Vesicoureteral reflux in young patients: Comparison of voiding color Doppler US with echo enhancement versus voiding cystourethrography for diagnosis or exclusion

We assessed the accuracy of voiding color Doppler ultrasonography (US) with echo enhancement for diagnosis or exclusion of vesicoureteral reflux (VUR) versus voiding cystourethrography (VCUG) and evaluated patient tolerance of the echo-enhancing agent. One hundred twenty-two patients (ages range, 1 month to 17 years) with 244 ureterorenal units underwent voiding color Doppler US with echo enhancement, which was followed by VCUG on the same day. After US of the urinary tract, the bladder was filled with saline solution via catheter. Then an echo-enhancing agent was instilled, and color Doppler US was performed. Reflux was diagnosed when microbubbles appeared in the ureter or the pelvicaliceal system. VUR was detected in 98 units. All grades of reflux were identified. In 13 units (13.3%), grade I reflux diagnosed at voiding color Doppler US was not observed at VCUG. No reflux was detected in 146 units by either method. In 231 (94.2%) of the 244 ureterorenal units, there was concordance between the two methods. The echo-enhancing agent was well tolerated by all patients. Voiding color Doppler US with echo enhancement is useful for the diagnosis or exclusion of VUR, being as good as VCUG. Therefore, it may reduce the number of patients exposed to ionizing radiation.     

Evaluating the accuracy of simplified VCUG in comparison with traditional VCUG for diagnosis of urinary-reflux in children: Radiation dose reduction

IntroductionVoiding cystourethrogram (VCUG) is an imaging technique for diagnosing urinary-reflux. VCUG requires X-ray exposure, increasing the risk of malignancies induced by ionizing radiation, especially in children. Considering the importance of early diagnosis of urinary-reflux using VCUG to prevent kidney complications and the significance of reducing the radiation dose during this imaging, this study intends to reduce the imaging views of VCUG and evaluate the urinary-reflux, using a reduced number of images.Material and methodsChildren referred to a University hospital who underwent VCUG participated in this study. The routine VCUG procedure contained five images. Two images of full-bladder and post-void of each patient were considered a simplified procedure and were evaluated by two radiologists to determine reflux and its grade. The sensitivity and specificity of simplified VCUG were determined.Results182 patients with a mean age of 5.36±4.95 years old participated in this study. There were 90% and 82% agreement between routine and simplified VCUG results in the left and right kidneys. The simplified VCUG had 87.2% and 100% sensitivity and specificity in detecting the left-side reflux, 83 .9% and 100%, to detect the right-side reflux.ConclusionThe results showed that using two images instead of five can effectively diagnose and grade urinary-reflux. The simplified VCUG had a relatively good and acceptable agreement in comparison to the routine cystourethrogram. It can effectively reduce the patient's radiation dose, especially in patients who need to perform serial bladder imaging for follow-up after operation.     

Three‐Dimensional Ultrasonography‐Based Virtual Cystoscopy of the Pediatric Urinary Bladder

Objective. The purpose of this study was to validate the feasibility and potential of 3‐dimensional ultrasonography (3DUS)‐based virtual cystoscopy in the pediatric urinary bladder. Methods. Twenty patients (age range, newborn–14 years) underwent urinary tract ultrasonography and 3DUS of the urinary bladder. From this data set, virtual cystoscopy was reconstructed for visualization of the inner bladder surface. Three‐dimensional ultrasonography was compared with 2‐dimensional ultrasonographic (2DUS) findings, voiding cystourethrography (VCUG) results, and reports from cystoscopy or surgery when available. Results. Three‐dimensional ultrasonography was feasible in all patients. Data quality was sufficient for virtual cystoscopy without major motion artifacts. The 3DUS results matched all other findings; particularly, 3DUS superiorly visualized the ureteral ostium and the bladder neck configuration; in 5 patients, 3DUS depicted pathologically shaped ostia not detected by 2DUS. This correlated with the presence of vesicoureteral reflux on VCUG. Performing virtual cystoscopy added 1 minute to the investigation time (range, 0.5–2 minutes) and 3 minutes for postprocessing and viewing (range, 2–5 minutes). Conclusions. Three‐dimensional ultrasonography‐based virtual cystoscopy is feasible in the pediatric urinary bladder without sedation. It reveals surface information not accessible by 2DUS, improving detection of pathologic conditions such as atypically shaped ureteral ostia. Three‐dimensional ultrasonography‐based cystoscopy may become a valuable adjunct to 2DUS of the pediatric urinary tract, improving selection criteria for further imaging such as VCUG, and potentially may help reduce the need for endoscopic cystoscopy. However, these preliminary results still have to be confirmed in prospective studies with larger patient numbers.     

Sonographic diagnosis of urethral anomalies in infants: value of perineal sonography.

OBJECTIVE: To assess the value of urethral sonography including a perineal approach in evaluating urethral anomalies in infants. METHODS: A radiology database review identified 88 patients (mean age +/- SD, 64 +/- 84 days) who underwent voiding cystourethrography (VCUG) and urethral sonography as part of extended sonography of the urinary tract. Sonographic and VCUG images and reports were reviewed to assess agreement between both modalities for detection of urethral anomalies. RESULTS: Sonography facilitated the correct diagnosis of all 3 posterior urethral valves. The only urethral diverticulum, the only ectopic ureteric insertion into the urethra, the only urogenital sinus, and the only urethrovaginal fistula were also shown on sonography. In 73 (94%) of 78 cases, sonography correctly showed the absence of anomalies. In 5 infants, sonography could not reliably assess the urethra and showed indirect signs of urethral anomalies; however, these patients had normal urethras on VCUG. CONCLUSIONS: Our data show that sonography of the urethra is a valuable tool for diagnosis of urethral anomalies. Especially, negative findings on sonography are highly suggestive of the absence of urethral anomalies. Positive or equivocal sonographic findings should indicate VCUG.     

Contrast-enhanced gray-scale and color Doppler voiding urosonography versus voiding cystourethrography in the diagnosis and grading of vesicoureteral reflux.

PURPOSE: The purpose of this study was to compare contrast-enhanced gray-scale voiding urosonography (CE-VUS) and contrast-enhanced color Doppler voiding urosonography (CE-CDVUS) with voiding cystourethrography (VCUG) to verify whether the use of color Doppler imaging improves the diagnosis and grading of vesicoureteral reflux (VUR). METHODS: In 74 patients, CE-VUS and CE-CDVUS were compared with VCUG, which was used as the gold standard. SHU 508 A (Levovist) was used as the echo-enhancing contrast agent. VUR was diagnosed if hyperechoic dots or color signals were visualized in the ureter on sonograms. VUR grading was based on morphologic and dynamic findings on CE-VUS and morphologic and color findings on CE-CDVUS. VCUG was performed conventionally, and grading by VCUG was in accordance with the international system of radiographic VUR grading. Patients who voided during 1 examination only (either CE-VUS and CE-CDVUS or VCUG) were excluded from the study. Agreement between the results of CE-VUS and VCUG and between those of CE-CDVUS and VCUG in diagnosing VUR was calculated by kappa statistics. CE-VUS and CE-CDVUS were compared for diagnostic accuracy by the McNemar test. RESULTS: The agreement between CE-VUS and VCUG in predicting VUR was 90% (kappa score, 0.77; p < 0.001). The agreement between CE-CDVUS and VCUG was 96% (kappa score, 0.91; p < 0.001). CE-CDVUS showed a significantly higher diagnostic accuracy than did CE-VUS (96% versus 90% of cases correctly classified; McNemar chi2 = 4; p < 0.05). This was mainly related to the lower number of false-negative results for grade I and grade II VUR when CE-CDVUS was used. CONCLUSIONS: The use of color Doppler imaging significantly improves the accuracy of contrast voiding urosonography in the detection and grading of VUR.     

Compound versus fundamental imaging in the detection of subdermal contraceptive implants.

OBJECTIVE: The purpose of this study was to compare the use of fundamental versus compound sonographic imaging in the localization of nonpalpable subdermal contraceptive implants. METHODS: We describe 3 cases of subdermal implants for which detection was requested via sonography. The implants were evaluated with both fundamental and compound imaging with various transducers ranging from 5-2 to 15-7 MHz. The fundamental and compound images were compared with respect to echogenicity and, therefore, visibility, of the contraceptive implant and the appearance of posterior acoustic features. RESULTS: Both fundamental and compound imaging visualized the focus representing the implant equally well. However, fundamental imaging proved superior to compound imaging for visualizing the posterior acoustic shadowing created by the implant. The posterior acoustic shadowing was the most helpful feature in the identification of these implant rods. CONCLUSIONS: When attempting to image a subdermal contraceptive implant with sonography, fundamental imaging should be used. Compound imaging may mask the posterior acoustic features that can aid in implant identification.     

Intraepithelial high-grade neoplasia and early adenocarcinoma in short-segment Barrett's esophagus (SSBE): curative treatment using local endoscopic treatment techniques

BACKGROUND AND STUDY AIMS: In recent years, short-segment Barrett's esophagus (SSBE) has attracted increasing attention in the context of reflux disease. However, there is continuing controversy regarding its potential for malignant transformation. PATIENTS AND METHODS: Between October 1996 and September 1999, 50/115 patients (43 %) with intraepithelial high-grade neoplasia or early Barrett's adenocarcinoma, who underwent local endoscopic treatment, had developed a malignant lesion in an (SSBE). In the framework of a prospective observational study, 28 patients were treated with endoscopic mucosal resection (EMR), 13 with photodynamic therapy, and three with argon plasma coagulation; six patients received combinations of these treatments. RESULTS: Complete local remission was achieved in 48/49 patients (98 %). One patient switched to surgery after the first EMR, because there was submucosal tumor infiltration, and in one patient out of 50 local endoscopic treatment failed. A mean of 1.7 +/- 1.4 treatment sessions was required for local endoscopic treatment. The method-associated mortality was 0 %. The rate of relevant complications (stenosis, bleeding) was 6 % (3/50 patients). No cases of severe hemorrhage (Hb fall >2 g/dl) or perforation occurred. During a mean follow-up period of 34 +/- 10 months, metachronous intraepithelial high-grade neoplasms or early adenocarcinomas were seen in 11/48 patients (23 %), who received further successful endoscopic treatment. Four patients died during the follow-up period, but in only one patient was this due to his Barrett's adenocarcinoma (this was the patient who underwent esophageal resection). CONCLUSIONS: The malignant potential of short-segment Barrett's esophagus must not be underestimated. Organ-preserving local endoscopic treatment shows good acute-phase and long-term results. Local endoscopic treatment represents an alternative to esophageal resection in the case of intraepithelial high-grade neoplasia and selected early adenocarcinomas in Barrett's esophagus.     

Sonographic evaluation of anatomic results after the pubovaginal sling procedure for stress urinary incontinence.

OBJECTIVE: To investigate the anatomic changes after the pubovaginal sling procedure in women with stress urinary incontinence by transrectal sonography METHODS: This study enrolled 56 women with varying types of stress urinary incontinence who were treated with the pubovaginal sling procedure using self-fashioned polypropylene mesh. The suburethral sling was fixed without tension and was placed at the position between the bladder neck and the proximal urethra. The patients were investigated preoperatively and postoperatively by transrectal sonography of the bladder and urethra. RESULTS: At a median follow-up of 24 months (range, 6-39 months), 48 patients (85.7%) were cured, 6 (10.7%) had improved, and 2 (3.6%) had treatment failures. Transrectal sonography revealed a well-suspended bladder neck and proximal urethra in all patients who were cured. As measured by changes of the axis of the pubovesical ligament, the position of the bladder neck was elevated by a mean of 29.6 +/- 21.5 degrees in the resting condition and 47.4 +/- 27.7 degrees in the straining condition. An incompetent bladder neck and proximal urethra were noted in 8 patients who had stress urinary incontinence after surgery. The incidence of opening of the bladder neck was 84.6% in 13 patients with de novo urgency or urge incontinence, whereas only 2 (4.7%) of 43 patients who did not have postoperative urgency had opening of the neck (P = .000). CONCLUSION: Transrectal sonography provides useful information about anatomic changes after the pubovaginal sling procedure. Bladder neck incompetence after surgery was closely related to postoperative urgency or urge incontinence.     

Evaluation of ureterocele with Doppler sonography

Ureterocele is a common disorder characterized by cystic dilatation of the terminal submucosal portion of 1 or both ureters. Conventional imaging modalities for the diagnosis of ureterocele include intravenous urography and voiding cystourethrography; gray-scale sonography, augmented by color Doppler and spectral analysis studies, can be useful in diagnosing and managing this condition as well. We describe the diagnosis of ureterocele using transvaginal gray-scale and color Doppler sonography with spectral analysis in 2 women. Color Doppler sonography demonstrated urine flow into the bladder, and spectral analysis was used to measure the flow velocity. Together, these modalities can provide additional information about urinary flow dynamics, aid in implementing treatment for patients with ureterocele, and eliminate the need for invasive diagnostic procedures.     

Correlation of color Doppler sonographic findings with pH measurements in gastroesophageal reflux in children

PURPOSE: We conducted a prospective study of color Doppler sonography in children with suspected gastroesophageal reflux (GER). The purpose of this study was to compare the accuracy of color Doppler sonography with that of continuous 24-hour pH monitoring of the esophagus in diagnosing GER and to determine how to interpret the reflux episodes detected on color Doppler sonography in children at high risk for reflux. METHODS: Color Doppler sonography and 24-hour esophageal pH monitoring were performed in 54 children ranging in age from 2 months to 10 years (mean, 3 years). The stomach of each patient was filled for adequate gastric distention just before the color Doppler sonographic examination. We counted the number of reflux episodes over a period of 15 minutes. One day after the sonographic examination, the reflux was evaluated with esophageal pH monitoring, and the resultant reflux index (ReI) was obtained. The ReI was considered to be pathologic when it was equal to or greater than 11.99%. The number of refluxes on color Doppler sonography and the ReI were correlated for each patient. RESULTS: The 2 tests showed an 81.5% agreement in the detection of GER. When pH monitoring was taken as the reference test, color Doppler sonography had a high sensitivity (95.5%) for diagnosing GER but a very low specificity (11.0%), with a positive predictive value of 84.3% and a negative predictive value of 33.3%. There was no statistically significant correlation between the frequencies of GER detected on color Doppler sonography and the ReIs on pH monitoring (p = 0.1103). There was no correlation between the reflux grades on sonography and the ReI grades on pH monitoring (p = 0.422). CONCLUSIONS: Color Doppler sonography is highly sensitive and easier to use than pH monitoring. Although there are no definite criteria for evaluating the severity of GER on color Doppler imaging, this modality may be useful in screening children for GER.