Diagnosis of vesicoureteral reflux with ultrasonography

Abstract

The primary diagnostic procedure for evaluation of vesicoureteral reflux (VUR) in children is fluoroscopic voiding cystourethrography (VCUG). Radionuclide cystography (RNC) is an alternative, sensitive method for diagnosing VUR, but it lacks spatial resolution. Over the past 2 decades, in an effort to eliminate the radiation exposure intrinsic to these methods, many endeavors had been made to use ultrasonography (US) for the diagnosis of VUR. The various attempts that have been undertaken are reviewed. The real breakthrough in the US diagnostic option has come with the availability of stable US contrast media that can be administered intravesically. Comparison between contrast-enhanced sonographic reflux examination (voiding urosonography, VUS) and VCUG/RNC has revealed the high concordance between these imaging modalities regarding the diagnosis or exclusion of VUR. Imaging of the urethra still necessitates the performance of VCUG. VUS is used in routine imaging primarily for follow-up cases, girls, and screening high-risk groups for reflux. Using these selection criteria, the number of VCUG investigations can be reduced by over half and, consequently, a significant reduction of radiation exposure in children can be achieved. With the emergence of harmonic US imaging, the sonographic reflux examination will gain further diagnostic potential and widespread application. The whole field of sonographic diagnosis of reflux is still in the process of rapid development.

Echo-enhanced voiding urosonography for detection of vesicoureteric reflux in children

“…Harmonic tissue imaging was not available on our US machines at the time of the study. The group from Heidelberg found excellent sensitivity (100%) of EEVUS compared with VCUG for detection of VUR when harmonic options were used [4,5]. Similar to us [3], McEwing et al [1] and Kenda et al [2] used only conventional US imaging and this was probably the reason for low sensitivity in the three studies.…”

Discrepancy between power-Doppler voiding urosonography and voiding cystourethrography is not relevant for the management of primary vesicoureteric reflux

“…More than being caused by intrinsic limitations of PD-VUS, reluctance of pediatric surgeons to use this tool could be easily caused by a lack of familiarity with its images, a low diagnostic confidence. Accordingly, Darge [24] maintained that the key step to make PD-VUS accepted is not the improvement of its accuracy, rather the possibility to print out images, which stand up to comparison with images of fluoroscopic examination.…”

Low contrast dose voiding urosonography in children with phase inversion imaging

“…The mean Levovist dose in our study was 5.8 ml, equivalent to 7.4% of the bladder volume (in our last 11 patients 4.3% of the bladder volume was sufficient for PIUS, indicating that the amount of contrast material required for completing an examination decreases further with increasing operator experience). Of all our patients, 41 out of 43 required only a single 2.5 g vial of Levovist, while [10]. Using this standard dose, we would have required a mean dose of 9.0 ml of Levovist with two 2.5 g vials in 14, 3 vials in 4 and 5 vials in one case.…”

“…VUS has been shown to be an accurate and reliable alternative to VCUG [8,9]. It is now routinely used as an alternative to VCUG in girls and for follow-up examinations in boys in some centers [10].…”