Evaluation of Vesicoureteral Reflux Not Limited to One Modality

A recent study was conducted to report the experience of using voiding urosonography (VUS) in a routine clinical setting over 6-years from one institution as the first step in the diagnosis of vesicoureteric reflux (VUR) in children.

Participants
610 children were included based on an abnormal ultrasound of the urinary tract, a history of recurrent urinary tract infections, or acute pyelonephritis.

Methodology
The children were divided into 2 groups.

Group A was comprised of 224 children with abnormalities on prenatal or postnatal ultrasound, including pyelectasis, kidney length discrepancy, and unilateral renal dysplasia.

Group B was comprised of 386 children affected by recurrent UTI or >=1 episode of acute pyelonephritis.

Over the course of 6 years, 2 different ultrasonographic contrast solutions were used. The bladder was infused with the solutions via a catheter, with subsequent examination of the full bladder via ultrasound and voiding after removal of catheter via real time ultrasound.

Grading of reflux was defined using the International Reflux Grading System.

Two groups of children referred to the center performing the study from 4 years previously, who underwent voiding cystourethrography (VCUG) were used as control groups.

These groups were also divided into group A and group B using the aforementioned criteria.

Results
In group A, VUS examinations showed reflux in 85 kidney-ureter units, while in group B, 180 kidney-ureter units demonstrated reflux.

As a second-level step, VCUG was performed in only 60 of 610 children. Diagnostic disagreement was recorded in only 3 of 60 children examined with VCUG.

Conclusions
Although the diagnostic accuracy of VUS with respect to VCUG has been described elsewhere, this study furthers the notion that VUS is an accurate alternative to VCUG as a first-line tool in assessing VUR.

The main limitation cited by the authors is its poor ability to document male urethral pathology. The advantages include the elimination of ionizing radiation, which is an area of increasing concern, particularly in the pediatric patient population.

Reviewer’s Comments
It is clear that the authors have extensive experience with VUS as a modality for assessing VUR. The broader conclusion to be drawn from this article is that the evaluation of VUR is not limited to one modality. There are options that can be considered that may aid in addressing patient-specific limitations, which include VUS, VCUG, and radionuclide cystography.

Author: Basil Hubbi, MD

Reference:
Giordano, Mario; Marzolla, Rocco, et al. Voiding Urosonography as First Step in the Diagnosis of Vesicoureteral Reflux in Children: A Clinical Experience. Pediatric Radiology. Volume 37, Number 7. (July 2007) pp. 674-677.