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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 3  |  Page : 488-491
Accuracy of cystosonography in the diagnosis of vesicourethral reflux in children

1 Pediatric Nephrology, Labafi-Nejad Hospital, Tehran, Iran
2 Medical Faculty Research Center, Tehran, Iran
3 Tehran University of Medical Science, Tehran, Iran

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Date of Web Publication7-May-2011


Vesicoureteric reflux (VUR) is found in 1% of all children and in 30%-50% of those with urinary tract infection. Furthermore, VUR in childhood is the main reason for pyelonephritis, hypertension and chronic kidney disease. Recently, a variety of procedures with low radiation have been recommended for diagnosis of VUR. Therefore, in this study, voiding urosonography (VUS) or cystosonography was performed for evaluation of VUR and for comparing it with radio nucleotide cystography (RNC). We studied 25 children admitted with initial diagnosis of VUR in our center in the year 2007. Simultaneously, RNC and VUS were performed for all the patients. VUR was detected in eight patients with the VUS procedure and in nine children with RNC. Another patient was diagnosed only by RNC, and two other patients by only VUS. The two methods were concordant in detection and exclusion of urinary reflux in 87% (P: 0.000, r: 0.728). Furthermore, the diagnosis of various grades of reflux by these two schemes were comparable (P: 0.0000, r: 0.724). Sensitivity and specifity of VUS was determined as 87% and 88%, respectively, with a 94% positive predictive value and a 77% negative predictive value. We conclude that VUS is a highly accurate, safe and inexpensive tool for the screening, diagnosis and follow-up of VUR.

How to cite this article:
Otukesh H, Hoseini R, Behzadi AH, Mehran M, Tabbaroki A, Khamesan B, Farjad R, Amirjalai V. Accuracy of cystosonography in the diagnosis of vesicourethral reflux in children. Saudi J Kidney Dis Transpl 2011;22:488-91

How to cite this URL:
Otukesh H, Hoseini R, Behzadi AH, Mehran M, Tabbaroki A, Khamesan B, Farjad R, Amirjalai V. Accuracy of cystosonography in the diagnosis of vesicourethral reflux in children. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 Aug 8];22:488-91. Available from: https://www.sjkdt.org/text.asp?2011/22/3/488/80485

   Introduction Top

From 1990 until now, there have been several attempts for finding an efficient, practical and with less-imposing radiation technique for screening of children with different grades of vesicoureteric reflux (VUR). Upon this, sonography with echo contrast materials, which has been introduced as a routine and safe diagnostic method in some centers. [1]

Essential substances for filling up the bladder in voiding ultrasonography (VUS) are normal saline, air bubbles and radio opaque derivatives. In two different studies, air was emphasized as a validate material for accentuating the diagnosis of VUR in VUS. [2],[3] Furthermore, Haburg et al demonstrated that the combination of air and normal saline enhance the accuracy of diagnosis of all of grades of VUR. [4]

Some studies compared VUS with other methods such as radio nucleotide cystography (RNC), of which many claimed a high specificity of VUS in distinguishing a variety of VUR, particularly the transitional one (pseudo VUR).

In this study, VUS was evaluated for safety, sensitivity and specificity in the diagnosis of VUR in children referred to our center.

   Materials and Methods Top

We studied 25 children under the age of 15 years with first episode of urinary tract infection evaluated at the Labafai Nejad Education and Treatment Center in the year 2007. All patients suffering from acute pyelonephritis or any complication of malfunction and/or anatomical defects related to the lower urinary tract system were excluded.

RNC and VUS tests were performed sequentially on all the study patients. RNC was considered as the gold standard diagnostic method. Before performing any diagnostic tests, a negative result of urine culture in the cases should be obtained.

VUS was accomplished by using a real-time equipment (Hitachi, 7.5 MHTZ transducer) under the supervision of an expert specialist in a double-blind fashion. The echo contrast solution used was Levovist suspension, an echo contrast substance composed of glucose and air bubbles with Pamtic acid.

Initially, the kidneys, ureters and bladder were evaluated by using ultrasonography, followed by measuring the urine residue in the bladder after voiding. In the final step, 10-20 mL of normal saline with a 5 mL/kg of Levovist suspension in children and 1 mL/kg in infants were entered into the bladder by a urine catheter. The diagnostic images were obtained during the loading and unloading periods of the contrast suspension in the bladder. The different grades of reflux were classified similar to the RNC. Accordingly, grade I was considered as mild, grades II and III as moderate and grades IV and V as severe. [5]

   Statistical Analysis Top

All the study findings were analyzed by SPSS (Version; 14). Specifically, sensitivity and negative and positive predictive values were determined for all the outcomes obtained from both the tests. A P-value < 0.05 was set as significant.

   Results Top

The study patients had an average age of 4.5 years (min, 6 months; max, 13 years). Twenty percent of the patients were male and the rest were female.

VUR was found in eight cases when using RNC and in nine cases with VUS. Another patient was diagnosed only by RNC, and two other patients by only VUS. In these two cases, Di Mercapto Succynil Acid (DMSA) scan demonstrated scarring damage [Table 1].
Table 1: Comparative results of radio nucleotide cystography and voiding ultrasonography in the study patients.

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VUS showed a sensitivity of 87%, a specificity of 88%, a positive predictive value of 77%, a negative predictive value (NPV) of 94%, and accuracy of 88%.

The results gathered from performing VUS and RNC were compared and a significant correlation was found (P: 0.000, r: 0.728). In addition, there was a positive correlation between various grades of reflux diagnosed by these two techniques (P: 0.000, r: 0.724).

   Discussion Top

VUR is one of the most common findings among children suffering from recurrent urinary tract infection. Congenital defects of the urinary tract are the main reasons for VUR. [6] The risk of fibrosis due to pyelonephritis is increased according to the severity of VUR. [7],[8],[9],[10],[11]

VUR is considered as one of the major predisposing factors for elevated blood pressure in children. In addition, VUR followed by renal fibrosis may result, gradually, in chronic renal failure in children. [12],[13],[14],[15],[16],[17]

VUS and RNC have been compared in previous studies in the literature. Meutzel et al reported that the sensitivity and specificity of VUS in comparison with RNC was 90% and 94.6%, respectively. [18] In a similar study, the specifity and sensitivity of VUS was reported as 100% and 88%, respectively. [1] In our study, all the patients with VUR diagnosed with VUS had grade I, and 40% of the cases assessed only with RNC suffering from grades I and II of VUR. [1] In our study, the NPV was 94%, being in the range of other previous studies. [8]

Accordingly, VUS at least has this capability to exclude high-grade VUR. In fact, some researchers recommend VUS as an initial test for evaluation and screening of VUR in females, for follow-up of cases and in high-risk patients, including the first degree relatives of the patients. [19]

In two studies, specifity and sensitivity of VUS as a comparison with RNC were reported as 86-100% and 88-100%, respectively, [1],[20],[21] which is in the range of our findings.

In contrast, sensitivity in VUS was lower in another study (67-79%), but specificity was 96%, similar to our study. [22]

In all these researches, there were some cases that reported the existence of VUR only with the RNC method. [20]

DMSA scan could be used to confirm the findings obtained by RNC. Two cases in our study were diagnosed only by VUS. DMSA has this ability to augment the transient VUR due to complete filling up of the urinary bladder. [1]

Although VCUG is considered a standard procedure for detecting VUR and contrast enhanced scentigraphy were introduced as a reliable imaging modality, which can be administrated in many cases. [24]

VUS and VCUG were compared. Interestingly, the range of disagreement between them was high (22%) in some studies. [25],[26] On the other hand, in some studies, the results were very close, but in case of disagreement, DMSA was performed to confirm the final result. RNC has less-invasive imaging than VCUG in the terms of exposure radiation. [26] The concordance between DMSA scan and VUS was reported to be around 85.3%. [23]

We conclude that VUS as a screening and diagnostic technique is highly useful, especially during follow-up of VUR with a low amount of exposure radiation and high accuracy.

   References Top

1.Darge K. Diagnosis of vesicoureteral reflux with ultrasonography. Pediatr Nephrol 2002;17 (1):52-60.  Back to cited text no. 1
2.Azen G, Wildberger JE, Ferris EJ, et al. Sonographic detection of vesicoureteral reflux with air: A new method. Eur Radiol 1994;4:142-5.  Back to cited text no. 2
3.Siamplis D, Vasiou K, Giarmenitis S, et al. Sonographic detection of vesicoureteral reflux with fluid and air cystography: Comparison with VCUG. Rofo 1996;165(2):166-9.  Back to cited text no. 3
4.Hanbury DC, Coulden RA, Farman P, et al. Ultrasound cystography in the diagnosis of vesicoureteric reflux. Br J Urol 1999;65(3): 250-3.  Back to cited text no. 4
5.Atala A, Keating MA. Vesicoureteral Reflux & Megaureter. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ. Campbell's Urology. 8th ed. Philadelphia, Saunders. 2002:2060-1.  Back to cited text no. 5
6.Elder JS. Vesicoureteral reflux. In: Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Saunders. 2004:1790-4.  Back to cited text no. 6
7.Tanagho EA.Vesicoureteral reflux. In: Tanagho EA, McAninch JW. Smith' General Urology. 15th ed. San Francisco, Appelton & Lange. 2000:179-94.  Back to cited text no. 7
8.Edmond T, Gonzales, JR, Roth RD, et al. Urinary tract infection. In: McMillian JA, DeAngeli GD, Feigin RD, Warshaw JB. Oski`s Pediatrics. 3rd ed. Pennsylvania, Lippincott Williams & Wilkins. 1999:1560-2.  Back to cited text no. 8
9.Kanematsu A, Yamamoto S, Yoshino K, et al. Renal scarring is associated with nonsecretion of blood type antigen in children with primary vesicoureteral reflux. J Urol 2005;174(4):1594-7.  Back to cited text no. 9
10.Tombesi M, Ferrari CM, Bertolotti JJ, et al. Renal damage in refluxing and non-refluxing siblings of index children with vesicoureteral reflux. Pediatr Nephrol 2005;20(8):1201-2.  Back to cited text no. 10
11.Goldman M, Bistritzer T, Horne T, et al. The etiology of renal scars in infants with pyelonephritis and vesicoureteral reflux. Pediatr Nephrol 2000;14(5):385-8.  Back to cited text no. 11
12.Hellerstein S. Urinary tract infections- old and new concepts. Pediatr Clin North Am. 1995;42 (6):1433-57.  Back to cited text no. 12
13.Roberts JA. Etiology and pathophysiology of pyelonephritis. Am J Kidney Dis 1991;17:1-9.  Back to cited text no. 13
14.Gill DG, Mendes de Costa B, Cameron JS, et al. Analysis of 100 children with severe and persistent hypertension in children with chronic pyelonephritis. Arch Dis Child 1976;51(12): 951-6.  Back to cited text no. 14
15.Holland NH, Kotchen T, Bhathena D, et al. Hypertension in children with chronic pyelonephritis. Kidney Int Suppl 1975;Suppl:S243-51.  Back to cited text no. 15
16.Holland NH, Kotchen T, Bhathena D. Reflux nephropathy and hypertension. In: Hodson CJ, Kincaid-smith. Reflux nephropathy. New York, Masson. 1976:257.  Back to cited text no. 16
17.Madani K, Otoukesh H, Rastegar A, et al. Chronic renal failure in Iranian children. Pediatr Nephrol 2001;16(2):140-4.  Back to cited text no. 17
18.Mentzel HJ, Vogt S, John U, et al. Voiding urosonography with ultrasonography contrast medium in children. Pediatr Nephrol 2002;17 (4):272-6.  Back to cited text no. 18
19.Darge K, Bruchelt W, Roessling G and Troeger J. Interaction of normal saline solution with ultrasound contrast medium: significant implication for sonogramphic diagnosis of vesicoureteral reflux. Eur Radiol 2003;13(1):213-8.  Back to cited text no. 19
20.Kenda RB, Novljan G, Kenig A, et al. Echoenhanced ultrasound voiding cystography in children: A new approach. Pediatr Nephrol 2000; 14(4):297-300.  Back to cited text no. 20
21.Gross G, Perlmutter S. VUR in children. e-Med 2002;20:14-8.  Back to cited text no. 21
22.Giordano M, Marzolla R, Puteo F, Scianaro L, Caringella DA, Depalo T. Voiding urosonography as first step in the diagnosis of vesicoureteral reflux in children: a clinical experience. Pediatr Radiol 2007;37(7):674-7.  Back to cited text no. 22
23.Synder H. Vesicoureteric reflux. BJU Int 2000; 85:54-7.  Back to cited text no. 23
24.Vassiou K, Vlychou M, Moisidou R, Sioka A, Fezoulidis IV. Contrast-enhanced sonographic detection of vesicoureteral reflux in children: comparison with voiding cystourethrography. Rofo 2004;176(10):1453-7.  Back to cited text no. 24
25.Ascenti G, Zimbaro G, Mazziotti S, Chimenz R, Baldari S, Fede C. Vesicoureteral Reflux: comparison between urosonography and radio-nuclide cystography. Pediatr Nephrol 2003;18 (8):768-71.  Back to cited text no. 25
26.Piaggio G, Deglinnocenti ML, Toma P, Calevo MG, Perfumo F. Cystosonograhy and voiding cystourethrography in the diagnosis of vesicoureteral reflux. Pediatr Nephrol 2003;18(1):18-22.  Back to cited text no. 26

Correspondence Address:
Ashkan Heshmatzade Behzadi
Medical Faculty Research Center, Tehran University of Medical Science, Tehran
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Source of Support: None, Conflict of Interest: None

PMID: 21566305

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