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Journal of Indian Association of Pediatric Surgeons
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Table of Contents   
CASE REPORT
Year : 2015  |  Volume : 20  |  Issue : 1  |  Page : 40-41
 

Voiding urosonography: Contrast-enhanced ultrasound cystography to diagnose vesico-ureteric reflux: A pilot study


1 Department of Pediatric Urology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
2 Department of Radiology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Date of Web Publication27-Nov-2014

Correspondence Address:
Ramesh Babu
Pediatric Urology Unit, Sri Ramachandra Medical College and Research Institute, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.145548

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   Abstract 

We report two children with hydronephrosis, in whom we have utilized voiding urosonography (VUS) in the evaluation of vesico-ureteric reflux. With wider availability of ultrasound contrast agents and high-end ultrasound machines, VUS is likely to become a popular tool to diagnose or exclude VUR.


Keywords: Contrast-enhanced ultrasound cystography, hydronephrosis, ultrasound, vesico-ureteric reflux, voiding urosonography


How to cite this article:
Babu R, Gopinath V, Sai V. Voiding urosonography: Contrast-enhanced ultrasound cystography to diagnose vesico-ureteric reflux: A pilot study . J Indian Assoc Pediatr Surg 2015;20:40-1

How to cite this URL:
Babu R, Gopinath V, Sai V. Voiding urosonography: Contrast-enhanced ultrasound cystography to diagnose vesico-ureteric reflux: A pilot study . J Indian Assoc Pediatr Surg [serial online] 2015 [cited 2019 Nov 13];20:40-1. Available from: http://www.jiaps.com/text.asp?2015/20/1/40/145548



   Introduction Top


Voiding urosonography (VUS) is a novel technique in the evaluation of vesico-ureteric reflux (VUR). The availability of second generation ultrasound contrast agent (UCA) and higher quality ultrasound machine has allowed the application of VUS without subjecting the child to ionizing radiation. [1],[2],[3],[4],[5] We report a pilot study in two children with hydronephrosis, in whom we have utilized this technique to look for VUR.


   Case reports Top


Case 1

A 1-year-old boy, previously diagnosed to have left-sided grade 5 VUR on VCUG at birth [Figure 1]a, was evaluated for resolution of VUR. We elected to perform VUS using stabilized aqueous suspension of sulfur hexafluoride (SF6) microbubbles with a phospholipid shell (SonoVue® Imaging Products India Private Limited) as UCA. Under antibiotic cover and aseptic precautions, bladder was catheterized with 6 F infant feeding tube. Sixty ml of normal saline along with 0.5 ml of UCA was filled slowly while imaging with a low mechanical index contrast-enhanced ultrasound (Aplio™ 400 Toshiba Medical Corporation). Parallel viewing of contrast mode and normal ultrasound mode was enabled and video capture of filling and voiding phases were recorded. VUS revealed prompt reflux of contrast in to the dilated left ureter and pelvi-calyceal system [Figure 1]b and c. No VUR could be demonstrated on the right side.
Figure 1: (a) VCUG reveals left-sided grade 5 VUR (b) VUS in same patient with parallel viewing of contrast mode and normal ultrasound mode. Dotted arrow points to refl ux of UCA in to dilated left ureter (c) Corresponding images of left kidney. Block arrow points to contrast filling dilated left pelvi-calyceal system demonstrating VUR

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Case 2

A 5-day-old boy, antenatally diagnosed with bilateral mild hydronephrosis, was confirmed to have the same findings on post-natal ultrasound. VCUG did not reveal any posterior urethral valve or VUR [Figure 2]a. We elected to perform VUS to re-establish absence of VUR. The technique was exactly similar to the previous case with 0.5 ml of UCA and 30 ml of normal saline. UCA could be demonstrated in the bladder, but no reflux was noted on VUS in to the ureter or pelvi-calyceal system on VUS [Figure 2]b and c.
Figure 2: (a) VCUG reveals normal study with no VUR (b) VUS in same patient with parallel viewing of contrast mode and normal ultrasound mode. Arrow points to presence of UCA in full bladder (c) Corresponding images of kidney shows no contrast in pelvi-calyceal system demonstrating absence of reflux

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   Discussion Top


The modalities available for diagnosing VUR at present include VCUG, radio nuclide cystogram (RNC), and VUS. VCUG has significant ionizing radiation due to the use of intermittent screening. RNC although highly sensitive, with less radiation exposure, lacks the anatomic resolution of VCUG. The main advantage of VUS over the other two is the fact that it does not expose the child to ionizing radiation.

Furthermore, VUS is a real time imaging compared to VCUG, which often gives only a snapshot of the procedure. Kis et al. reported VUS to be more sensitive than VCUG since it has the potential to detect intermittent VUR. [1] It also can be repeated without exposure to radiation in case of failed procedure. One disadvantage of VUS is limited visualization of urethra, although others have suggested that adequate imaging of urethra is possible with VUS. [1],[2],[3],[4],[5]

Sulfur hexafluoride (SonoVue) can be injected as an intravenous contrast agent also to identify enhancement on ultrasound in vascular lesions. It is excreted by lungs and has a good safety profile. [6] The contrast agent has a good shelf life of 6-12 hours after reconstitution. For VUS, 0.5 ml with appropriate volume of normal saline is used to fill bladder. As it comes as 5 ml pack, it can be used for up to ten children, thereby reducing the cost.

Darge [2] proposed classification of VUR using VUS: Grade I Microbubbles only in the ureter; Grade II Microbubbles in the renal pelvis; no significant renal pelvic dilatation; Grade III Microbubbles in the renal pelvis + significant renal pelvic dilatation + moderate calyceal dilatation; Grade IV Microbubbles in the renal pelvis + significant renal pelvic dilatation + significant calyceal dilatation; Grade V Microbubbles in the renal pelvis + significant renal pelvic dilatation and calyceal dilatation + loss of renal pelvis contour + dilated tortuous ureters.

In our pilot study of two cases, we found that presence or absence of VUR could be correctly diagnosed with the help of VUS. With wider availability of UCA and high-end ultrasound machines, VUS is likely to become a popular tool to rule out VUR in children with UTI and look for resolution in those previously diagnosed with VUR. With no radiation exposure, it may also become an acceptable tool to screen siblings of children with VUR. Further larger studies are warranted to establish sensitivity and specificity of this new diagnostic test.

 
   References Top

1.
Kis E, Nyitrai A, Várkonyi I, Máttyus I, Cseprekál O, Reusz G, et al. Voiding urosonography with second-generation contrast agent versus voiding cystourethrography. Pediatr Nephrol 2010;25:2289-93.  Back to cited text no. 1
    
2.
Darge K. Voiding urosonography with ultrasound contrast agents for the diagnosis of vesicoureteric reflux in children. I. Procedure. Pediatr Radiol 2008;38:40-53.  Back to cited text no. 2
    
3.
Novljan G, Kenig A, Rus R, Kenda RB. Cyclic voiding urosonography in detecting vesicoureteral reflux in children. Pediatr Nephrol 2003;18:992-5.  Back to cited text no. 3
    
4.
Papadopoulou F, Anthopoulou A, Siomou E, Efremidis S, Tsamboulas C, Darge K. Harmonic voiding urosonography with a second-generation contrast agent for the diagnosis of vesicoureteral reflux. Pediatr Radiol 2009;39:239-44.  Back to cited text no. 4
    
5.
Darge K, Troeger J. Vesicoureteral reflux grading in contrast-enhanced voiding urosonography. Eur J Radiol 2002;43:122-8.  Back to cited text no. 5
    
6.
Bokor D, Chambers JB, Rees PJ, Mant TG, Luzzani F, Spinazzi A. Clinical safety of SonoVue, a new contrast agent for ultrasound imaging, in healthy volunteers and in patients with chronic obstructive pulmonary disease. Invest Radiol 2001;36:104-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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