Renal Scan Findings Research Articles

V84 - Sutureless purely off-clamp robot-assisted partial nephrectomy: Nuclear renal scan findings from a pilot study

V84 - Sutureless purely off-clamp robot-assisted partial nephrectomy: Nuclear renal scan findings from a pilot study

Urine Biomarkers Combined With Ultrasound for the Diagnosis of Obstruction in Pediatric Hydronephrosis.

Introduction: To establish the efficacy of ultrasound (US) combined with urine biomarkers in differentiating patients who require surgical management from those who do not, avoiding invasive investigations.Materials and Methods: From February 2019 to February 2021, all pediatric patients who presented with hydronephrosis were selected for the study. All renal units (RU) were evaluated by US, and fresh frozen voided urine samples were collected at the time of inclusion. Hydronephrosis grade was evaluated by the Society for Fetal Urology (SFU) and an alternative grading system (AGS). Patients who had high-grade hydronephrosis on US were referred to renal scan (RS) or intervention, when there was an increase of dilatation in subsequent follow-up images. Fresh frozen urine from the control group with no history of renal diseases and no renal anomalies on US was collected. We compared differences of US parameters combined with urine biomarkers between surgically and non-surgically managed patients and between the groups of patients when they were stratified by different RS findings and analyzed whether urinary biomarkers give any additional value to US. Instead of the anterior–posterior diameter (APD), we used its ratio with mid-parenchymal thickness. The additional efficacy of biomarkers to US was calculated when the US component was derived to a cumulative APD/mid-parenchymal ratio.Results: Sixty-four patients with hydronephrosis were prospectively included in the study accounting for a total of 81 patient visits and 162 RUs evaluated. A control group of 26 patients was collected. The mean age at inclusion in the hydronephrosis group was 43.7(±45.5) months, and a mean age in a control group was 61.2(±41.3) months. The cumulative APD/mid-parenchymal ratio combined with urinary albumin, β2 microglobulin (β2-M), and urinary neutrophil gelatinase-associated lipocalcin may have a better performance in the prediction of surgical intervention than the cumulative APD/mid-parenchymal ratio alone (p = 0.1). The best performance to detect the increased tissue transit time and obstructive curve on RS was demonstrated by the β2-M creatinine ratio. An increased cumulative APD/mid-parenchymal ratio with biomarkers together had a fairly good sensitivity and specificity for detection of DRF < 40%.Conclusions: According to our data, the APD/mid-parenchymal ratio alone has good efficacy in prediction of surgery and abnormal RS findings especially when combined with urine biomarkers.

Glomerular Filtration Rate Estimation With Commonly Used Methods Among Healthy Live Kidney Donors of South Punjab, Pakistan.

BackgroundAccurate estimation of the donor’s glomerular filtration rate (GFR) is crucial for not only ensuring the medical appropriateness of the donor but also for the prediction of future allograft performance. The aim of this study was to compare the GFR estimation formulas and 24-hour urine creatinine clearance with diethylene triamine pentaacetic acid (DTPA) renal scan GFR.MethodsThis cross-sectional study was done at the Department of Nephro Urology Dialysis & Renal Transplantation, Bahawal Victoria Hospital, Quaid e Azam Medical College, Bahawalpur, Pakistan from September 2018 to September 2021. A total of 92 potential healthy live-related kidney donors of both genders, aged 18 to 60 years having body mass index below 35 kg/m2 were included. GFR was calculated with modification of diet in renal disease (MDRD), Cockcroft-Gault (CG), chronic kidney disease epidemiology (CKD-EPI) equations as well as by 24-hour urine creatinine clearance. DTPA renal scan was done to record GFR findings. GFR was compared using analysis of variance (ANOVA) among different methods.ResultsOut of a total of 92 individuals, 49 (53.3%) were male and 43 (46.7%) female. Mean age and BMI were noted to be 34.62±10.57 years and 24.40±2.71 kg/m2, respectively. Statistically significant differences existed between various methods of GFR estimation (p<0.001). Mean GFR as per DTPA renal scan findings was noted to be 97.32±9.39 ml/min/1.73 m2. Difference of 31.48±20.81, 27.37±21.1, 23.38±6.38, 15.52±37.52 was noted in estimated GFR (ml/min/1.73 m2) with CG formula, MDRD formula, EPI-CKD formula and 24-hour urine creatinine clearance respectively when compared with DTPA renal scan findings. The highest proportion of patients was seen with normal GFR with DTPA renal scan findings as 83 (90.2%) individuals while 24-hour urine creatinine clearance observed these to be 59 (64.1%), CG EPI-CKD formula 44 (47.8%), MDRD formula 39 (42.4%) and 40 (43.5%) with CG formula.ConclusionNone of the GFR estimation methods resulted in similar findings. With reference to the DTPA renal scan, 24-hour urine creatinine clearance was the closest GFR estimation followed by CKD-EPI and MDRD equations.

Transient minimal hydronephrosis on contralateral kidney in infants with unilateral hydronephrosis: Is it an early sign of worsening of the affected kidney?

Background/aim The criteria for surgical management of ureteropelvic junction obstruction are not well-defined, and there is a risk for loss of renal function before the operation. In this context, certain changes in contralateral kidney had been investigated in order to increase the sensitivity of diagnosis. In this study, we aimed to investigate whether contralateral transient minimal hydronephrosis (CTMH) can be considered as an “early alarm” sign for worsening of the affected kidney in infants with hydronephrosis.Materials and methods A total of 182 infants (92 surgically treated and 90 conservatively followed-up) with unilateral hydronephrosis were retrospectively analyzed. Ultrasonography and renal scan findings were evaluated. Correlation between the appearance of CTMH, contralateral compensatory hypertrophy (CCH) on ultrasonography, and prognosis of the affected kidney were evaluated.ResultsAmong the surgically treated patients, 18 (19.6%) patients developed CTMH on average 7 months (0–13 months) before surgery. Among these 18 patients with CTMH, 12 patients (66.6%) had loss of renal function preoperatively, while this ratio was 29.7% on their counterparts (p = 0049). CCH was observed in 31 (33.7%) individuals in surgically treated patient group including all 18 patients with CTMH, while none of the conservatively followed-up patients developed CCH and/or CTMH. In the multiple logistic regression analysis, among the variables investigated, CTMH was found as an independent predictor of the deterioration in the affected kidney and of the poor prognosis (p = 0.011 and p = 0.0004, respectively).Conclusion In our study, among the variables investigated, CTMH was found as an independent predictor of the deterioration in the affected kidney and poor prognosis in infants followed-up with isolated unilateral hydronephrosis. Additionally, CTMH can be considered as an “early alarm” sign for worsening of the affected kidney and the need for surgical intervention.

Abnormal DMSA renal scan findings and associated factors in older children with vesicoureteral reflux.

There are scanty data on the rate of abnormal Tc-99m dimercaptosuccinic acid (DMSA) renal scintigraphy and associated factors in children older than 5years with diagnosis of VUR. We do not have knowledge about which older children should undergo DMSA after VUR diagnosis. This study aims to assess the rate of abnormal DMSA findings and associated factors in children older than 5years of age diagnosed with VUR. We retrospectively reviewed the medical records of 258 children with VUR diagnosed at or older than 5year age. 179 children [42 (23.5%) males and 137 (76.5%) females] with complete data were included. 268 reflux units were compared according to gender, bilaterality, grade, reflux phase at voiding cystourethrography, febrile urinary tract infection (fUTI), lower urinary tract dysfunction (LUTD), and DMSA findings with uni- and multivariate analysis. The median age was 110 (60-216) months. VUR grades were I, II, and III in 197 (73.6%) units and IV-V in 71 (26.4%). 138 (51.5%) renal units had abnormal DMSA. VUR grade (p < 0.01), unilaterality (p = 0.048), and fUTI (p = 0.031) in univariate but only grade and unilaterality in multivariate analysis are significantly associated with abnormal DMSA. Although reflux at filling phase was predominant in high-grade VUR group, reflux at voiding phase (p = 0.006) in low-medium-grade (1-3) VUR was associated with abnormal DMSA. Children older than 5years of age diagnosed with VUR should be regarded as a high-risk group for abnormal DMSA regardless of gender, unilaterality, grade, reflux phase, fUTI, and LUTD.

Deceased vs. living donor kidney transplantation in prediction of acute renal allograft rejection using Tc-99m DTPA renal scan

No data are available regarding different prognostic values of Tc-99m diethylenetriaminepentaacetic acid (DTPA) renal scan in kidney transplantation (KT) recipients according to two distinct donor types: deceased donor KT (DDKT) and living donor KT (LDKT). We evaluated whether the interpretation of Tc-99m DTPA renal scan should be different by the donor type in predicting acute renal allograft rejection (AR). One hundred and seven KT recipients (61 DDKT and 46 LDKT) were included in this study. Tc-99m DTPA renal scan was performed 1week after KT. AR was defined as pathological evidence of renal allograft rejection during the first 6months of KT. Clinical factors and Tc-99m DTPA renal scan findings were compared between patients with and without AR. To further analyze the effect of the donor type, they were again compared within DDKT and LDKT recipients, respectively. AR occurred in 15 patients (7 DDKT and 8 LDKT recipients). Among all patients, time to peak uptake (TTP) of the cortex (TTPCX) measured by Tc-99m DTPA renal scan was independently predictive of AR. Moreover, TTPKD (TTP of the whole transplanted kidney) and TTPCX were the only predictors of AR among DDKT recipients. The most accurate predictors were TTPCX and kidney area on renal scan for DDKT and LDKT, respectively. However, these parameters could not predict AR for the opposite donor type. AR could be effectively predicted by Tc-99m DTPA renal scan obtained at 1week post-KT. Different parameters should be applied according to the donor type in the prediction of AR.

Antenatal hydronephrosis: outcomes a decade later in a regional cohort

Antenatal hydronephrosis is seen in up to 5% of pregnancies and may be due to structural anomalies in the urinary tract. The aim of the study was to look at how children born with antenatally diagnosed in 2007 have fared ten years on. A retrospective cohort study was done on all children born in 2007 with antenatally diagnosed Hydronephrosis using the SFU grading. The status of this cohort in 2017 was studied. The collected data included clinical characteristics including gender, diagnosis, gestation, signs, febrile UTIs, serum creatinine, surgical procedures and complications if any. Post natal imaging e.g. renal ultrasound, VCUG, renal scan findings were noted. The status of the Hydronephrosis in 2017 was recorded with regards to resolution. 110 (82 males) children with antenatally diagnosed hydronephrosis were born in 2007. Sixty-one of these children had unilateral hydronephrosis. Seventy of these children did not get a specific diagnosis at birth. Pelviureteric junction obstruction (n=15) was the commonest diagnosis. No intervention was needed in 72 children. Twenty-five children (25/38) required intervention within 6 months of birth. Renal scarring was seen more commonly in children with vesico-ureteric reflux and posterior urethral valves. Surgical interventions were most commonly done in children with an obstructive lesion in the urinary tract (31/33). Sixty-one children had complete resolution of their hydronephrosis (46 had no intervention). Seven children continue to have worsening of Hydronephrosis. Antenatal hydronephrosis well investigated and managed appropriately in the post natal period along with regular and good surveillance leads to good long term outcomes in a majority.

Assessment of Agreement between 99mTc-DMSA Renal Scan and Ultrasonography in the Evaluation of Renal Pathology in Children with Recurrent urinary tract infection

Imaging of urinary tract plays a very important role in children with recurrent urinary tract infection (UTI). Various imaging techniques are used and the imaging protocol in children with UTI continues to be a subject of debate. Most authors recommended combination of imaging. The children with recurrent urine infection may be at increased risk of renal parenchymal scarring, hypertension, impaired renal function and end stage renal disease. But early diagnosis and timely proper treatment has an excellent prognosis. 99m-Tc-dimercaptosuccinic acid (DMSA) renal scan and Ultrasonography (US) are routinely performed studies in children with recurrent UTI. If there is agreement between these two investigation procedures, they will be interchangeable, which will benefit the patient by one procedure instead of two. This will be less time consuming and cost effective. This analytical study was carried out at the National Institute of Nuclear Medicine and Allied Sciences (NINMAS), Bangabandhu Sheikh Mujib Medical University campus, Dhaka, from July 2013 to June 2014, for a period of 12 months. The objective of this study was to assess the agreement between 99mTcdimercaptosuccinic acid (DMSA) renal scan and Ultrasonography (US) US for evaluating the renal size, renal position, pelvicalyceal dilatation, hydronephrosis and renal scarring in children with recurrent UTI. Study population consisted of 85 children with age range of 6 months to 12 years, who had laboratory evidence of at least two incidence of UTI within 6 months period. All children underwent 99mTc-DMSA renal scan (plannar) and renal tract ultrasonography (US). Among 85 children, 26 (30.6%) had normal DMSA scan and 59 (69.4%) had abnormal DMSA scan findings. In case of US, 23 (27.1%) had normal US findings and 62 (72.9%) had abnormal US findings of renal system. The comparison of DMSA renal scan and US findings were done by Kappa analysis to see their agreement in the evaluation of size, position, pelvicalyceal dilatation and hydronephrosis. This study gave an impression that DMSA scan and US has good agreement in the evaluation of renal size, position of the kidney and fair agreement in the evaluation of presence of hydronephrosis. In case of mild pelvicaliceal dilatation evaluation, DMSA was underestimated comparing to US.The overall accuracy of US for the evaluation of focal scarring of right and left kidney were 89.4% and 78.8% respectively. For the evaluation of diffuse scarring the overall accuracy of US were 92.9% and 97.6% for the right and left kidney respectively. Therefore, in the evaluation of renal scarring the accuracy of US was underestimated by using DMSA scan as a gold standard. In the evaluation of kidney size, position and presence of hydronephrosis, both DMSA and US can be interchangeable. Whereas DMSA was underestimated comparing to US in the evaluation of mild pelvicaliceal dilatation. On the other hand DMSA renal scan is more sensitive and specific for detecting cortical scaring compared to the US. In light of present study, both DMSA scan and US are recommended in the combination for complete evaluation of renal abnormalities in recurrent UTI. Bangladesh J. Nuclear Med. 18(1): 32-38, January 2015

MP55-01 CONTEMPORARY PRACTICE PATTERNS IN VOIDING CYSTOURETHROGRAM (VCUG) USE: THE IMPACT OF EVIDENCE-BASED GUIDELINES

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-01 CONTEMPORARY PRACTICE PATTERNS IN VOIDING CYSTOURETHROGRAM (VCUG) USE: THE IMPACT OF EVIDENCE-BASED GUIDELINES Linda Lee, Armando Lorenzo, Rakan Odeh, Paul Bowlin, Jeffrey Traubici, and Martin Koyle Linda LeeLinda Lee More articles by this author , Armando LorenzoArmando Lorenzo More articles by this author , Rakan OdehRakan Odeh More articles by this author , Paul BowlinPaul Bowlin More articles by this author , Jeffrey TraubiciJeffrey Traubici More articles by this author , and Martin KoyleMartin Koyle More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.592AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES While VCUG is a widely accepted test, it is invasive and associated with radiation exposure. Most cases of VUR are low-grade and unlikely to be associated with acquired renal scarring. In an effort to select patients at greatest risk, the American Academy of Pediatrics (AAP) published revised guidelines on urinary tract infections in children ages 2 to 24 months in 2011. In this project, we examine contemporary practice patterns and indications for VCUG, in the context of newer evidence-based guidelines. We hypothesize that the rate of VCUGs has declined over time, which may be geared towards detection of more clinically significant VUR. METHODS All VCUGs performed at our institution from 2008 to present were identified. Follow-up VCUGs were excluded. Further data collection was performed for patients whom had a VCUG in the first six months of 2009 and 2014, in order to obtain representative data before and after publication of the 2011 AAP guidelines. Medical records for these patients were retrospectively reviewed for baseline patient characteristics, indication for VCUG, type of ordering physician, prior history of febrile UTIs, renal and bladder ultrasound and renal scan findings. RESULTS From January 2008 to August 2014, a total of 8214 VCUGs were performed at our institution. The annual number of VCUGs has declined steadily over time. We then compared the 6-month periods from January to June (inclusive) in 2009 and 2014, which identified 634 and 292 VCUGs, respectively. There were no statistically significant differences in mean age or gender between both groups. Although there was a decline in VCUGs in 2014, the rate of VCUGs performed for UTIs remained the same (65% in 2009 and 64% in 2014, p=0.88). In both groups, pediatric urologists comprised the minority of ordering physicians (14% in 2009 and 16% in 2014, p=0.48). While there is no statistically significant difference in detection rate of VUR from 2009 to 2014 (31% vs. 37%, p=0.07), there has been a three-fold increase in diagnosis of high grade (IV-V) VUR in 2014, compared to 2009 (10.2% vs 3.2%, p=0.0001). CONCLUSIONS There has been an overall trend towards fewer VCUGS being performed at our institution, even prior to the 2011 AAP guidelines. While the majority of VUR cases detected remain low-grade, there has been a higher detection rate of high-grade (IV-V) VUR in 2014, compared to 2009. This may be a reflection of changing practice patterns of ordering physicians. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e735 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Linda Lee More articles by this author Armando Lorenzo More articles by this author Rakan Odeh More articles by this author Paul Bowlin More articles by this author Jeffrey Traubici More articles by this author Martin Koyle More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic-assisted Laparoscopic Pyeloplasty: Analysis of Symptomatic Patients With Equivocal Renal Scans

To review the objective and subjective success rates of robotic-assisted laparoscopic pyeloplasty in symptomatic patients with radiographic findings suggestive of uretero-pelvic junction obstruction (UPJO), but equivocal renal scans (diuretic T1/2 <20 minutes). We reviewed 77 patients with symptomatic UPJO, who underwent robotic-assisted laparoscopic pyeloplasty between August 2006 and March 2013. We grouped patients by renal scan findings into 1 of 2 groups, obstructed (diuretic T1/2 ≥20 minutes) or equivocal (diuretic T1/2 <20 minutes). All patients were symptomatic and had radiographic findings suggestive of UPJO (eg hydronephrosis). Mean age was 40.7 years (range 17-80) with 70% female. UPJO occurred 44% left and 56% right, with 92% presenting with flank pain. Of 77 patients, 45 had obstruction on renal scan, with 41 (91%) having resolution of obstruction postoperatively and 44 of 45 (98%) having complete resolution of their initial symptoms. Thirty-two patients had equivocal findings with mean diuretic T1/2 of 12.6 minutes (range: 5.5-19.26) on renal scan. In this latter group, patients had significantly less of a decrease in their diuretic T1/2 postoperatively (4 vs 64 minutes, P = .018) and reported less pain resolution (53% vs 98%, P ≤.001) than group 1. Many studies have demonstrated excellent success of pyeloplasty, with most series including patients meeting strict diagnostic criteria for obstruction. Our study examines outcomes in patients with clinically symptomatic UPJO and equivocal diuretic renography. In our cohort, equivocal patients were significantly less likely to have subjective resolution of symptoms than patients in the obstructed group.

Association of Renal and Bladder Ultrasonography Findings with Urinary Tract Infection Recurrence, High-Grade Vesicoureteral Reflux, and Renal Scarring

Introduction: This study investigated whether renal and bladder ultrasonography (RBUS) findings performed in children with the first incidence of febrile urinary tract infection (UTI) can predict UTI recurrence, high-grade vesicoureteral reflux (high-grade VUR), or acquired renal scarring (aRS). Methods: In all, 917 children who were admitted to our hospital from January 2001 to October 2010, owing to the first incidence of febrile UTI were enrolled in this study. All children underwent RBUS during admission. The mean follow-up was 7.9 months (standard deviation [SD]±13.3). UTI recurrence rates were calculated according to various clinical parameters. By using bivariate and multiple logistic regression analyses, we determined whether age, sex, abnormal RBUS findings, abnormal dimercaptosuccinic acid renal scan findings, or RBUS findings parameters were predictive of UTI recurrence, high-grade VUR, or aRS. Results: On RBUS, hydronephrosis and congenital anomaly of the kidney and urinary tract significantly predicted UTI recurrence. A small kidney, hydroureter, hydronephrosis, cortical thinning, and increased parenchymal echogenicity significantly predicted high-grade VUR. However, their odds ratios (OR) are low compared to normal RBUS findings (recurrent UTI: OR 0.432 and 0.354 vs. 0.934, respectively, high-grade VUR: .019, 0.329, 0.126, 0.058, and 0.188 vs. 2.082, respectively). No RBUS findings significantly predicted aRS. Recurrent UTI, high-grade VUR, and abnormal RBUS findings significantly predicted aRS (OR of 4.80, 4.61, and 2.58, respectively). Conclusion: RBUS is necessary to exclude severe congenital renal scarring, obstructive uropathy, and renal abscess at the first incidence of febrile UTI and is helpful in determining the need for subsequent clinical imaging. Key words: Renal sonogram; Urinary tract infection recurrence; High-grade vesicoureteral reflux; Acquired renal scarring

99mTc-DMSA renal scan and 99mTc-DTPA renography findings in patients with horseshoe kidneys: experience of a single institute

Purpose: Horseshoe kidney is a congenital malformation that is found incidentally in many of the asymptomatic patients undergoing 99mTc- DTPA renography and 99mTc-dimercaptosuccinic acid (DMSA) renal scans in the nuclear nephrology division of National Institute of Nuclear Medicine &amp; Allied Sciences (NINMAS). Scan findings of year 2012 and 2013 are demonstrated in this study. Methods: Few of the patients had known ultrasound reports of ectopic positioned or non-visualized kidney and mostly referred to our institute for 99mTc-DTPA renogram. Each diuretic renogram consisted of dynamic renal scan images obtained with camera in both anterior and posterior positions and15% window centered at 140 keV using 64 X 64matrix. Acquisition started with bolus injection of 99mTc-DTPA and dynamic images were acquired at 16-seconds/ frame for 75 frames. Intravenous injection of furosemide (1 mg / kg body weight) was given between 10-15 minutes of the study. They each underwent a 99mTc-DMSA renal cortical scan to confirm the horseshoe kidney. Results: In a 2-year period, 14 patients (5 children and 9 adults) with horseshoe kidney were found with age ranging from 6 to 43 yrs (mean + SD,23.93 ± 9.19) and a male to female ratio of 9:5.Nearly one third of patients (35.8%) were asymptomatic. Urinary tract infections or infection like symptoms were present in five (35.8 %), whereas few showed vague symptoms like flank pain (7.1 %), abdominal pain (7.1 %), gastrointestinal symptoms such as nausea (7.1 %), abdominal distension and fullness (7.1 %). Three kidneys (21.42 %) showed stasis of radioactive urine in the renal pelvic region prior to diuretic injection, suggesting functional obstruction. Only one kidney (7.17 %) showed frank unilateral hydronephrosis and 2(14.28%) showed obstructive nephropathy. There was no incidence of bilateral hydronephrosis. Gross parenchymal disease was seen in 2 (14.28%) and mild parenchymal insufficiency in 4 (28.57%). In 2 (14.28%) cases normal renal function with low GFR were observed. 35.71% patients show horseshoe kidneys with normal function and GFR with variation of sizes of two distinct kidneys. Of the 14 patients, asymmetrical renal cortical function between the two kidneys was found in10 (71.4%). Conclusion: 99mTc-DMSA renal scan and diuretic renogram with 99mTc-DTPA are the simple techniques for the assessment of the patency of horseshoe shaped kidneys, because they can evaluate functional anatomy and urodynamics. DOI: http://dx.doi.org/10.3329/bjnm.v17i1.22488 Bangladesh J. Nuclear Med. 17(1): 25-29, January 2014

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

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

English

Ureteropelvic junction obstruction is a condition in which blockage occurs at the junction where the ureter attaches to the renal pelvis, resulting in decreased flow of urine down the ureter and an increase of fluid pressure inside the kidney. Our study included 52 children from 3rd day of life to 14 years presenting at a tertiary care pediatric hospital with UPJO from May 2006 to April 2013.The presenting features, ultra sonographic findings, operative findings, intrinsic causes, renal isotope scan findings, and histological features, special stains were analyzed. We found that UPJO in pediatric age group is mainly due to intrinsic abnormalities i.e., fibrosis, excessive collagen fibers around the hypertrophied muscle bundles. Severity depends on extent of obstruction, so early correction by pyeloplasty improves morbidity

614 VUR INDEX (VURX): A NOVEL TOOL TO PREDICT VESICOURETERAL REFLUX (VUR) RESOLUTION BASED ON THE FIRST VCUG IN CHILDREN LESS THAN TWO YEARS OF AGE

You have accessJournal of UrologyPediatrics: Imaging (Genital & Urinary Tract)/Infections and Vesicoureteral Reflux1 Apr 2012614 VUR INDEX (VURX): A NOVEL TOOL TO PREDICT VESICOURETERAL REFLUX (VUR) RESOLUTION BASED ON THE FIRST VCUG IN CHILDREN LESS THAN TWO YEARS OF AGE Arun Srinivasan, Lindsay Herrel, Edwin Smith, Jane Share, David Blews, Hal Scherz, and Andrew Kirsch Arun SrinivasanArun Srinivasan Atlanta, GA More articles by this author , Lindsay HerrelLindsay Herrel Atlanta, GA More articles by this author , Edwin SmithEdwin Smith Atlanta, GA More articles by this author , Jane ShareJane Share Atlanta, GA More articles by this author , David BlewsDavid Blews Atlanta, GA More articles by this author , Hal ScherzHal Scherz Atlanta, GA More articles by this author , and Andrew KirschAndrew Kirsch Atlanta, GA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.692AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The usefulness of International Reflux Grading System is limited by evidence based on small sample sizes, poor inter-observer concordance, and poor predictive values for moderate grade VUR. We aim to provide an indexing tool to more reliably predict resolution rates by improving concordance rates among physicians and improve our ability to predict VUR resolution based on the first VCUG. METHODS We identified all patients aged < 2 years diagnosed with VUR between 2006-2010. We excluded patients with secondary VUR, ureteroceles, and megaureters. Patient age, indication for VCUG, ultrasound and renal scan findings as available, gender, anomalies, follow up data and eventual outcomes were collected. Two blinded radiologists reviewed the VCUGs and recorded the phase of VCUG when reflux (timing of reflux) was first noted. We categorized timing of reflux as early filling, end filling and voiding phase. Univariate and multivariate analysis was performed to identify factors that best predict VUR resolution. A Multilayer Perceptron neural network model was used to construct the VUR index (VURx) with normalized importance for each variable. The VURx was then validated by ROC and Kaplan-Meier curves. RESULTS 229 patients fit our patient criteria. 75% of the VCUGs were performed for UTI at a mean age of 0.42 years. By multivariate logistic regression analysis, absence of high grade reflux (OR 5.53), absence of anomalies (OR3.54) and timing of reflux (OR5.37) were found to be predictors of spontaneous resolution. The neural network model found the same variables to be predictive of reflux resolution with high normalized importance. A VURx was constructed using these three variables with a minimum value of 1 signifying a high resolution rate (92.3%) and maximum value of 5 signifying low rate of resolution (8.3%). This model was tested using resolution graphs (p<0.05), ROC curves (AUC 0.82) and Kaplan-Meier curves (p<0.05) all signifying high correlation. CONCLUSIONS VUR index – a score based on presence of high grade reflux, anomalies and timing of VUR is highly predictive of spontaneous resolution in children aged < 2 years. Patients with a low VURx may not require further studies by virtue of their high resolution rate while those with high VURx may be better served by earlier intervention. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e250 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arun Srinivasan Atlanta, GA More articles by this author Lindsay Herrel Atlanta, GA More articles by this author Edwin Smith Atlanta, GA More articles by this author Jane Share Atlanta, GA More articles by this author David Blews Atlanta, GA More articles by this author Hal Scherz Atlanta, GA More articles by this author Andrew Kirsch Atlanta, GA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Editorial Comment

Pediatric urologists, much as Christopher Marlowe's Dr. Faustus, have discovered to their chagrin that knowledge does not necessarily bring happiness. Advances in ultrasonography have allowed for the prenatal detection of hydronephrosis in infants who were not yet, or might never become, symptomatic. Similarly, imaging of other conditions has led to the incidental discovery of otherwise asymptomatic hydronephrosis. We have come to the realization that we cannot be sure when an “obstruction” is really an “obstruction” and that hydronephrosis does not necessarily require surgery. This report offers insights into this matter and helps to clarify the observation process; especially important in cases of antenatally discovered hydronephrosis. A prolonged drainage half-time on diuretic nuclear renal scans importantly does not necessarily predict progression to surgery, and no overall difference was found between the groups in the changes of renal function. It is not clear whether the difference observed by the authors when comparing the operative and nonoperative groups with differences in function was clinically significant. With an acknowledged 5.5%-6.5% variability, even if the largest difference before and after operation (8.4% in group 1) were used that leaves only a 1.9%-2.9% true effect. Is that clinically meaningful? Operative Versus Nonoperative Management of Ureteropelvic Junction Obstruction in ChildrenUrologyVol. 73Issue 3PreviewTo describe and validate our strategy for treating patients with ureteropelvic junction obstruction operatively or nonoperatively according to ultrasonography and nuclear renal scan findings. Full-Text PDF

Operative Versus Nonoperative Management of Ureteropelvic Junction Obstruction in Children

To describe and validate our strategy for treating patients with ureteropelvic junction obstruction operatively or nonoperatively according to ultrasonography and nuclear renal scan findings. A retrospective analysis of 243 patients from 1999 to 2006 with grade 3-4 hydronephrosis was performed. Depending on the grade of hydronephrosis with parenchymal thinning on ultrasonography and renal function on the nuclear renal scan, patients were treated with immediate pyeloplasty, pyeloplasty after a period of observation, or observation only. Of 243 patients, 116 were found to have UPJO as determined by a half-life >20 minutes. The mean follow-up was 24.0 months (range 3-69). Immediate pyeloplasty was performed in 32 children, and 84 were treated conservatively. Crossover from observation to surgery occurred in 47 children. In the immediate pyeloplasty group, the mean pre- and postoperative differential function was 30.4% and 38.8%, respectively (P < .0001). In the observation-only group (n = 37), the initial mean renal function was 41.4% and stayed stable throughout the follow-up period, at a mean of 43.2% (P = .2764). In the delayed pyeloplasty group (n = 47), the initial mean renal function was 35.9% and increased to a mean of 41.6% after intervention (P = .0003). The median improvement of hydronephrosis on ultrasonography for those who underwent immediate surgery from before to after the intervention was from grade 4 to grade 3 (P < .0001). For those not undergoing surgery, it improved from grade 4 to grade 2.25 (P = .0026) and for those who underwent delayed surgery, from grade 4 to 3 (P = .0003). According to our findings, the serial ultrasonography findings and initial renal function on nuclear renal scan are better indicators than the half-life alone for determining whether pyeloplasty is indicated.

POS-02.80: Diuresis renography for differentiation of upper urinary tract dilatation from obstruction: F+20 and F-15 methods

The aim of this study was to evaluate diuresis renography with an intravenous injection of furosemide 20 minutes after administering the radiopharmaceutical (F+20 protocol) or 15 minutes before (F-15 protocol) in patients with upper urinary tract dilatation.Twenty-one patients with pyelocaliceal system dilatation, but not ureteral dilatation, on ultrasonography were evaluated. The patients underwent diuresis renography using the F+20 and F-15 protocols. Renal scan findings and kidney split function were recorded. Then, the patients underwent surgical or conservative treatment according to their clinical conditions and imaging results. Follow-up was done 3 and 6 months postoperatively by physical examination, intravenous urography, and diuresis renography.Eleven patients (52.4%) had complete obstruction in both protocols of renography, and 5 (23.8%) had an equivocal result in the F+20 and an obstructive pattern in the F-15. These patients underwent surgical operation. In 3 patients (14.3%), both protocols demonstrated a normal urinary tract. In 2 patients (9.5%), a nonobstructive response in the F+20 and an equivocal result in the F-15 were seen. One of them underwent surgical operation because of impaired kidney function during the follow-up and 1 was treated conservatively. Overall, obstruction was found in 16 out of 21 patients (76.2%) by the F-15 protocol, while it was found in 11 (52.4%) by the F+20 protocol (P=.01). The mean kidney split function was 55.15% +/- 7.82% and 54.81% +/- 6.87% in F+20 and F-15 protocols, respectively (P=.45).Using the F-15 protocol may reduce the equivocal results of the F+20 for diuresis renography.

Renal Allograft Venous Thrombosis Is Salvageable

Background Renal vein thrombosis (RVT) is an uncommon but serious complication. It usually occurs early after surgery. While compression of the renal vein is the most common cause, early rejection and hemostatic defects are other known causes. The symptoms are nonspecific and diagnosis is often delayed. Ultrasonography and renal isotope scan findings may resemble acute rejection or acute tubular necrosis. Patients and Methods We retrospectively reviewed the records of 684 recipients who were transplated between November 1993 and May 2006. The diagnosis of RVT was suspected by an unexplained drop in urine output, rise in serum creatinine, or hematuria, and confirmed by Doppler ultrasound and isotope scanning. Urgent exploration was performed in all suspected cases. Results Seven incidences of biopsy-proven RVT were encountered, including 3 associated with hematoma and 1 with rejection. Four grafts were from cadaveric donors. Three grafts were salvaged. Conclusions The incidence of RVT in the present series was 1%. All cases developed in the first 2 weeks after transplantation. It was more common in adults, in female recipients, and in cadaveric grafts. Early diagnosis and intervention were the keys to salvage.

Acute pyelonephritis and renal scarring in Kuwaiti children: a follow-up study using 99mTc DMSA renal scintigraphy

The aim of this study was to determine the prevalence of renal scarring in a group of Kuwaiti Arab children with their first documented acute pyelonephritis (APN). Eighty-two Kuwaiti Arab children (10 males and 72 females) who had abnormal (99m)Tc DMSA renal scan findings of acute pyelonephritis were prospectively studied with the same imaging modality 6 months after treatment to identify those who developed renal scarring. A micturition cystourethrogram (MCUG) was performed for all of the children 1 month after diagnosis. Children were divided into 3 age groups (<2 years, 2-5 years and above 5 years). The follow-up DMSA renal scans 6 months after diagnosis revealed normalization of renal changes in 56% (46 patients), much improvement with residual renal abnormality in 6% (5 patients), and persistent parenchymal defects in 38% (31 patients). Vesicoureteric reflux (VUR) was found in 32% of children (26/82) and the majority were between grade I and III. Thirteen of those with VUR (50%) developed renal scars on follow-up. Fifty-three percent of the scarred kidneys (19/36) were drained by non-refluxing ureters. In this study, children older than 2 years had less VUR yet were more susceptible to APN and to the development of renal scars. Girls were more prone to developing APN and renal scarring than boys. This work shows that APN is a serious cause for renal scarring in our patients, particularly if associated with other risk factors such as recurrent infections and the female sex.