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Ren J, Ma T, Huang S, Chen G, Dietrich CF, Peng Y, Cui X. A narrative review on the applications of intracavitary contrast-enhanced ultrasonography in pediatric lower genitourinary anomalies. Front Pediatr 2023; 11:984643. [PMID: 37274817 PMCID: PMC10236366 DOI: 10.3389/fped.2023.984643] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 04/13/2023] [Indexed: 06/07/2023] Open
Abstract
PURPOSE We mainly aimed to perform a narrative review of clinical applications of the three intracavitary contrast-enhanced ultrasonography (CEUS) including contrast-enhanced voiding urosonography (ceVUS), contrast-enhanced retrograde urethrosonography (ceRUG), and contrast-enhanced genitosonography (ceGS) in pediatric lower genitourinary anomalies. METHOD A literature search in the PubMed and Web of Science databases was conducted up to 1 July 2022 on all studies published in English using the search terms "contrast-enhanced voiding urosonography", "contrast-enhanced retrograde urethrosonography", and "contrast-enhanced genitosonography". Trials were limited to pediatric subjects (ages ≤18 years) with no time restrictions. The inclusion criteria were studies on ceVUS, ceRUG, and ceGS to evaluate pediatric lower genitourinary anomalies. Two independent authors summarized the included articles. RESULTS Finally, a total of 48 original articles and 6 case reports or case series were included, of which 50 (93%) were only relevant to ceVUS, 3 (5%) articles involved ceGS, while only one (2%) article involved ceRUG, and 87% of the applications of ceVUS were focused on vesicoureteral reflux (VUR). We also searched 24 related reviews, of which 20 involved ceVUS in diagnosing VUR and 4 involved ceRUG and ceGS for other lower genitourinary anomalies. CONCLUSION Intracavitary CEUS including ceVUS, ceRUG, and ceGS in pediatrics has many advantages over other radiological examinations in diagnosing lower genitourinary anomalies. Although ceVUS is widely used in detecting VUR, ceRUG and ceGS have also become promising techniques for evaluating the urethral pathologies and urogenital sinus.
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Affiliation(s)
- Jiayu Ren
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Ma
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuyan Huang
- Department of Ultrasound, The First People’s Hospital of Huaihua, Huaihua, China
| | - Gongquan Chen
- Department Allgemeine Innere Medizin, Kliniken Hirslanden Bern, Beau Site, Salem und Permanence, Bern, Switzerland
| | - Christoph F. Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden Bern, Beau Site, Salem und Permanence, Bern, Switzerland
| | - Yuexiang Peng
- Department of Ultrasound, The Third Hospital of Wuhan, Wuhan, China
| | - Xinwu Cui
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Sofia C, Solazzo A, Cattafi A, Chimenz R, Cicero G, Marino MA, D'angelo T, Manti L, Condorelli E, Ceravolo G, Mazziotti S, Ascenti G. Contrast-enhanced voiding urosonography in the assessment of vesical-ureteral reflux: the time has come. Radiol Med 2021; 126:901-909. [PMID: 33954899 DOI: 10.1007/s11547-021-01360-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/19/2021] [Indexed: 02/02/2023]
Abstract
Vesicoureteral reflux (VUR) is a pathological condition contradistinguished by monolateral or bilateral retrograde flow of urine from the bladder to the ureter and to the kidney. If not properly recognized and treated, VUR can potentially be associated to several complications such as recurrent infections and possible secondary scars with Chronic Kidney Disease (CKD). Furthermore, it represents an important risk factor for nephrovascular hypertension. During the last 20 years, the diagnostic approach to this entity has passed through several, drastic changes: indeed, since its introduction in 1994 contrast-enhanced voiding urosonography (ceVUS) has gradually accompanied the voiding cystourethrography (VCUG) as alternative imaging technique for the diagnosis and staging of VUR. Despite a large number of papers has strongly encouraged its use in clinical practice, due to the lack of ionizing radiations and its high sensitivity rate, to date almost all the guidelines only include the VCUG for VUR diagnosis. The introduction of technologically advanced US software and the approval of the intravesical administration of ultrasound contrast agents by the Food and Drug Administration (FDA) and by the European Medicine Agency (EMA) have to induce the Scientific Community to a deep revaluation of the role of ceVUS in the diagnosis and follow-up of VUR: urosonography might extensively replace VCUG as the reference method, reserving to cystourethrography a role in the most complex anatomic settings for pre-surgical evaluation.
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Affiliation(s)
- Carmelo Sofia
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Antonio Solazzo
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Antonino Cattafi
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Roberto Chimenz
- Unit of Pediatric Nephrology With Dialysis, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, "G. Martino" Policlinic, Messina, Italy
| | - Giuseppe Cicero
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Maria Adele Marino
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Tommaso D'angelo
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Lauretta Manti
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Elvira Condorelli
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Giorgia Ceravolo
- Unit of Emergency Pediatric, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, "G. Martino" Policlinic, Messina, Italy
| | - Silvio Mazziotti
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
| | - Giorgio Ascenti
- Section of Radiological Sciences, Department of Biomedical, Dental Sciences and Morphological and Functional Imaging, University of Messina, "G. Martino" Policlinic, Via Consolare Valeria 1, 98100, Messina, Italy
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Cvitkovic-Roic A, Turudic D, Milosevic D, Palcic I, Roic G. Contrast-enhanced voiding urosonography in the diagnosis of intrarenal reflux. J Ultrasound 2021; 25:89-95. [PMID: 33635511 PMCID: PMC8964875 DOI: 10.1007/s40477-021-00568-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/03/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Although contrast-enhanced urosonography (ceVUS) has shown capable diagnostic accuracy for the diagnosis of vesicoureteral reflux (VUR) in children, the ability of ceVUS to detect intrarenal reflux (IRR) is considered limited. The purpose of our study is to assess the ability of ceVUS to detect IRR as well as its association with age, gender, and the grade of VUR. METHODS This study included 5153 children who were referred to our clinic for ceVUS. All children underwent sonographic examinations, which were performed on a LOGIQ S8 machine equipped with dedicated software for contrast-enhanced studies with harmonic imaging. Standard ultrasound of the urinary tract was followed by bladder catheterisation and instillation of physiological normal saline and the US contrast medium (SonoVue®, Bracco). RESULTS VUR was diagnosed by ceVUS in 1959 out of 5153 children (38%), of whom IRR was found in 233 of 1959 children (11.9%). A total of 285 ureteral units showing IRR were found. High grades of VUR (IV + V) with IRR were found in a total of 235 of 285 (82.81%) renal units. Bilateral IRR was found in 53 patients, usually with a high-grade VUR on both sides. Most children had VUR grade IV, predominantly those < 12 months. The younger the child, the higher the likelihood of higher-grade VUR (p = 0.02). CONCLUSION ceVUS, combined with harmonic imaging and second-generation ultrasound contrast media, enabled IRR detection in almost 12% of our patients with VUR. IRR is most commonly found in children under 1 year of age with VUR grades IV and V.
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Affiliation(s)
- Andrea Cvitkovic-Roic
- Helena Clinic for Pediatric Medicine, Kneza Branimira 71, 10000 Zagreb, Croatia ,Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Daniel Turudic
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva 12, 10 000, Zagreb, Croatia.
| | - Danko Milosevic
- School of Medicine, University of Zagreb, Salata 3, 10 000 Zagreb, Croatia
| | - Iva Palcic
- Helena Clinic for Pediatric Medicine, Kneza Branimira 71, 10000 Zagreb, Croatia
| | - Goran Roic
- Children′s Hospital Zagreb, Ul. Vjekoslava Klaića 16, 10000 Zagreb, Croatia ,The Faculty of Medicine, University of Rijeka, Braće Branchetta 20/1, 10 000 Zagreb, Croatia
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[Sensitivity of voiding urosonography as a function of the number of the cyclic bladder fillings]. Radiologe 2021; 61:490-496. [PMID: 33587149 DOI: 10.1007/s00117-021-00818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Vesicoureteral reflux (VUR) can occur intermittently. Cyclic testing of VUR (observation of multiple phases of filling and micturition) increases the detection rate of VUR, as has been shown in studies which have generally used a two-cycle test period. OBJECTIVES How large is the dependence of the sensitivity in voiding urosonography (VUS) on the number of observed cycles when more than two cycles are observed in a larger number of patients? How many cycles should be observed in order to achieve sufficient sensitivity? PATIENTS AND METHODS The study population consisted of 302 patients (225 female, average age 2.5 years [range 1 month-17 years]; 77 male, average age 6 months [range 1 month-2.5 years]) with 607 kidney-ureter units (KUU), examined in a pediatrican practice from 05 January 2016 to 31 December 2019. The examinations were performed by contrast-enhanced color Doppler voiding urosonography using the ultrasound contrast agent SonoVue® (Bracco Imaging, Milan, Italy) for an average of 3.14 cycles and, in the case of undetectable VUR, for an average of 3.5 cycles (range 1-6 cycles). RESULTS In all, 118 of 302 patients were found to have VUR. In terms of KUU, 163 of 607 KUU exhibited reflux. VUR occurred intermittently in 32.5% of KUU. Depending on the number of cycles observed, there was a significant increase in sensitivity of the VUS. Using the observation of five cycles as a reference for the sensitivity, the following values are obtained: 1 cycle = 82.2%, 2 cycles = 87.7%, 3 cycles = 96.3%, 4 cycles = 98.8%, 5 cycles = 100%. CONCLUSIONS To achieve a sensitivity of 96% in detecting VUR, three cycles must be observed. If less than three cycles are observed, the sensitivity shows a marked decrease.
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Siomou E, Giapros V, Serbis A, Makrydimas G, Papadopoulou F. Voiding urosonography and voiding cystourethrography in primary vesicoureteral reflux associated with mild prenatal hydronephrosis: a comparative study. Pediatr Radiol 2020; 50:1271-1276. [PMID: 32638052 DOI: 10.1007/s00247-020-04724-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/01/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Contrast-enhanced harmonic voiding urosonography has been introduced as a sensitive, radiation-free imaging method for the diagnosis of vesicoureteric reflux. OBJECTIVE To evaluate the occurrence/severity of vesicoureteric reflux in infants with mild prenatal hydronephrosis comparing voiding cystourethrography and voiding urosonography. MATERIALS AND METHODS Sixty infants with prenatal hydronephrosis were studied (anteriοposterior pelvic diameter 5-9 mm on ultrasound [US] at gestational weeks 21-30). Postnatal US was performed within the first month of life, as well as voiding cystourethrography and contrast-enhanced voiding urosonography at 1.5-2.5 months at the same session. RESULTS Vesicoureteric reflux was diagnosed on at least one modality in 19/60 (32%) infants, and more often on contrast-enhanced voiding urosonography (18/60, 30%) than on voiding cystourethrography (8/60, 13%), P=0.046. Among girls, reflux was more often seen on contrast-enhanced voiding urosonography (6/16, 38%) than on voiding cystourethrography (1/16, 6%), P=0.03. Vesicoureteric reflux missed by voiding cystourethrography was more severe (Grades I, II and III in one, nine and four kidney-ureter-units, respectively), compared with a single case missed by contrast-enhanced voiding urosonography (Grade I in one kidney-ureter-unit). CONCLUSION In the absence of a reference standard, our results imply that voiding cystourethrography might underdiagnose reflux, and/or contrast-enhanced voiding urosonography may overdiagnose reflux.
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Affiliation(s)
- Ekaterini Siomou
- Department of Pediatrics, University Hospital of Ioannina, Stavros Niarchos Avenue, GR-45 500, Ioannina, Greece.
| | - Vasileios Giapros
- Department of Neonatal Intensive Care Unit, University Hospital of Ioannina, Ioannina, Greece
| | - Anastasios Serbis
- Department of Pediatrics, University Hospital of Ioannina, Stavros Niarchos Avenue, GR-45 500, Ioannina, Greece
| | - George Makrydimas
- Department of Obstetrics-Gynecology, University Hospital of Ioannina, Ioannina, Greece
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Ntoulia A, Anupindi SA, Darge K, Back SJ. Applications of contrast-enhanced ultrasound in the pediatric abdomen. Abdom Radiol (NY) 2018; 43:948-959. [PMID: 28980061 DOI: 10.1007/s00261-017-1315-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Contrast-enhanced ultrasound (CEUS) is a radiation-free, safe, and in specific clinical settings, highly sensitive imaging modality. Over the recent decades, there is cumulating experience and a large volume of published safety and efficacy data on pediatric CEUS applications. Many of these applications have been directly translated from adults, while others are unique to the pediatric population. The most frequently reported intravenous abdominal applications of CEUS in children are the characterization of focal liver lesions, monitoring of solid abdominal tumor response to treatment, and the evaluation of intra-abdominal parenchymal injuries in selected cases of blunt abdominal trauma. The intravesical CEUS application, namely contrast-enhanced voiding urosonography (ceVUS), is a well-established, pediatric-specific imaging technique entailing the intravesical administration of ultrasound contrast agents for detection and grading of vesicoureteral reflux. In Europe, all pediatric CEUS applications remain off-label. In 2016, the United States Food and Drug Administration (FDA) approved the most commonly used worldwide second-generation ultrasound contrast SonoVue®/Lumason® for pediatric liver and intravesical applications, giving new impetus to pediatric CEUS worldwide.
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Affiliation(s)
- Aikaterini Ntoulia
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Sudha A Anupindi
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Susan J Back
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Kuzmanovska D, Risteski A, Kambovska M, Trpcevski T, Sahpazova E, Petrovski M. Voiding Urosonography with Second-Generation Ultrasound Contrast Agent for Diagnosis of Vesicoureteric Reflux: First Local Pilot Study. Open Access Maced J Med Sci 2017; 5:215-221. [PMID: 28507631 PMCID: PMC5420777 DOI: 10.3889/oamjms.2017.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND: Vesicoureteric reflux (VUR) is an important association of paediatric urinary tract infection (UTI) found in 30-50% of all children presenting with first UTI. Contrast-enhanced voiding ultrasonography (ceVUS) has become an important radiation-free method for VUR detection in children. Its sensitivity in detecting VUR has greatly improved due to the development of the contrast-specific ultrasound techniques and the introduction of the second-generation ultrasound contrast agent, superseding the diagnostic accuracy of standard radiological procedures. AIM: This article aimed to summarise the current literature and discuss the first local pilot study performed in our institution on detection of vesicoureteric reflux by contrast-enhanced voiding ultrasonography with second- generation agent (SonoVue, Bracco, Italy). MATERIAL AND METHODS: Retrospective review of the first 31 ceVUS (24 girls, 7 boys) was presented. Age range was 2 months to 18 years (mean = 6.4 ± 4.9). RESULTS: All examinations were well tolerated without any adverse incident. VUR was shown in 20 (64.5%) children in 32/62 (51.6) nephroureteral units (NUUs). In 18 NUUs, VUR was grade II/V, in 11 Grade III/V and in 3 grade IV/V, respectively. Urethra was shown in 19/31 children and in all boys, without pathological finding. In two girls spinning top urethra has been detected. Subsequent urodynamic studies revealed functional bladder problem in both. CONCLUSIONS: Contrast-enhanced voiding urosonography using intravesical second generation ultrasound contrast agent could be recommend as a valid alternative diagnostic modality for detecting vesicoureteral reflux and evaluation of the distal urinary tract in children, based on its radiation-free, highly efficacious, reliable, and safe characteristics.
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Affiliation(s)
- Dafina Kuzmanovska
- University Children's Hospital, Medical Faculty, Ss Cyril and Methodius University of Skopje, Vodnjanska 17, Skopje, Republic of Macedonia
| | | | | | - Tase Trpcevski
- Private Hospital Plodnost, ASNOM 9, Bitola, Republic of Macedonia
| | - Emilija Sahpazova
- University Children's Hospital, Medical Faculty, Ss Cyril and Methodius University of Skopje, Vodnjanska 17, Skopje, Republic of Macedonia
| | - Mile Petrovski
- University Pediatric Surgery Clinic, Medical Faculty, Ss Cyril and Methodius University of Skopje, Vodnjanska 17, Skopje, Republic of Macedonia
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Sauer A, Wirth C, Platzer I, Neubauer H, Veldhoen S, Dierks A, Kaiser R, Kunz A, Beer M, Bley T. Off-label-use of sulfur-hexafluoride in voiding urosonography for diagnosis of vesicoureteral reflux in children: A survey on adverse events. World J Clin Pediatr 2017; 6:52-59. [PMID: 28224096 PMCID: PMC5296630 DOI: 10.5409/wjcp.v6.i1.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/30/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the risk profile of sulfur hexafluoride in voiding urosonography (VUS) based on a large cohort of children.
METHODS Since 2011 sulfur hexafluoride (SH, SonoVue®, Bracco, Italy) is the only ultrasound contrast available in the European Union and its use in children has not been approved. Within a 4-year-period, 531 children with suspected or proven vesicoureteral reflux (f/m = 478/53; mean age 4.9 years; 1 mo-25.2 years) following parental informed consent underwent VUS with administration of 2.6 ± 1.2 mL SH in a two-center study. A standardized telephone survey on adverse events was conducted three days later.
RESULTS No acute adverse reactions were observed. The survey revealed subacute, mostly self-limited adverse events in 4.1% (22/531). The majority of observed adverse events (17/22) was not suspected to be caused by an allergic reaction: Five were related to catheter placement, three to reactivated urinary tract infections, five were associated with perineal disinfection before voiding urosonography or perineal dermatitis and four with a common cold. In five patients (0.9%) hints to a potential allergic cause were noted: Perineal urticaria was reported in three interviews and isolated, mild fever in two. These were minor self-limited adverse events with a subacute onset and no hospital admittance was necessary. Ninety-six point two percent of the parents would prefer future VUS examinations with use of SH.
CONCLUSION No severe adverse events were observed and indications of self-limited minor allergic reactions related to intravesical administration of SH were reported in less than 1%.
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Awais M, Rehman A, Zaman MU, Nadeem N. Recurrent urinary tract infections in young children: role of DMSA scintigraphy in detecting vesicoureteric reflux. Pediatr Radiol 2015; 45:62-8. [PMID: 24993242 DOI: 10.1007/s00247-014-3062-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 04/29/2014] [Accepted: 05/21/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Performing micturiting cystourethrography (MCUG) in young children with recurrent urinary tract infections is controversial with discrepancy among the major guidelines. OBJECTIVE Previous studies have shown that a normal dimercaptosuccinic acid (DMSA) scintigraphy may avoid the need of performing MCUG for detecting vesicoureteric reflux in children with first febrile urinary tract infection. However, the role of DMSA for ruling out vesicoureteric reflux in children with recurrent urinary tract infections has not been studied. MATERIALS AND METHODS Approval from institutional ethical review committee was sought and the requirement of informed consent was waived. A total of 50 children under the age of 10 years with recurrent urinary tract infections underwent MCUG scan within 3 months of DMSA scan from January 2011 to September 2012 at our institution. Diagnosis of recurrent urinary tract infections and grading of vesicoureteric reflux was according to previously established standards. Abnormalities on DMSA scan - scarring, hydronephrosis and reduced differential renal function - were compared with presence of vesicoureteric reflux on MCUG. RESULTS High-grade vesicoureteric reflux was noted on MCUG in 22 (44%) cases. The findings on DMSA included hydronephrosis and scarring in 25 (50%) and 25 (50%) cases, respectively. Abnormalities on DMSA scan for detecting the presence of high-grade vesicoureteric reflux on MCUG examination had sensitivity, specificity, positive and negative predictive values of 95.45%, 35.71%, 53.85% and 90.91%, respectively. The positive and negative likelihood ratios were 1.48 and 0.13 respectively. CONCLUSION DMSA scan had high overall sensitivity and negative predictive value with a low negative likelihood ratio for ruling out high-grade vesicoureteric reflux on MCUG, which may obviate the need of invasive MCUG along with its associated drawbacks.
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Affiliation(s)
- Muhammad Awais
- Department of Radiology, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan,
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Contrast-enhanced voiding urosonography with intravesical administration of a second-generation ultrasound contrast agent for diagnosis of vesicoureteral reflux: prospective evaluation of contrast safety in 1,010 children. Pediatr Radiol 2014; 44:719-28. [PMID: 24442338 DOI: 10.1007/s00247-013-2832-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 10/25/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the safety of intravesical administration of a second-generation ultrasound (US) contrast agent for the diagnosis of vesicoureteral reflux in children. MATERIALS AND METHODS One thousand and ten children (563 girls, 447 boys; mean age: 2.9 years, range: 15 days-17.6 years) with 2,043 pelvi-ureter-units underwent contrast-enhanced voiding urosonography (ce-VUS) to rule out vesicoureteral reflux. A second-generation US contrast agent (SonoVue®, Bracco, Milan) was administered intravesically through transurethral bladder catheterization at a dose of 0.5 ml/bladder filling. Possible adverse events were monitored during the examination and followed up for 7 days after ce-VUS by phone calls. Urine analysis and culture were performed 3-5 days before ce-VUS in all children and 24-48 h in any patient who reported with adverse events. RESULTS No case of serious adverse event was recorded. Minor events were reported in 37 children (3.66% of the study population). These included dysuria (n = 26, 2.57%), urinary retention (n = 2, 0.2%), abdominal pain (n = 2, 0.2%), anxiety (n = 1, 0.1%) and crying (n = 1, 0.1%) during micturition, blood and mucous discharge (n = 1, 0.1%), increased frequency of micturition (n = 1, 0.1%), vomiting (n = 1, 0.1%), perineal irritation (n = 1, 0.1%), and an episode of urinary tract infection 10 days after ce-VUS (n = 1, 0.1%). Of these adverse events, 91.9% were subacute in onset and 8.1% were delayed. All events were self-limited and none required hospitalization. CONCLUSION There were no serious adverse events. Only a few minor events were reported, most likely due to the catheterization process. Thus, ce-VUS with intravesical administration of the second-generation US contrast agent (SonoVue®) for vesicoureteral reflux detection or exclusion had a favorable safety profile in our study group.
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Darge K, Papadopoulou F, Ntoulia A, Bulas DI, Coley BD, Fordham LA, Paltiel HJ, McCarville B, Volberg FM, Cosgrove DO, Goldberg BB, Wilson SR, Feinstein SB. Safety of contrast-enhanced ultrasound in children for non-cardiac applications: a review by the Society for Pediatric Radiology (SPR) and the International Contrast Ultrasound Society (ICUS). Pediatr Radiol 2013; 43:1063-73. [PMID: 23843130 DOI: 10.1007/s00247-013-2746-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 05/28/2013] [Accepted: 05/28/2013] [Indexed: 12/17/2022]
Abstract
The practice of contrast-enhanced ultrasound in children is in the setting of off-label use or research. The widespread practice of pediatric contrast-enhanced US is primarily in Europe. There is ongoing effort by the Society for Pediatric Radiology (SPR) and International Contrast Ultrasound Society (ICUS) to push for pediatric contrast-enhanced US in the United States. With this in mind, the main objective of this review is to describe the status of US contrast agent safety in non-cardiac applications in children. The five published studies using pediatric intravenous contrast-enhanced US comprise 110 children. There is no mention of adverse events in these studies. From a European survey 948 children can be added. In that survey six minor adverse events were reported in five children. The intravesical administration of US contrast agents for diagnosis of vesicoureteric reflux entails the use of a bladder catheter. Fifteen studies encompassing 2,951 children have evaluated the safety of intravesical US contrast agents in children. A European survey adds 4,131 children to this group. No adverse events could be attributed to the contrast agent. They were most likely related to the bladder catheterization. The existing data on US contrast agent safety in children are encouraging in promoting the widespread use of contrast-enhanced US.
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Affiliation(s)
- Kassa Darge
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Arthurs OJ, Edwards AD, Joubert I, Graves MJ, Set PAK, Lomas DJ. Interactive magnetic resonance voiding cystourethrography (iMRVC) for vesicoureteric reflux (VUR) in unsedated infants: a feasibility study. Eur Radiol 2011; 21:1874-81. [PMID: 21499959 DOI: 10.1007/s00330-011-2124-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 02/18/2011] [Accepted: 02/23/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The current reference standard for diagnosing vesicoureteric reflux is the X-ray-based Micturating CystoUrethroGram (MCUG). The aim of this study was to evaluate the feasibility of performing interactive Magnetic Resonance voiding cysto-urethrography (iMRVC) in un-sedated infants. METHODS Twelve infants underwent conventional single-cycle MCUG followed by iMRVC. In iMRVC, patients were examined using an in-house developed fluoroscopic pulse sequence, which allows on-the-fly control of image contrast and geometry. A single acquisition was performed during bladder filling, during and after micturition, with interactive control over imaging parameters. Images were assessed for diagnostic quality and presence of VUR. RESULTS Every case of reflux identified with MCUG was identified on iMRVC (100% sensitivity). Over 24 renal units, there was 88% concordance (21/24) according to the presence of reflux between the two methods. There were three "false positives" detected by MRI, giving a specificity of 83.3%, PPV of 66.7% and NPV of 100%. CONCLUSION iMRVC is a feasible method for evaluating the renal tract in infants without the need for radiation or sedation. A formal evaluation is required to establish its diagnostic potential.
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Affiliation(s)
- Owen J Arthurs
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Box 219, Addenbrookes Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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Harmonic voiding urosonography with a second-generation contrast agent for the diagnosis of vesicoureteral reflux. Pediatr Radiol 2009; 39:239-44. [PMID: 19096835 DOI: 10.1007/s00247-008-1080-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Revised: 10/10/2008] [Accepted: 10/19/2008] [Indexed: 12/22/2022]
Abstract
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.
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Darge K. Voiding urosonography with ultrasound contrast agents for the diagnosis of vesicoureteric reflux in children. I. Procedure. Pediatr Radiol 2008; 38:40-53. [PMID: 17618429 PMCID: PMC2292498 DOI: 10.1007/s00247-007-0529-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Revised: 04/23/2007] [Accepted: 05/01/2007] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kassa Darge
- Department of Pediatric Radiology, University Hospital Wuerzburg, Josef-Schneider Strasse 2/D31, Wuerzburg, Germany.
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Darge K. Voiding urosonography with US contrast agents for the diagnosis of vesicoureteric reflux in children. II. Comparison with radiological examinations. Pediatr Radiol 2008; 38:54-63; quiz 126-7. [PMID: 17639371 DOI: 10.1007/s00247-007-0528-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Revised: 04/23/2007] [Accepted: 05/01/2007] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kassa Darge
- Department of Pediatric Radiology, University Hospital Wuerzburg, Josef-Schneider Strasse 2/D31, Wuerzburg, Germany.
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Contrast-enhanced ultrasonography (voiding urosonography) of vesicoureteral reflux: State of the art. Radiol Med 2007; 112:1211-24. [PMID: 18074194 DOI: 10.1007/s11547-007-0218-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 03/15/2007] [Indexed: 10/22/2022]
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Stefanidis CJ, Siomou E. Imaging strategies for vesicoureteral reflux diagnosis. Pediatr Nephrol 2007; 22:937-47. [PMID: 17216249 PMCID: PMC6904398 DOI: 10.1007/s00467-006-0396-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2006] [Revised: 11/09/2006] [Accepted: 11/09/2006] [Indexed: 10/25/2022]
Abstract
The prevalence of vesicoureteral reflux (VUR), although reported to be low in the general population, is high in children with urinary tract infection (UTI), first degree relatives of patients with known VUR and children with antenatal hydronephrosis. In addition, it has been shown that VUR and UTIs are associated with renal scarring, predisposing to serious long-term complications, i.e., hypertension, chronic renal insufficiency and complications of pregnancy. Therefore, diagnostic imaging for the detection of VUR in the high-risk groups of children has been a standard practice. However, none of these associations has been validated with controlled studies, and recently the value of identifying VUR after a symptomatic UTI has been questioned. In addition, several studies have shown that renal damage may occur in the absence of VUR. On the other hand, some patients, mainly males, may have primary renal damage, associated with high-grade VUR, without UTI. Recently, increasing skepticism has been noted concerning how and for whom it is important to investigate for VUR. It has been suggested that the absence of renal lesions after the first UTI in children may rule out VUR of clinical significance and reinforces the redundancy of invasive diagnostic techniques. Therefore, the priority of imaging strategies should focus on early identification of renal lesions to prevent further deterioration.
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Affiliation(s)
- Constantinos J Stefanidis
- Department of Nephrology, P. & A. Kyriakou Children's Hospital of Athens, Goudi, 14562, Athens, Greece.
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