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Vesicoureteral Reflux: Latest Option for Evaluation in Children¹

¹ From the Department of Radiology, Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229-3039. Received August 1, 2001; accepted August 3. Address correspondence to the author (e-mail: s.ohara@chmcc.org).

Index terms: Bladder, US, 83.12988, 83.12989 • Editorials • Ultrasound (US), contrast media, 82.12988, 83.12988 • Ureter, reflux, 82.85, 83.85 • Ureter, US, 82.12988, 82.12989 • Voiding cystourethrography, 82.123, 83.123

In our world of ever increasing choices, add contrast material–enhanced cystosonography to the menu of radiographic voiding cystourethrography and radionuclide cystography for detection of vesicoureteral reflux in pediatric patients. Actually, radiologists in the United States will have to wait a little longer for U.S. Food and Drug Administration approval of ultrasonographic (US) contrast agents. Still, these agents will likely send the clinical pathways for evaluation of urinary tract infection right back to the committees that struggled to reach a consensus in their last revision.

Urinary tract imaging makes up a substantial portion of the pediatric workload in radiology departments. The scope of screening in children with urinary symptoms, primarily urinary tract infection, is justified by the roughly 25% of renal transplants that are a result of chronic renal failure caused by potentially treatable problems, namely, vesicoureteral reflux, recurrent urinary tract infection, and hydronephrosis or urinary tract obstruction (1,2). The imaging work-up in these patients has been controversial for many years (3). At national meetings, there is inevitably an expert panel discussion of the appropriate work-up of urinary tract infection, or at least some new research papers are delivered to add data to our evidence-based imaging algorithms. At the recent International Pediatric Radiology Meeting in Paris, France (May 28 to June 1, 2001), seven of the 10 studies in the genitourinary scientific session dealt with urinary tract infections; US contrast agents were used in two of the seven studies. Clearly, this is a topic that is not going away.

The study by Berrocal et al (4) in the current issue of Radiology is not the first on the subject and likely will not be the last (5–8). Their investigation was based on a larger study population than was used in previous reports and bolsters the credibility of prior works with similar data or results. Cystosonography appears to be as sensitive as voiding cystourethrography in the detection of vesicoureteral reflux; it may actually be more sensitive, on the basis of improved detection of transient vesicoureteral reflux with continuous US versus intermittent fluoroscopic imaging (4). The authors admit the decreased sensitivity of cystosonography in the detection of low-grade reflux that reaches only the lower ureter, which is a similar limitation of radionuclide cystography. Both techniques involve continuous imaging but are limited by the presence of echoes or radioactivity in the bladder that masks subtle reflux into the adjacent lower ureter. In fact, many urologists do not treat this grade of reflux, so the drawback is minimized. The lack of ionizing radiation is a big advantage for cystosonography, especially in light of recent media attention to the issue of radiation exposure from diagnostic imaging in pediatric patients. Anatomic detail is clearly superior when US images are obtained at cystosonography than when gamma camera images are obtained at radionuclide cystography.

Despite these advantages, I have a few practical concerns regarding the cystosonographic technique. Berrocal et al (4) report a mean examination time of 26 minutes for baseline US and cystosonography. Twenty minutes of this time is devoted to bladder catheterization and cystosonography. How will US departments that are already busy absorb this new demand on room time? How quickly can sonographers be trained in the techniques of bladder catheterization and cystosonography? Given the shortage of well-trained pediatric US technologists and the increasing demands for their skills in Doppler and other advanced imaging techniques, is this a duty that should be imposed on them? How much will SH U 508A (Levovist; Schering, Berlin, Germany) (and other agents) cost when they become available in the United States? Will some parents continue to insist that their children be sedated? Finally, is there a way to create contrast bubbles in the native urine of well-hydrated patients that can obviate the invasive component of catheterization at cystography? No radiation, no bladder catheterization, no sedation, low cost, high sensitivity, and excellent anatomic detail—now that would be the perfect screening cystographic examination. With all these factors considered, cystosonography is fairly close to the mark.

FOOTNOTES

See also the article by Berrocal et al (pp 359–365 ) in this issue.

REFERENCES

1. McDonald R, Donaldson L, Emmett L, Tejani A. A decade of living donor transplantation in North American children: the 1998 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Pediatr Transplant 2000; 4:221-234.
2. Seikaly M, Ho PL, Emmett L, Tejani A. The 12th Annual Report of the North American Pediatric Renal Transplant Cooperative Study: renal transplantation from 1987 through 1998. Pediatr Transplant 2001; 5:215-231.
3. Slovis TL. Is there a single most appropriate imaging workup of a child with an acute febrile urinary tract infection?. Pediatr Radiol 1995; 25(suppl 1):S46-S49.
4. Berrocal T, Gayá F, Arjonilla A, Lonergan GJ. Vesicoureteral reflux: diagnosis and grading with echo-enhanced cystosonography versus voiding cystourethrography. Radiology 2001; 221:359-365.
5. Escape I, Martinez J, Bastart F, Solduga C, Sala P. Usefulness of echocystography in the study of vesicoureteral reflux. J Ultrasound Med 2001; 20:145-149.
6. Darge K, Troeger J, Duetting T, et al. Reflux in young patients: comparison of voiding US of the bladder and retrovesical space with echo enhancement versus voiding cystourethrography for diagnosis. Radiology 1999; 210:201-207.
7. Bosio M. Cystosonography with echocontrast: a new imaging modality to detect vesicoureteric reflux in children. Pediatr Radiol 1998; 28:250-255.
8. Mentzel HJ, Vogt S, Patzer L, et al. Contrast enhanced sonography of vesicoureterorenal reflux in children: preliminary results. AJR Am J Roentgenol 1999; 173:737-740.

This Article Full Text (PDF) All Versions of this Article: 2212011309v1 221/2/283    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by O’Hara, S. M. Search for Related Content PubMed PubMed Citation Articles by O’Hara, S. M.