The use of echo-enhanced voiding urosonography (VUS) to detect VUR is an attractive option.
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1 The role of the echo-enhanced voiding urosonography (VUS) compared to micturating cystourethrography (MCU) in daily practice in the study of vesicoureteral reflux (VUR) Poster No.: C-1201 Congress: ECR 2015 Type: Scientific Exhibit Authors: F. Ferrari, C. Modolon, F. Carfagnini, R. Sciutti, G. Tani, M. Zompatori; Bologna/IT Keywords: DOI: Dosimetric comparison, Cystography / Uretrography, Contrast agent-other, Ultrasound, Conventional radiography, Urinary Tract / Bladder, Pediatric, Kidney /ecr2015/C-1201 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10
2 Aims and objectives Vescicoureteric reflux (VUR) is defined as retrograde flow of urine from the bladder into the renal collecting system that provides a pathway for ascent of bacteria in the presence of urinary tract infection. Early diagnosis and a proper treatment will reduce the risks of renal scarring and subsequent renal hypertension and, even worse, renal failure (reflux nephropathy is responsible for 30%-50% of end-stage renal disease in pediatric patients and for 20% in adults). Actually the gold standard in diagnosing VUR is micturating cystouretherography (MCU) but this examination exposes the young patient to ionising radiation. The use of echo-enhanced voiding urosonography (VUS) to detect VUR is an attractive option. Our aim is to reviewing the sensitivity of VUS in the VUR diagnosis. Methods and materials Twenty-one patients (1 male, 10 females), aged from 13 days to 21 years old (mean age: 5 y.o.) underwent VUS examination in our institution between June 2010 and April Nine of them also performed a CMU study with a remote controlled system. The clinical indications for examinations were: pyelectasis (6 cases), urinary tract infections (9), megaureter (3), ureterocele (1), surgically treated cloacal malformation (1) and a follow-up of a known VUR. By means of an ultrasound machine (Philips iu22) with a specific preset for contrast agents and after a baseline ultrasound examination of the urinary system, we started to fill the bladder until obtaining a complete and homogeneous opacification ( Fig. 1 on page 3 ). The bladder catheter was connected to a three-way system for the rapid introduction of physiological saline solution and a second-generation contrast agent (2,5 cc of SonoVue, Bracco). The presence and grade of passive and active VUR have been evaluated. The diagnosis of VUR was confirmed when contrast material was present in the ureter and, possibly, in the renal pelvis ( Fig. 2 on page 3 ). VUR was graded as: Grade I: microbubbles seen in ureter only; Grade II: microbubbles seen in non-dilated pelvicaliceal system; Page 2 of 10
3 Grade III: microbubbles detected in the renal pelvis + significant renal pelvic dilatation + moderate calyceal dilatation; Grade IV: microbubbles detected in the renal pelvis and calyces + significant calyceal dilatation; Grade V: Grade 4 + loss of renal pelvis contour + dilated tortuous ureter. Examination time was about 30 minutes. Images for this section: Fig. 1: Voiding urosonography with contrast agent in two different patients: A) Transverse scan of the bladder shows homogeneous filling of vesical lumen. B) A common artifact due to the presence of air microbubble (arrow) in the bladder. (Left Image: Contrastspecific harmonic imaging mode) Page 3 of 10
4 Fig. 2: A normal examination without contrast material reflux. On the right: a kidney with regular morphology; On the left: no documented bubbles in the renal pelvis. Page 4 of 10
5 Fig. 3: VUR in a 7-months-old boy with a urinary tract infection was depicted on both a (A) longitudinal cystosonogram and (B) frontal MCU image. In (A), which was obtained during filling of the bladder, grade 3 VUR is depicted in both renal poles. In (B), VUR is depicted with similar features and equal grade as are seen in (A). Fig. 4: A three years-old boy had neurogenic bladder. A) The sonogram shows left IV grade VUR with hydronephrosis and presence of microbubbles in dilated pelvicaliceal system; B) MCU confirm left Grade IV VUR. Fig. 5: A four months-old boy. A) Renal sonogram shows right severe hydronephrosis (Grade V VUR) with contrast material in pelvicaliceal system, in dilated ureter (asterisk) and into the bladder (arrow); B) MCU confirm right VUR. Page 5 of 10
6 Results Vescicoureteral reflux was detected in 11 patients (52%) (Fig. 3 on page 6 ; Fig. 4 on page 6 ; Fig. 5 on page 7) and a bladder diverticulum in 1 patient (5%). The CMU has confirmed the bladder diverticulum and all cases of VUR except for 1 (94%); in particular VUR hasn't confirmed the bilateralism of VUR. Images for this section: Fig. 3: VUR in a 7-months-old boy with a urinary tract infection was depicted on both a (A) longitudinal cystosonogram and (B) frontal MCU image. In (A), which was obtained during filling of the bladder, grade 3 VUR is depicted in both renal poles. In (B), VUR is depicted with similar features and equal grade as are seen in (A). Page 6 of 10
7 Fig. 4: A three years-old boy had neurogenic bladder. A) The sonogram shows left IV grade VUR with hydronephrosis and presence of microbubbles in dilated pelvicaliceal system; B) MCU confirm left Grade IV VUR. Fig. 5: A four months-old boy. A) Renal sonogram shows right severe hydronephrosis (Grade V VUR) with contrast material in pelvicaliceal system, in dilated ureter (asterisk) and into the bladder (arrow); B) MCU confirm right VUR. Page 7 of 10
8 Conclusion MCU have been routinely used for the diagnosis of VUR. Considering the radiation burden in this procedure VUS is a promising alternative for detection of VUR, with the main additional advantage of enabling continuous observation without radiation exposure. The main disadvantage of VUS is that the technique is operator- and patientdependent. We confirm the high sensitivity and specificity of VUS for the study of VUR, thus emphasizing the great advantage of radioprotection. Personal information Ferrari F., Radiology Unit, Cardio-Thoracic-Vascular Dept, University Hospital S. Orsola- Malpighi, Via Massarenti 9, Bologna, Italy. Modolon C., Radiology Unit, Emergency Radiology Dept, University Hospital S. Orsola- Malpighi, Via Massarenti 9, Bologna, Italy. Carfagnini F., Radiology Unit,, Pediatric Radiology, University Hospital S. Orsola- Malpighi, Via Massarenti 9, Bologna, Italy. Sciutti R., Radiology Unit,, Pediatric Radiology, University Hospital S. Orsola-Malpighi, Via Massarenti 9, Bologna, Italy. Tani G., Radiology Unit,, Pediatric Radiology, University Hospital S. Orsola-Malpighi, Via Massarenti 9, Bologna, Italy. Zompatori M., Radiology Unit, Cardio-Thoracic-Vascular Dept, University Hospital S. Orsola-Malpighi, Via Massarenti 9, Bologna, Italy. Page 8 of 10
9 References Berrocal T, Gayá F, Arjonilla A, Lonergan GJ. Vesicoureteral reflux: diagnosis and grading with echo-enhanced cystosonography versus voiding cystourethrography. Radiology Nov;221(2): Mahant S, Friedman J and MacArthur C. Renal ultrasound findings and vesicoureteric reflux in children hospitalized with urinary tract infection. Archives of Disease in Childhood 2002; 86(6): Berrocal T, Gaya# F, Arjonilla A and Lonergan GJ. Vesicoureteric reflux: Diagnosis and grading with echo-contrast cystosonography versus voiding cystouretherography. Radiology 2001; 221(2): Zimbaro G, Ascenti G, Visalli C, Bottari A, Zimbaro F, Martino N, Mazziotti S. Contrastenhanced ultrasonography (voiding urosonography) of vesicoureteral reflux: state of the art. Radiol Med Dec;112(8): Riccabona M. Application of a second-generation US contrast agent in infants and children--a European questionnaire-based survey. Pediatr Radiol Dec;42(12): Faizah M, Kanaheswari Y, Thambidorai C, Zulfiqar M. Echocontrast cystosonography versus micturating cystourethrography in the detection of vesicoureteric reflux. Biomed Imaging Interv J Jan-Mar;7(1):e7. Kenda RB, Kenig A, Novljan G, Ponikvar R, Ponikvar JB. Cyclic voiding urosonography for detecting vesicoureteric reflux in renal transplant recipients. Nephrol Dial Transplant Nov;16(11): Page 9 of 10
10 Adibi A, Gheysari A, Azhir A, Merikhi A, Khami S, Tayari N. Value of sonography in the diagnosis of mild, moderate and severe vesicoureteral reflux in children. Saudi J Kidney Dis Transpl Mar;24(2): Darge K. Voiding urosonography with US contrast agent for the diagnosis of vesicoureteric reflux in children: an update. Pediatr Radiol Jun;40(6): La Scola C, De Mutiis C, Hewitt IK, Puccio G, Toffolo A, Zucchetta P, Mencarelli F, Marsciani M, Dall'Amico R, Montini G. Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics Mar;131(3):e Page 10 of 10
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