 11 studies reported data on the test performance of RBUS in detecting high-grade VUR; the summary sensitivity and specificity estimates were 0.59 (95% CI 0.45 to 0.72) and 0.79 (95% CI 0.65 to 0.87), respectively. A total of 19 studies reported data on the test performance of DMSA in detecting VUR; the summary sensitivity and specificity estimates were 0.75 (95% CI 0.67 to 0.81) and 0.48 (95% CI 0.38 to 0.57), respectively. A total of 10 studies reported data on the accuracy of DMSA in detecting high-grade VUR. The summary sensitivity and specificity estimates were 0.93 (95% CI 0.77 to 0.98) and 0.44 (95% CI 0.33 to 0.56), respectively. Neither the renal ultrasound nor the DMSA scan is accurate enough to detect VUR (of all grades). Although a child with a negative DMSA test has an < 1% probability of having high-grade VUR, performing a screening DMSA will result in a large number of children falsely labelled as being at risk for high-grade VUR. Accordingly, the usefulness of the DMSA as a screening test for high-grade VUR should be questioned.

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

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

Emergency Hospital Admissions for Initial Febrile Urinary Tract Infection: Do Patient Demographics Matter?

BackgroundIn 2011, the American Academy of Pediatrics revised practice parameters regarding febrile urinary tract infection (fUTI) in children aged 2–24 months. The Section on Urology opposed the omission of voiding cystourethrogram (VCUG), and expressed concern that potential untoward consequences of deferring VCUG may be most felt by children on Medicaid. ObjectiveWe ascertained imaging and characteristics of children presenting to the Emergency Department (ED) with initial fUTI to determine the impact of patient demographics on admissions for pyelonephritis. MethodsChildren aged 2–24 months presenting to the ED with initial fUTI were identified. Demographics, insurance status, laboratory studies, renal-bladder ultrasound (RBUS), VCUG, and hospital admission status were evaluated. ResultsThree-hundred fifty patients met inclusion criteria; 88 (25.1%) were admitted. Admitted patients were significantly (p < 0.001) younger (mean 0.31 ± 0.33 years) than those managed as outpatients (mean 0.91 ± 0.7 years). On univariate analysis, male gender (p < 0.001), Medicaid insurance (p < 0.05), and non-Hispanic race (p < 0.05) were associated with admission. Race retained significance on multivariate analysis; Caucasian children were 2.35 times (95% confidence interval [CI] 0.79–7.23) and African-American children 3.8 times more likely to be admitted than Hispanic patients (95% CI 1.88–7.63). Children with abnormal RBUS were 12.8 times more likely to require admission (95% CI 4.44–37.0). Medicaid was also independently predictive of admission; such patients were 2.6 times more likely to be admitted than those with private insurance (95% CI 1.15–5.88). ConclusionsAbnormal ultrasound, non-Hispanic race, and public insurance were strongly associated with hospital admission in children presenting to the ED with initial febrile urinary tract infection.

Renal Bladder Ultrasonography and Late 6-Month DMSA Scan Screening for High-Grade Vesicoureteral Reflux After First Febrile Urinary Tract Infection in Infants Aged &amp;lt;1 Year

The best approach for radiologic investigation in a child after the first febrile urinary tract infection (UTI) remains contentious. Many advocates agree that the detection of high-grade vesicoureteral reflux (VUR) is important because of the increased risk of recurrent UTI and renal scars. The objective was to study the ability of renal bladder ultrasonography (RBUS) and …

MP44-06 THE MODIFIED TOP DOWN APPROACH TO IMAGING: ANORMAL DMSA PREDICTS RECURRENT FEBRILE UTI RISK

You have accessJournal of UrologyPediatrics: Urinary Tract Infection & Vesicoureteral Relux1 Apr 2014MP44-06 THE MODIFIED TOP DOWN APPROACH TO IMAGING: ANORMAL DMSA PREDICTS RECURRENT FEBRILE UTI RISK Melise Keays, Colby Adams, Kimberly Mizener, Karen Pritzker, William Smith, Janelle Traylor, Carlos Villanueva, Warren Snodgrass, and Nicol C. Bush Melise KeaysMelise Keays More articles by this author , Colby AdamsColby Adams More articles by this author , Kimberly MizenerKimberly Mizener More articles by this author , Karen PritzkerKaren Pritzker More articles by this author , William SmithWilliam Smith More articles by this author , Janelle TraylorJanelle Traylor More articles by this author , Carlos VillanuevaCarlos Villanueva More articles by this author , Warren SnodgrassWarren Snodgrass More articles by this author , and Nicol C. BushNicol C. Bush More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1381AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives The goal of imaging after febrile UTI (FUTI) in children is to identify anatomic anomalies predisposing to recurrent FUTI and/or renal damage. Recommendations have varied from no imaging after 1st FUTI to renal/bladder ultrasound (RBUS) and VCUG in all patients. We used DMSA obtained ≥3 months after FUTI to evaluate baseline renal damage (Snodgrass et al, 2013) and determined rates of VUR and recurrent FUTI longitudinally. We present results of this modified “top-down” approach. Methods Beginning in 2008, consecutive children referred following FUTI underwent standardized evaluation and management. Imaging comprised RBUS, and DMSA ≥ 3 months after the last FUTI. Abnormal DMSA was defined as function <44% and/or cortical renal defect(s). VCUG was only done in those with abnormal DMSA if not obtained before referral. Patients with normal DMSA were observed without antibiotic prophylaxis regardless of VUR status, whereas those with abnormal DMSA had injection or reimplantation to resolve VUR, when present. Patients were followed at 6 month intervals until considered toilet-trained. Data was prospectively collected at time of service. Results There were 618 patients (79% female) referred after FUTI at median age 3.4 years. Of these, 149 (24%) had abnormal DMSA, in whom RBUS was normal in 66% and VUR was present in 76%. Follow up data was available in 602 children at mean of 1.7 years (5m-4y), with 119 (20%) developing recurrent FUTI. Risk factors for recurrent FUTI included abnormal DMSA (OR 2.5, 1.3-4.9), and ≥ 2 FUTI (OR 1.64, 1.3-2.1) before referral. Neither VUR nor VUR grade were independent risk factors for recurrent FUTI. Bowel/bladder dysfunction, diagnosed and managed in 61% of 505 toilet trained patients, also did not predict recurrent FUTI. Conclusions Abnormal delayed DMSA occurred in 24% of referred children after FUTI, despite a normal RBUS in 66%. Abnormal DMSA was a risk factor for recurrent FUTI, as was recurrent FUTI before referral. Although VUR is a risk factor for abnormal DMSA, it did not predict recurrent FUTI during follow up despite no treatment in those with normal DMSA. Top down imaging using DMSA ≥3 months after last FUTI identifies patients with renal damage, and those at risk for recurrent FUTI. Cystography can be reserved for patients with abnormal DMSA or with recurrent UTI despite normal DMSA. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e445 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Melise Keays More articles by this author Colby Adams More articles by this author Kimberly Mizener More articles by this author Karen Pritzker More articles by this author William Smith More articles by this author Janelle Traylor More articles by this author Carlos Villanueva More articles by this author Warren Snodgrass More articles by this author Nicol C. Bush More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Multicystic dysplastic kidney: Impact of imaging modality selection on the initial management and prognosis

ObjectiveTo evaluate the impact of imaging modalities on the evaluation and prognosis of children with multicystic dysplastic kidney (MCDK) disease. Patients and methodsA retrospective analysis of all children with MCDK diagnosed from 2004 until 2012 was performed. The study included 63 patients for whom all postnatal imaging modalities were available: renal bladder ultrasound (RBUS), dimercaptosuccinic acid scan (DMSA) and voiding cystourethrogram (VCUG). Cases with major congenital abnormalities or incomplete data were excluded. Abnormalities in the contralateral kidney and the fate of MCDK were also addressed. ResultsAt diagnosis, the average age was four-and-a-half months. The majority of cases were detected antenatally (87%). Postnatal RBUS and DMSA scans established the diagnosis of MCDK in 92% and 98% of patients, respectively. DMSA showed photopenic areas in the contralateral kidneys in 10% of patients; all of them had hydronephrosis and were confirmed to have vesicoureteral reflux (VUR). Contralateral VUR was detected in 16 patients; 63% of them had hydronephrosis. After a mean follow-up of three-and-a-half years, involution occurred in 62% of patients and the involution rate was inversely proportional to the initial size. ConclusionsThe classical appearance of MCDK on RBUS was sufficient to establish the diagnosis in most patients. DMSA scan was more accurate in confirming the diagnosis and evaluating the contralateral kidney. Selective screening for VUR in patients with contralateral hydronephrotic kidney should be considered.