Cystosonography and voiding cystourethrography in the diagnosis of vesicoureteral reflux

The availability of US (ultrasonography) contrast media in the last few years has prompted investigation into their use in the diagnosis of vesicoureteral reflux (VUR) in children, a common cause of urinary tract infections (UTI) or pyelonephritis. We performed voiding cystourethrography (VCUG) and cystosonography (CSG) in the same session in 158 children (M/F 97/61, mean age 3.9 years, age range 0.1-12.7 years) with clinical suspicion of VUR, studied over a year with an ATL plus 3000 real-time scanner (ATL Ultrasound, Bothell, USA), equipped with 2- to 4- and 4- to 7-MHz convex transducers. US contrast medium Levovist (Schering, Berlin, Germany) was used. VCUG and CSG diagnosed 74 (24.2%) and 77 (25.2%) cases of VUR, respectively. There was no agreement in 67 cases (22%). The percentage of false negatives was similar and high with both techniques. CSG seems to be more sensitive in detecting intermediate (second- and third-degree) VUR. In spite of the moderate relative diagnostic adequacy of both methods, we believe that CSG is an alternative to VCUG, avoiding the risk of ionizing radiation, in the following conditions: (1) first diagnosis in females (not in males, due to the poor vesical and urethral anatomical detail it provides), (2) VUR follow-up, (3) VUR diagnosis in megaureters and/or in ureteroceles, and (4) VUR diagnosis in transplanted kidneys. Further improvements of CSG, both in US contrast media and in US technique, could possibly increase its sensitivity.     

Detection of missing vesicoureteral reflux with bethanechol chloride-aided voiding cystourethrography

Experience in the detection of absent vesicoureteral reflux with bethanechol-aided voiding cystourethrography is presented. The detection rate with conventional contrast-enhanced voiding cystourethrography among 9 study subjects, in whom vesicoureteral reflux otherwise was highly suspected from accompanying clinical, urographic and endoscopic features, and in whom it was absent contralaterally or bilaterally, was improved from 33 per cent (only 3 of 9 patients were positive for reflux) to 100 per cent (all 9 were proved to have vesicoureteral reflux) after bethanechol stimulation. Some representative cases are presented and the mechanisms of inducing vesicoureteral reflux with bethanechol are discussed as well as its clinical relevance. Bethanechol-aided voiding cystourethrography is suggested as a highly sensitive method to detect absent vesicoureteral reflux.     

Comparison of screening of vesicoureteral reflux with renal ultrasound and voiding cystourethrography

Purpose To suggest a different method for diagnosing vesicoureteral reflux (VUR) in lieu of voiding cystourethrography (VCU), in order to prevent radiation exposure. Materials and methods Fifty-two ureterorenal units of 26 patients were evaluated ultrasonographically for visualizing the renal collecting systems, both before and after filling up the bladder with saline infusion. Every patient also underwent evaluation with VCU. Results All patients with Grade 2 or higher degrees of VUR on VCU can be identified by ultrasound (USG). Overall sensitivity and specificity of this technique were 66.7% and 93.48%, respectively, in our patient group. Conclusion After being diagnosed with VCU initially a VUR patient can be effectively followed up by USG in order to prevent radiation exposure. Considering the clinical management of a patient with Grade 1 VUR which could not be detected with USG, it is concluded that failure to detect Grade 1 VUR will not be a handicap.     

Cyclic voiding urosonography in detecting vesicoureteral reflux in children

Three methods are currently used to identify vesicoureteral reflux (VUR) in children, namely X-ray voiding cystourethrography (VCUG), radionuclide voiding cystography (RVC), and, recently, echo-enhanced voiding urosonography (VUS). It is known that the sensitivity of VCUG and RVC for detecting VUR can be improved by using cyclic procedures, such as repeated bladder filling and voiding. The purpose of our prospective study was to evaluate whether the cyclic procedure is superior to the conventional (one cycle only) procedure in VUS also. VUS was performed in 49 patients, aged 1.4–15.8 years (mean 4.1 years). After the first micturition, the catheter was left in place and the whole procedure was repeated under the same conditions. The results of the first and second cycles and the combined procedure were compared. In the initial cycle, 7 of 35 (20%) refluxing renal units that were detected in the second cycle and 4 of 26 (15%) children with at least unilateral VUR were missed. Cyclic VUS detected 25% more VURs than the conventional (one cycle only) VUS (P=0.049) and revealed 50% more VUR III than the first cycle. Our results suggest that cyclic VUS is superior to conventional VUS.     

Indirect voiding urosonography for detecting vesicoureteral reflux in children

The purpose of our prospective study was to determine the value of indirect voiding urosonography without the use of contrast-media and without filling of the bladder through a catheter (IVUS) for detection of vesicoureteral reflux (VUR) in children, compared with echo-enhanced voiding urosonography (VUS). Among 57 children (45 girls and 12 boys, aged 2.7 to 12.0 years) admitted for echo-enhanced VUS either as part of routine evaluation after urinary tract infection (UTI) or follow-up of a previously detected VUR, IVUS was also successfully performed in 47 children. The results were considered positive when there was any increase in pelvis size and/or ureter lumen width during voiding. The overall sensitivity of IVUS in the detection of VUR was 49%, specificity 75%. The most accurate results were obtained with VUR grade III, where IVUS correctly detected 6 out of 7 cases, a sensitivity of 86%. The average increase of AP pelvis diameter during voiding was highly significant only in uretero-renal units with VUR grade III. Considering the obstacles in conducting the investigation and its relatively low overall sensitivity and specificity, it seems that IVUS is not sufficiently reliable to replace echo-enhanced VUS.     

Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction

PURPOSE: Dysfunctional voiding influences the presence and persistence of vesicoureteral reflux. We used a standardized published instrument, the dysfunctional voiding symptom score, to evaluate the association of dysfunctional voiding with vesicoureteral reflux. We report its use for monitoring improvement in and resolution of vesicoureteral reflux. MATERIALS AND METHODS: In 1998, 114 patients with dysfunctional voiding were placed on behavioral modification. Of 58 patients (51%) who presented with urinary tract infection 27 (47%) had abnormal voiding cystourethrography, including 19 with reflux only. Baseline and followup dysfunctional voiding symptom score was determined in these 19 patients, who underwent prospective observational therapy and behavioral modification. We correlated the dysfunctional voiding symptom score with the evolution of vesicoureteral reflux. RESULTS: Vesicoureteral reflux was present in 19 of the 58 patients (33%) with dysfunctional voiding and urinary tract infection. All affected patients were female with a mean age of 6.7 years and a mean followup of 24 months. Reflux grade in the 24 units was I to IV in 7, 9, 7 and 1, respectively. Mean dysfunctional voiding symptom score was 13.3 in patients with normal voiding cystourethrography and 11.7 in the vesicoureteral reflux group (p = 0.6). Reflux resolved in 3, 2 and 2 cases of grades I, II and III disease, respectively, while improvement (decrease of 2 or more grades) was noted in 4. Initial dysfunctional voiding symptom score in these 11 cases decreased from a mean of 9.6 (range 4 to 18) to 3.7 (range 0 to 12, p = 0.01). The 8 patients with persistent reflux had an initial dysfunctional voiding symptom score of 14.4 (range 4 to 21), which decreased to 11.1 (range 1 to 19, p = 0.18). CONCLUSIONS: A significant decrease in the dysfunctional voiding symptom score appears to confirm compliance with behavioral modification and predicts ultimate reflux resolution. The dysfunctional voiding symptom score provides a noninvasive means of monitoring compliance with therapy during expectant treatment of patients with vesicoureteral reflux.     

Cyclic voiding cystourethrography in the diagnosis of occult vesicoureteric reflux

Cyclic voiding cystourethrography (CVC) enhances the detection of vesicoureteric reflux (VUR). We investigated whether more-severe VUR may be overlooked, and whether older children are at risk of having their VUR missed with the conventional single-cycle study. Three hundred and seventy patients, 168 boys and 202 girls aged 1 month to 16 years, consecutively admitted over 1 year for suspicion of VUR, underwent two complete cycles of filling and voiding CVC. One hundred and four subjects, 33 boys and 71 girls, were older than 3 years (mean age 5.7 years, range 3.2–16 years).Sixty-six refluxing ureters from 51 patients were identified in the first cycle and 61 refluxing ureters from 45 patients were identified only with the second cycle. Four instances of grade IV VUR in 4 patients and three of grade V VUR in 3 patients were overlooked completely in the first cycle. Seven episodes of VUR ≤ grade III from 5 patients diagnosed in the first cycle were upgraded to ≥ grade IV at the second cycle. The presence of VUR was identified only in the second cycle in 35 of 74 subjects aged ≤ 3 years and in 10 of 22 aged >3 years (not significant). Of the 10 children aged >3 years, 2, who had diagnosis only at the second cycle, had ≥ grade IV VUR. More-severe VUR may be overlooked or down-graded in a single-cycle study. Two-cycle CVC is also useful in children older than 3 years. Received: 4 June 1998 / Revised: 11 January 1999 / Accepted: 22 January 1999     

Indirect radionuclide cystography: a sensitive technique for the detection of vesico-ureteral reflux

The detection or exclusion of vesico-ureteral reflux (VUR) has classically been by micturating cystourethrography (MCUG). Radionuclide cystography will detect VUR but fails to provide the same detailed anatomical informations as MCUG. This study allowed a comparison of indirect radionuclide cystography (IRC) and MCUG in 65 children. Renal reflux was detected by IRC in 32% of renal units, while VUR was seen in 36% by MCUG. When a comparison was made with MCUG, IRC had a sensitivity of 74.1% and a specificity of 90.5%. The markedly reduced radiation dose, avoidance of a bladder catheter plus the ability to monitor the urinary tract constantly during the entire procedure should ensure that IRC is the examination of choice in follow-up studies for VUR in all toilet-trained children.     

The relationship between dysfunctional voiding and congenital vesicoureteral reflux

Voiding dysfunction may play an etiological role in congenital vesicoureteral reflux in otherwise normal children. There is increasing evidence to suggest that in some infants and older children, vesicoureteral reflux is associated with congenital structural deficiency of the trigonal ureterovesical junction valve mechanism as well as aberrant lower urinary tract function. In the youngest infants this abnormal function can be present at birth, whereas in older children it may be acquired and learned during the toilet training years, if it is not already present. Voiding dysfunction may spontaneously improve or require additional therapy. Increased rates of breakthrough infection, renal scarring and surgical failure have been associated with undiagnosed and untreated lower urinary tract dysfunction, emphasizing the importance of its recognition. Controversy remains regarding the role of invasive urodynamics and anticholinergic medication, and further large-scale prospective studies are necessary before either modality becomes routine when assessing and treating these children.     

Postoperative cystography and endoscopic treatment of low-grade vesicoureteral reflux

INTRODUCTION: The endoscopic subureteral injection of tissue-bulking agents has become an established alternative to long-term antibiotic prophylaxis and open surgery with a high success rate, especially for low-grade reflux (>90%). Though it is recognized that a routine postoperative voiding cystourethrography (VCUG) is unnecessary following a ureteroneocystostomy, most teams perform one after an endoscopic treatment. MATERIALS AND METHODS: In this paper, we report on our experience with the endoscopic correction of vesicoureteral reflux in 72 ureteral units, for whom no routine postoperative cystography was performed. DISCUSSION: Two children presented with postoperative recurrent febrile urinary tract infections (UTIs), which were not correlated with cystography findings. Postoperative VCUGs after a ureteroneocystostomy are invasive and expose the child to radiation, they are associated with a substantial cost, and most of all, they do not allow the identification of those patients at risk of recurrent febrile UTIs. Further, the endoscopic subureteral injection of tissue-bulking agents have been used for several years, and numerous studies, set in various clinical settings, have since been published, confirming excellent long-term results for low-grade reflux. CONCLUSIONS: We feel that postoperative cystograms should be reserved for children who present with recurrent UTIs, new sonographic abnormalities, or who were treated for high-grade reflux.     

Intrarenal reflux in children with vesicoureteral reflux]

Voiding cystourethrography (VCU) of 407 children with vesicoureteral reflux (VUR) at our hospital during 1969-1990 was reviewed and 7 cases (8 ureters) of intrarenal reflux (IRR) were found. All the children were male and had had an episode of febrile urinary infection under one year of age. One child had a left flank mass, which was later proven a urinoma. VUR was moderate (grade III) in 3 and massive (grade IV and V) in 5. VUR was estimated as primary in one child and as secondary in 6 (anterior urethral ring 2, posterior urethral valve 2, neurogenic bladder 2). IRR was localized to the upper area in 3, to the lower area in 2, and to the whole kidney in 3. Sixty percent of those with IRR in the polar areas was associated with moderate VUR, whereas all of those in the whole kidney was with massive one. Renal scarring was assessed by excretory urography (IVP) and/or 99mTc-DMSA renoscintigraphy. Seven kidneys were evaluable; polar scars in 5, dwarf with polar scar in 1 and dwarf with poor function (suspected hypodysplasia) in 1. In 4 kidneys new scar formation was observed. It was noted, however, that IRR did not necessarily accompany renal scars of the corresponding areas and IRR to the whole kidney did not always lead to multiple scars in the whole kidney. The nature and problems of IRR, renal scars and 99mTc-DMSA renoscintigraphy were discussed. It was suggested that urinary infection played a greater part in renal scar formation.     

Microalbuminuria in children with vesicoureteral reflux

Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that may be inherited. Reflux of infected urine may cause scarring in susceptible kidneys with the potential to compromise renal function. The aim of the study was to evaluate the possible influence of different grades of VUR on glomerular damage using microalbuminuria as a parameter. Children with VUR detected by voiding cystourethrography (VCUG) were investigated. According to the grade of VUR, patients were separated into three groups. The first group included 12 children with VUR grade I-II. The second group consisted of 12 children with grade III of VUR. Patients with VUR grade IV-V (n = 11) were members of the third group. The control group consisted of 17 healthy children. Microalbuminuria was examined in samples of morning urine specimens using a microalbumin/creatinine reagent kit. Serum urea, creatinine levels and creatinine clearance (CCR) were measured as markers of renal function. The mean value of microalbumin excretion in the third group showed a statistically significant increase (p < 0.001) compared to all other groups. CCR in the third group was statistically significantly decreased (p < 0.05) in comparison to the group of healthy children. There were no statistically significant changes of microalbumin excretion and CCR in the first and second group compared to control values. We discussed the presence of microalbuminuria and decrease of CCR in children with high grade of VUR as a possible consequence of retrograde urine flow (intrarenal reflux), glomerulosclerosis, and consecutive hyperfiltration.     

Relationship of voiding dysfunction to urinary tract infection and vesicoureteral reflux in children.

A total of 109 children were evaluated for urinary tract infections or for voiding dysfunction without infections. The relationship of voiding dysfunction to urinary infection and vesicoureteral reflux was then examined in girls. The number of males studied was too small for statistical analysis. While 40.6 percent of females with infections had voiding dysfunction, in 66.6 percent of those females having voiding dysfunction infections also developed. Voiding dysfunction was noted in 33.3 percent of females with reflux, probably due to the strong association of reflux and infections. However, all of females with voiding dysfunction, only 20.6 percent also had reflux. These findings were statistically significant (p = 0.01) and suggest that voiding dysfunction is common in girls with infections, perhaps even predisposing to the development of infections. However, voiding dysfunction in this population did not predispose to reflux.     

Quantitation of vesico-ureteral reflux by radionuclide cystography and urodynamics

A method is described for the quantitation of vesico-ureteral reflux by synchronous combined direct radionuclide cystography and urodynamics. Intravesical pressures and volumes are co-ordinated with volumes of reflux. Peak reflux volumes in 11 children diagnosed as having severe (grades 3–4) reflux on conventional contrast cystography ranged from 1 to 50 ml/kidney. A number of different patterns of reflux were observed. Reflux may occur progressively throughout low pressure filling or incrementally with unstable bladder contractions. Reflux during voiding may be maximal as detrusor pressure falls. The method requires wider application to explore the potential for a functional classification of the reflux problem.