Grading of reflux by radionuclide cystography

Over a three-year period, radionuclide cystography (RC) was performed on 145 patients. Of these, 31 nephroureteral units in 25 patients demonstrated vesicoureteral reflux by RC and also by radiographic cystography (XC). The RC and XC studies were performed within three months of one another. The grading of reflux was determined by RC and then compared with that of XC using the criteria for grading as established by the International Reflux Study Committee (IRSC). Of 18 nephroureteral units in 14 patients with grade II reflux by XC, 14 were similarly graded by RC (78%). Of five nephroureteral units in five patients with grade III reflux by XC, the correlation by RC was 100%. However, when grades II and III were combined into a single category of low-grade reflux, the correlation achieved between the two cystographic techniques was 100%. Of five nephroureteral units in four patients with grade IV reflux by XC, the correlation was 60%, and in three units in two patients with grade V reflux the correlation was 100%. When grades IV and V are combined into a category of high-grade reflux, a correlation of 100% is achieved. When the reflux is graded into the five IRSC categories, the overall unequivocal correlation between the two studies is 80%. However, when only two categories are used (low grade = grades II and III, and high grade = grades IV and V), a correlation of 100% is obtained.     

Comparison of direct radionuclide cystography and voiding direct cystography in the detection of vesicoureteral reflux

Purpose: The aim of this study is to compare the results of direct radionuclide cystography (DRNC) and voiding cystourethrography (VCUG) in a group of children with a high suspicion of vesicoureteral reflux (VUR).Methods: For this purpose, 25 children were studied with both VCUG and DRNC. Among 50 ureter units able to be compared 39 ureter units did not show any VUR on either study. Eleven ureter units (10 children) had VUR either on one study or on both (VCUG and DRNC). In the children who had VUR on either study, a dimercaptosuccinic acid scintigraphy (DMSA) was performed to determine their cortical function.Results: We identified the following four patterns: 1) Five ureter units (five children) read positive on DRNC who were negative on VCUG and four of these children had positive findings on DMSA; 2) Four ureter units (four children) read positive on VCUG who were negative on DRNC, and two of them had positive findings on DMSA; 3) Two ureters (one child) read positive in both studies and also had abnormal DMSA findings; 4) Thirtynine ureter units read as negative on both studies.Conclusion: Although the results of these two methods did not show a significant difference, DRNC offers a high sensitivity in the younger age group whereas VCUG seems to be more sensitive in the older age group. DRNC also offers continuous recording during the study, ease of assessment and lower radiation dose to the gonads, which makes it a preferable method for the initial diagnosis and follow-up of VUR.     

Comparison of direct radionuclide cystography and voiding direct cystography in the detection of vesicoureteral reflux

PURPOSE: The aim of this study is to compare the results of direct radionuclide cystography (DRNC) and voiding cystourethrography (VCUG) in a group of children with a high suspicion of vesicoureteral reflux (VUR). METHODS: For this purpose, 25 children were studied with both VCUG and DRNC. Among 50 ureter units able to be compared 39 ureter units did not show any VUR on either study. Eleven ureter units (10 children) had VUR either on one study or on both (VCUG and DRNC). In the children who had VUR on either study, a dimercaptosuccinic acid scintigraphy (DMSA) was performed to determine their cortical function. RESULTS: We identified the following four patterns: 1) Five ureter units (five children) read positive on DRNC who were negative on VCUG and four of these children had positive findings on DMSA; 2) Four ureter units (four children) read positive on VCUG who were negative on DRNC, and two of them had positive findings on DMSA; 3) Two ureters (one child) read positive in both studies and also had abnormal DMSA findings; 4) Thirty-nine ureter units read as negative on both studies. CONCLUSION: Although the results of these two methods did not show a significant difference, DRNC offers a high sensitivity in the younger age group whereas VCUG seems to be more sensitive in the older age group. DRNC also offers continuous recording during the study, ease of assessment and lower radiation dose to the gonads, which makes it a preferable method for the initial diagnosis and follow-up of VUR.     

CT cystography versus conventional cystography in evaluation of bladder injury.

OBJECTIVE: The objective of this study was to evaluate prospectively the use of CT cystography, using retrograde filling of the bladder with diluted iodinated contrast material, versus conventional cystography to identify bladder injury in patients with hematuria after blunt abdominal trauma. SUBJECTS AND METHODS: Inclusion criteria consisted of the adult hemodynamically stable abdominal trauma patient with hematuria referred for abdominopelvic CT and also being considered for cystography. An initial abdominopelvic CT scan using IV iodinated contrast material was obtained, as would have been done routinely in the trauma victim. A second CT scan through the pelvis was obtained after retrograde distention of the bladder with dilute iodinated contrast material. CT cystography revealing bladder injury was followed with appropriate therapy. CT cystograms not revealing injury were followed by conventional cystography. Results of patient outcome were evaluated. RESULTS: Over a 21-month period from January 1995 through September 1996, CT cystography was performed on 55 patients who presented with hematuria after blunt abdominal trauma. Five of the 55 patients had bladder injury on CT cystography. The injury in each of these five patients was confirmed intraoperatively. In the remaining 50 patients, both CT and conventional cystography did not reveal bladder injury. CONCLUSION: CT cystography is an accurate method for evaluating bladder injury in the blunt abdominal trauma victim with hematuria. CT cystography, performed in conjunction with routine CT of the abdomen and pelvis for evaluating traumatic hematuria, would therefore preclude conventional cystograms in these patients.     

Indirect radionuclide renocystography for determination of vesico-ureteral reflux in children

Indirect radionuclide renocystography (IRRCG) is a method for the detection of vesico-ureteral reflux by analysis of the activity-time curves over the kidneys and bladder during voiding of urine about 30 min after intravenous administration of a radioactive indicator. This paper presents a new method for detection of reflux by a statistical test, the magnitude of the reflux is evaluated by the reflux volume per 1.73 m2 body surface area. Residual urine volume and urine voiding efficiency are also calculated. In a retrospective study of 154 children examined for renal and urological diseases consisting mainly of urinary tract infections, vesico-ureteral reflux was found by IRRCG in 16% of the kidneys (23% of the children). Reflux volumes were below 10 ml/1.73 m2 in 90% of the children with reflux. The mode value of the reflux volume was 2 ml/1.73 m2. For a subgroup of 97 children, the results were compared with micturating cysto-urethrography (MCU). This showed that a negative IRRCG in conjunction with the renal mean transit time of the radioactive indicator determined by gamma camera renography could be used as a screening test for vesico-ureteral reflux when MCU was considered a true reference method. Hence, about 75% of the invasive and high radiation dose MCU can be replaced by the non-invasive and low radiation dose IRRCG. The discrepancies between the two methods and the reasons for them are discussed.     

Indirect radionuclide cystography demonstrates reflux under physiological conditions

Indirect radionuclide cystography (IRC) is a useful technique for the detection and quantification of vesico-ureteric reflux (VUR). Its principal advantage over micturating contrast cysto-urethrography (MCU) is its ability to demonstrate VUR under physiological conditions. Three children (age range 6-9 years) reported here illustrate some physiological features of micturition readily seen only on IRC. The most important of these was uretero-ureteric reflux which, because of bladder activity, is not usually identifiable on IRC or MCU but is probably more common than previously thought and misinterpreted as VUR.     

CT cystography in the evaluation of bladder trauma

At our trauma center we have replaced plain film cystography with CT cystography to evaluate trauma patients with hematuria sent for emergent CT of the abdomen and pelvis. Ten cases of ruptured bladders evaluated by CT are tabulated, and characteristic images are presented.     

Indirect radionuclide renocystography for determination of vesico-ureteral reflux in children

Indirect radionuclide renocystography (IRRCG) is a method for the detection of vesico-ureteral reflux by analysis of the activity-time curves over the kidneys and bladder during voiding of urine about 30 min after intravenous administration of a radioactive indicator. This paper presents a new method for detection of reflux by a statistical test, the magnitude of the reflux is evaluated by the reflux volume per 1.73 m² body surface area. Residual urine volume and urine voiding efficiency are also calculated. In a retrospective study of 154 children examined for renal and urological diseases consisting mainly of urinary tract infections, vesico-ureteral reflux was found by IRRCG in 16% of the kidneys (23% of the children). Reflux volumes were below 10 ml/1.73 m² in 90% of the children with reflux. The mode value of the reflux volume was 2 ml/1.73 m². For a subgroup of 97 children, the results were compared with micturating cysto-urethrography (MCU). This showed that a negative IRRCG in conjunction with the renal mean transit time of the radioactive indicator determined by gamma camera renography could be used as a screening test for vesico-ureteral reflux when MCU was considered a true reference method. Hence, about 75% of the invasive and high radiation dose MCU can be replaced by the non-invasive and low radiation dose IRRCG. The discrepancies between the two methods and the reasons for them are discussed.     

Prediction of vesico-ureteral reflux in children from intravenous urography films.

Intravenous urography and voiding urethrocystography were performed on 255 children with urinary tract infection. Eighty-six (34%) of these children had some kind of abnormality of the urinary tract. Vesico-ureteral reflux was observed to 96 ureters (19%) in 69 children (27%). The prediction of vesico-ureteral reflux by two radiologists from urography films only gave 46 (48%) and 51 (53%) false negative results respectively. In cases of clinically important reflux (III--V degrees), however, the rate of false negative predictions was 0/18 and 1/18 (6%) respectively. The rate for false positive predictions were 45/413 (11%) for both radiologists. In view of the number of pathological findings in this series i.v. urography is recommended as a routine in children undergoing urological work-up after their first urinary tract infection. As the clinically important vesico-ureteral reflux seems to be predictable from urography films alone, voiding urethrocystography seems not to be justified in children with negative i.v. urography, and can be postponed and carried out later if the urinary tract infection recurs.     

应用核素显像评价小儿肾瘢痕形成与膀胱输尿管返流

目的：探讨膀胱输尿管返流（VUR）与急性肾盂肾炎（APN）后肾瘢痕形成的关系及评价小儿泌尿道感染（UTI）核素显像方法。方法：研究对象为临床首次诊断为上尿路感染的患儿48例，均经^99Tc^m-二巯基丁二酸（DMSA）肾皮质显像确诊为APN。肾显像后10d内行直接法放射性核素膀胱显像（DRC）以评价VUR。结果：（1）肾皮质显像示29．2％（14／48例）患儿APN伴瘢痕形成。DRC示47．9％（23／48例）患儿、44．8％（30／67个）病变肾存在VUR。（2）伴瘢痕形成APN患儿，其VUR发生率为85．7％，明显高于无瘢痕者（32．4％，P＜0．01）；伴瘢痕肾VUR发生率为88．2％，明显高于无瘢痕肾（30．0％，P＜0．01）。（3）有VUR的30个肾中，重度VUR侧肾瘢痕发生率为73．3％，明显高于无VUR及轻、中度VUR侧肾（11．5％，P＜0．01）。结论：证实VUR是诱发APN后肾瘢痕形成的危险因素之一。DRC为一辐射低、灵敏度高的评价VUR的方法，尤其适用于小儿。     

Effectiveness of direct and indirect radionuclide cystography in detecting vesicoureteral reflux.

A modification of the direct radionuclide cystography technique to include filling, voiding, and postvoiding phases of the examination permitted a simulated comparison between direct and indirect radionuclide cystography. One hundred thirty-seven examples of reflux were documented with this technique. Of these, 96 instances of reflux (70%) were recorded during two or more phases and thus would have been detected by either technique. Twenty-nine examples (21%) were only detected during filling and thus would have been missed by the indirect radionuclide technique and by some roentgenographic techniques. Only 12 examples (9%) were detected during the voiding phases only. The modified direct method of radionuclide cystography, which continuously monitors the urinary tracts during filling, voiding, and postvoiding, is offered as the best current technique for assessing vesicoureteral reflux.     

CT cystography in the evaluation of major bladder trauma.

Computed tomographic (CT) cystography has been advocated in lieu of conventional cystography in the initial work-up of patients with suspected urinary bladder trauma. CT cystography was applied to a classification scheme for bladder injury based on the degree of wall injury and anatomic location and demonstrated characteristic imaging features for each type of injury. In bladder contusion (type 1), findings are normal. In intraperitoneal rupture (type 2), CT cystography demonstrates intraperitoneal contrast material around bowel loops, between mesenteric folds, and in the paracolic gutters. Manifestations of interstitial injury (type 3) include intramural hemorrhage and submucosal extravasation of contrast material without transmural extension. In extraperitoneal rupture (type 4), the path of extravasated contrast material is variable: Extravasation is confined to the perivesical space in simple extraperitoneal ruptures, whereas in complex extraperitoneal ruptures, contrast material extends beyond the perivesical space and may dissect into a variety of fascial planes and spaces. Combined intra- and extraperitoneal rupture (type 5) usually demonstrates extravasation patterns that are typical for both types of injury. Familiarity with these CT cystographic features allows accurate classification of bladder injury and allows prompt, effective treatment with less radiation exposure than and without the added cost of conventional cystography.