Harmonic voiding urosonography with a second-generation contrast agent for the diagnosis of vesicoureteral reflux

Background  Voiding urosonography with harmonic imaging (VUS HI) has been introduced as a sensitive and radiation-free imaging method for the diagnosis and follow-up of vesicoureteral reflux (VUR) in children. Objective  The purpose of this study was to evaluate the sensitivity of VUS HI using a second-generation US contrast agent compared to standard voiding cystourethrography (VCUG). Materials and methods  A total of 228 children with 463 kidney-ureter units (KUUs) underwent two cycles of VUS HI and two cycles of VCUG at the same session. VUS HI was performed after intravesical administration of 1 ml of a second-generation US contrast agent (sulphur-hexafluoride gas microbubbles, SonoVue, Bracco, Italy). For statistical analysis we used McNemar’s test, Student’s t-test and k coefficient tests. Results  VUR was shown in 161/463 (34.7%) KUUs, 57 by both methods, 90 only by VUS, and 14 only by VCUG. Concordance in findings regarding the presence or absence of VUR was found in 359/463 (77.5%) KUUs (k=0.40). The difference in the detection rate of reflux between the two methods was significant (P<0.01). More importantly, reflux missed by VCUG was of higher grade (2 grade I, 65 grade II, 19 grade III, 4 grade IV) than that missed by VUS (8 grade I, 5 grade II, 1 grade III). Conclusion  VUS HI and a second-generation contrast agent improved the identification of reflux in children. Our data reveal a higher sensitivity of the method compared to VCUG. Thus it can be used as an alternative radiation-free imaging method.     

Simultaneous voiding cystourethrography and voiding urosonography reveals utility of sonographic diagnosis of vesicoureteral reflux in children

AIM: To evaluate the diagnostic potential of voiding urosonography (VUS) compared with fluoroscopic voiding cystourethrography (VCUG) under identical conditions and to evaluate potential reasons for false-negative VUS results, particularly regarding bladder concentrations of the US contrast agent, Levovist. METHODS: Fifty-six paediatric patients (M/F 34/22, mean age 2.3 y, age range 1 mo-14 y) underwent simultaneous VUS and VCUG under identical conditions. The bladder was filled by simultaneous administration of Levovist and the X-ray contrast medium, DIP Conray. Levovist concentrations in bladders were calculated using amounts of Levovist injected and total DIP Conray infused when reflux was first observed in either procedure. RESULTS: Sensitivities of VUS and VCUG for detection of vesicoureteral reflux (VUR) were both 86%, assuming that VUR detected by either method represented a true-positive, and no reflux by either method represented a true-negative. Patients under 24-mo of age displayed a better VUS sensitivity, of 94%. Levovist concentrations in bladders ranged from 1.8% to 23%, with older children tending to demonstrate increased bladder capacity and lower concentration. All VUS false-negative units displayed Levovist bladder concentrations of less than 5%. CONCLUSION: The present simultaneous study suggests that: 1) the two techniques demonstrate similar sensitivity for detection of reflux; 2) sustained Levovist bladder concentrations of below 5% may not allow detection of reflux on VUS; and 3) VUS represents a suitable technique, particularly for small children whose bladder capacity is not so large.     

Voiding urosonography with second-generation ultrasound contrast versus micturating cystourethrography in the diagnosis of vesicoureteric reflux

Vesicoureteric reflux has been associated with paediatric urinary tract infection. Fluoroscopic micturating cystourethrography (MCU) has been the gold standard of diagnostic test for decades; however, it has been criticized owing to its lower detection rate and radiation dose to children. Therefore, new radiation-free reflux imaging modalities have been developed, in which ultrasound-based contrast-enhanced voiding urosonography (ceVUS) is a good example. However, ultrasonography has been considered as an operator-dependent examination. Therefore, our study aimed to examine the inter-observer agreement of this sonographic technique, which has not been evaluated before. Moreover, the second-generation ultrasound contrast SonoVue has been recently marketed, and the data on its efficacy on intravesical use in ceVUS is relatively scarce. Thus, we also aimed to investigate the diagnostic performance and safety profile of SonoVue-enhanced VUS in the diagnosis of vesicoureteric reflux. Our prospective comparative study compared the diagnostic performance of ceVUS with MCU in young children presenting with first episode of urinary tract infection. We performed sequential ceVUS and MCU examinations in 31 patients (62 pelvi-ureter units). Perfect inter-observer agreement (Cohen’s kappa statistics?=?1.0, p?<?0.001) was achieved in ceVUS, suggesting its good reliability in reflux detection and grading. Using MCU as reference, ceVUS had 100 % sensitivity and 84 % specificity and carried higher reflux detection rate than MCU (p?<?0.001). There was no complication encountered. Conclusion: Voiding urosonography is a reliable, sensitive, safe and radiation-free modality in the investigation of vesicoureteric reflux in children. It should be incorporated in the diagnostic algorithm in paediatric urinary tract infection.     

排尿性尿路超声造影对儿童原发性膀胱输尿管反流的诊断价值

目的 探讨排尿性尿路超声造影(contrast-enhanced voiding urosonography,CeVUS)对儿童原发性膀胱输尿管反流(vesicoureteral reflux,VUR)的诊断价值.方法 回顾性分析上海儿童医学中心2018年12月至2020年6月116例[232个肾盂-输尿管单位(pye...     

Voiding urosonography with ultrasound contrast agents for the diagnosis of vesicoureteric reflux in children

Voiding urosonography (VUS) encompasses examination of the urinary tract with intravesical administration of US contrast agent (UCA) for diagnosis of vesicoureteric reflux (VUR). The real breakthrough for US examination of VUR came with the availability of stabilized UCAs in the mid-1990s. This article presents a comprehensive review of various procedural aspects of VUS. Different US modalities are available for detecting the echogenic microbubbles: fundamental mode, colour Doppler US, harmonic imaging and dedicated contrast imaging with multiple display options. The reflux is graded (1 to 5) in a similar manner to the system used in voiding cystourethrography (VCUG). The most commonly used UCA for VUS, Levovist, is galactose-based and contains air-filled microbubbles. The recommended concentration is 300 mg/ml at a dose of 5–10%, or less than 5%, of the bladder filling volume when using fundamental or harmonic imaging modes, respectively. There are preliminary reports of VUS using a second-generation UCA, SonoVue. Here the UCA volume is less than 1% of the bladder filling volume. There is no specific contraindication to intravesical administration of UCA. The safety profile of intravesical Levovist is very high with no reports of side effects over a decade of use in VUS.     

Voiding urosonography with US contrast agent for the diagnosis of vesicoureteric reflux in children: an update

Voiding urosonography (VUS) entails the intravesical administration of US contrast agent (USCA) for the diagnosis of vesicoureteric reflux (VUR). VUS is now recognized as a practical, safe, radiation-free modality with comparable or higher sensitivity than direct radionuclide cystography (DRNC) and voiding cystourethrography (VCUG), respectively. An extensive review of the literature regarding both the procedural aspects and comparative diagnostic values of VUS has been published (Darge Pediatr Radiol 38:40–63, 2008a, b). The aim of this review is to provide an update on various facets of VUS that have taken place since the publication of the above-mentioned two reviews.     

超声排泄性尿路造影在膀胱输尿管反流分级中的诊断价值

目的 评估超声排泄性尿路造影(CeVUS)在膀胱输尿管反流(VUR)诊断及分级评判中的准确性及超声观察者间分级的一致性.方法 纳入39例(共79个肾盂-输尿管单位)进行CeVUS及X线逆行尿路造影(VCUG)检查的患儿进行回顾性分析.以VCUG检查结果为金标准,计算CeVUS对VUR诊断的特异度、灵敏度及分级的准确率....     

儿童膀胱输尿管反流行超声尿路造影病例系列报告

目的 探讨超声尿路造影(CeVUS)对诊断和随访膀胱输尿管反流(VUR)的价值。方法 选择复旦大学附属儿科医院2018年9月27日至2019年5月10日收治的VUR高危患儿,利用六氟化硫微泡造影剂经膀胱内给药,进行CeVUS检查。总结CeVUS的检查结果,并结合临床特点进行分析。结果 50例患儿行CeVUS检查,男21例(42%,孤立肾2例),女29例(孤立肾1例),中位年龄25.0(2.3~99)月。①首次接受CeVUS检查者26例(50个PUUs),阳性15例(57.7%),其中低级别反流6例(40.0%),中、高级别反流9例(60.0%)。21/50个PUUs存在VUR,中、高级别反流14个(66.7%)。②24例(47个PUUs)既往行MCU,随访行CeVUS检查仍有24/47个(51.1%)PUUs 存在反流。反流好转患儿CeVUS与MCU检查间隔时间明显长于随访恶化或相仿患儿的随访时间(19.1月 vs 12.2月,P=0.02)。③在接受CeVUS的患儿中,14例已通过前期B超等检查发现存在除VUR以外的泌尿系发育畸形或有肾外表现。9例在完善CeVUS检查前已行MCU检查提示存在VUR。未发现造影剂相关的不良事件。结论 CeVUS可用于VUR的诊断和随访。     

儿童膀胱输尿管反流行超声尿路造影病例系列报告

目的 探讨超声尿路造影(CeVUS)对诊断和随访膀胱输尿管反流(VUR)的价值。方法 选择复旦大学附属儿科医院2018年9月27日至2019年5月10日收治的VUR高危患儿,利用六氟化硫微泡造影剂经膀胱内给药,进行CeVUS检查。总结CeVUS的检查结果,并结合临床特点进行分析。结果 50例患儿行CeVUS检查,男21例(42%,孤立肾2例),女29例(孤立肾1例),中位年龄25.0(2.3~99)月。①首次接受CeVUS检查者26例(50个PUUs),阳性15例(57.7%),其中低级别反流6例(40.0%),中、高级别反流9例(60.0%)。21/50个PUUs存在VUR,中、高级别反流14个(66.7%)。②24例(47个PUUs)既往行MCU,随访行CeVUS检查仍有24/47个(51.1%)PUUs 存在反流。反流好转患儿CeVUS与MCU检查间隔时间明显长于随访恶化或相仿患儿的随访时间(19.1月 vs 12.2月,P=0.02)。③在接受CeVUS的患儿中,14例已通过前期B超等检查发现存在除VUR以外的泌尿系发育畸形或有肾外表现。9例在完善CeVUS检查前已行MCU检查提示存在VUR。未发现造影剂相关的不良事件。结论 CeVUS可用于VUR的诊断和随访。     

Comprehensive ultrasound versus voiding cysturethrography in the diagnosis of vesicoureteral reflux

This study evaluates the accuracy of noninvasive renal ultrasound (US) in the detection of dilative vesicoureteric reflux (VUR) compared to voiding cysturethrography (VCUG), taking both sonographic morphology and kidney length into account. The data and images of 205 paediatric patients who had renal ultrasound and VCUG performed were reviewed. Abnormalities of renal length and kidney morphology were compared with degree of reflux on VCUG for each renal unit. A total of 407 renal units were evaluated. When the sonographic diagnosis of reflux was based solely on morphological criteria and degree of dilatation, correlation with VCUG results was poor. However, the fraction of kidneys of anomalous size increased markedly with grade of reflux, from 10% of non-refluxing renal units to 50% of renal units subjected to grade 4 and 5 VUR. Taking abnormal kidney length into account as well, dilative VUR was diagnosed by ultrasound with a sensitivity of 92% (95% CI 82%-100%) and a sensitivity of 67% (95% CI 63%-72%), P<0.001. CONCLUSION: the results of this study show that ultrasound cannot accurately diagnose vesicoureteric reflux by morphological changes alone, but requires the consideration of age-adjusted abnormalities in kidney length.     

Voiding urosonography with US contrast agents for the diagnosis of vesicoureteric reflux in children

Studies comparing voiding urosonography (VUS) with voiding cystourethrography (VCUG) and direct radionuclide cystography (DRNC) were analyzed and detailed tables demonstrating the diagnostic values and grading of vesicoureteric reflux (VUR) are presented. Comparative studies of DRNC were too few and did not allow definite conclusions. Using VCUG as the reference, the results of VUS were as follows: sensitivity 57–100%, specificity 85–100%, positive/negative predictive values 58–100%/87–100%, respectively, and diagnostic accuracy 78–96%. With the exception of two studies the diagnostic accuracy reported was 90% and above. In 19% of pelviureteric units (PUUs) the diagnosis was made only by VUS and in 10% only by VCUG. Thus in 9% of PUUs more refluxes were detected using VUS. In 73.6% the reflux grades were concordant in VUS and VCUG. Reflux grade was found to be higher with VUS than with VCUG in 19.6% of PUUs. In 71.2% of PUUs with grade I reflux on VCUG, the reflux was found to be grade II and higher on VUS. The common selection criteria for VUS as the primary examination for VUR currently include (a) follow-up studies, (b) first examination for VUR in girls, and (c) screening high-risk patients.     

Voiding urosonography as first step in the diagnosis of vesicoureteral reflux in children: a clinical experience

Background Contrast-enhanced voiding urosonography (VUS) is becoming more widely used for the diagnosis of vesicoureteric reflux (VUR), but until now its use has only been accepted for first diagnosis in females and in the follow-up of children, including boys, who have already undergone voiding cystourethrography (VCUG). Objective To describe our 6-year experience with VUS used as a first step in the diagnosis of VUR. Materials and methods A total of 610 children (334 boys, 276 girls; mean age 22 months), underwent VUS as the first step in the diagnosis of VUR. In selected children, VCUG was also performed. Results VUR was detected in 199 of 610 VUS examinations, and 265 refluxing kidney–ureter units were found. Children with VUR underwent antibiotic prophylaxis or surgery. Children without VUR underwent clinical follow-up. Just 60 children underwent VCUG. The criteria for VCUG were: high-grade VUR after consultation with a urologist, onset of urinary tract infection while receiving prophylaxis, nondiagnostic VUS, and other malformations with or without clinical signs. Conclusion Our experience suggests that we can use VUS as the first step in the diagnosis of VUR in children, boys and girls, with a significant reduction in radiation exposure.     

Intraoperative contrast-enhanced urosonography during endoscopic treatment of vesicoureteral reflux in children

Background

There are many controversies surrounding the effectiveness of endoscopic treatment of vesicouretheral reflux (VUR) in children, thus it is of highest priority to analyze factors influencing the outcome of therapy and to search for new methods that would increase the success rate and reduce the number of reinjections.

Objective

The aim of the study was to analyze whether intraoperative contrast-enhanced urosonography (ce-US) may increase the effectiveness of endoscopic anti-reflux therapy.

Materials and methods

Intraoperative contrast-enhanced urosonography (ce-US) with SonoVue® was performed in 17 patients (25 ureteral units) undergoing endoscopic treatment of VUR. Ce-US was performed in the operating room before the procedure and after injection of the bulking material. When VUR persisted, the operator repeated the injection, which was followed by ce-US. The results were compared with those obtained from a control group (15 patients; 22 ureteral units).

Results

A repeat injection during a single endoscopic treatment was required in 24% of cases. The overall success rate confirmed at 6–12 months’ follow-ups was 84%. The success rate was significantly higher in comparison to the control group (success: 64%).

Conclusion

Intraoperative ce-US performed during endoscopic treatment of VUR enables immediate monitoring of outcome and provides the opportunity for repeat injection during the same procedure, thus increasing the efficacy of the procedure and reducing the number of reinjections.