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Imaging and Other Investigations CHAPTER 13 Committee 9 Imaging and other Investigations Chairman A. TUBARO (ITALY) Members W. ARTIBANI (ITALY), C. BARTRAM (UK), J.D. DELANCEY (USA), H.P. DIETZ (AUSTRALIA), V. K HULLAR (UK), P. Z IMMERN (USA) Consultant W. UMEK (AUSTRIA) 707 CONTENTS C. IMAGING IN FAECAL A. INTRODUCTION INCONTINENCE B. IMAGING IN URINARY D. PAD TESTING INCONTINENCE AND PELVIC FLOOR DYSFUNCTION E. OTHER INVESTIGATIONS B1. IMAGING OF THE UPPER URINARY TRACT F. CONCLUSIONS B2. LOWER URINARY TRACT (LUT) IMAGING B3. SPECIAL ISSUES 708 Imaging and other Investigations A. TUBARO W. ARTIBANI, C. BARTRAM, H.P. DIETZ, V. KHULLAR, J.D. DELANCEY,P. ZIMMERN W. UMEK modalities may provide evidence regarding the seve- A. INTRODUCTION rity of the disease, indications for treatment, pro- gnostic values as treatment outcome or patient pro- gnosis, but they can also be used to monitor patient conditions over time and in treatment follow-up. The committee evaluated the current evidence regar- Imaging can also be used to evaluate treatment out- ding imaging techniques and clinical indications in come as well as for research purposes. At the end of patients with urinary or faecal incontinence, pelvic each paragraph, recommendations for the clinical floor dysfunction and pelvic organ prolapse. Addi- use of a certain imaging modality are provided and tional related issues such as pad testing were also reviewed. The present chapter is based upon the out- the relative level of evidence is stated. Areas of inter- come of the 2nd International Consultation on Incon- est for further research are identified. tinence which was held in Paris in 2001 [1]. The application of standard levels of evidence and The 2001 chapter was reviewed in the light of the grade of recommendations as proposed by the publications which appeared in the peer-review lite- Oxford Centre for Evidence Based Medicine and rature from 2001 until today. Modifications to the endorsed by the International Consultation on Urolo- previous chapter were proposed by the committee gical Diseases (ICUD) to the field of diagnostic ima- members who were allocated the different topics ging is not without problems. The Authors of this included in the new chapter and then jointly revie- chapter have tried to apply the proposed ICUD sys- wed until a consensus was reached. The chapter tem whenever possible, all diagnostic techniques structure has been modified as it now includes also have been at lest evaluated with reference to their imaging issues in patients with faecal incontinence. technical performance, accuracy and impact of clini- cal management. The various imaging issues were considered and ana- lysed also regarding the particular questions which may arise when dealing with different clinical and I. LEVEL OF EVIDENCE pathophysiological conditions so that the neurogenic or non-neurogenic origin of incontinence was consi- • Level 1 evidence (incorporates Oxford 1a, 1b) dered beyond the more obvious distinction deriving usually involves meta-anaylsis of trials (RCTs) or from age and gender. Imaging of the central nervous a good quality randomised controlled trial, or ‘all system in the incontinent patient was also included or none’ studies in which no treatment is not an as this is a very dynamic field which is highly ins- option, for example in vesicovaginal fistula. trumental in understanding the physiology and • Level 2 evidence (incorporates Oxford 2a, 2b and pathophysiology of lower urinary tract dysfunction 2c) includes “low” quality RCT (e.g. < 80% fol- in neurogenic and non-neurogenic patients. low up) or meta-analysis (with homogeneity) of Imaging and other investigations were evaluated good quality prospective ‘cohort studies’. These with reference to the techniques and their clinical may include a single group when individuals who value taking into consideration what is the possible develop the condition are compared with others impact of the diagnosis on patient management. It is from within the original cohort group. There can important in fact to consider that some imaging be parallel cohorts, where those with the condition 709 in the first group are compared with those in the second group. B. IMAGING IN URINARY • Level 3 evidence (incorporates Oxford 3a, 3b and INCONTINENCE AND PELVIC 4) includes: FLOOR DYSFUNCTION good quality retrospective ‘case-control studies’ where a group of patients who have a condition are matched appropriately (e.g. for age, sex etc) B1. IMAGING OF THE UPPER with control individuals who do not have the condition. URINARY TRACT good quality ‘case series’ where a complete group Urinary incontinence is defined as the complaint of of patients all, with the same condition/ disease/ any involuntary leakage of urine, it can be urethral or therapeutic intervention, are described, without a extraurethral. This latter condition either results from comparison control group. congenital anomalies such as ectopic ureters (inser- • Level 4 evidence (incorporates Oxford 4) includes ting in the female distal urethra or vagina), iatroge- expert opinion were the opinion is based not on nic or traumatic conditions such as fistula. In some evidence but on ‘first principles’ (e.g. physiologi- patients, lower urinary tract dysfunction causing uri- cal or anatomical) or bench research. The Delphi nary incontinence, might compromise the transport process can be used to give ‘expert opinion’ grea- of urine from the kidneys to the bladder resulting in ter authority. In the Delphi process a series of hydronephrosis and renal failure. The relationship questions are posed to a panel; the answers are between high bladder storage pressure and renal collected into a series of ‘options’; the options are deterioration has been well established in neuropa- serially ranked; if a 75% agreement is reached thic patients [1]. In male patients, chronic retention then a Delphi consensus statement can be made. of urine can be associated with urinary incontinence and lead to chronic renal failure. In females, severe urogenital prolapse may cause angulation of the pel- II. GRADE OF RECOMMENDATION vic ureter by the uterine arteries leading to hydrone- phrosis in up to 30-40% of patients [2] (Figure. 1 • Grade A recommendation usually depends on a,b). consistent level 1 evidence and often means that the recommendation is effectively mandatory and I. INDICATIONS placed within a clinical care pathway. However, there will be occasions where excellent evidence Generally speaking, there is no need for upper tract (level 1) does not lead to a Grade A recommenda- imaging in cases of urinary incontinence unless any tion, for example, if the therapy is prohibitively of the previously described conditions is suspected expensive, dangerous or unethical. Grade A or diagnosed. Patients with extraurethral incontinen- recommendation can follow from Level 2 eviden- ce may also benefit from upper urinary tract ima- ce. However, a Grade A recommendation needs a ging. greater body of evidence if based on anything except Level 1 evidence The objectives used for upper tract imaging in the incontinent patient are as follows: • Grade B recommendation usually depends on consistent level 2 and or 3 studies, or ‘majority 1. Evaluation of the upper urinary tract when the pre- evidence’ from RCT’s. sence of an ectopic ureter or ureterovaginal fistu- la are suspected. • Grade C recommendation usually depends on level 4 studies or ‘majority evidence’ from level 2. Evaluation of the kidneys whenever urinary incon- 2/3 studies or Dephi processed expert opinion. tinence is related to bladder dysfunction with high Grade C recommendation is given when expert storage pressures (e.g. in neurogenic voiding dys- opinion is delivered without a formal analytical function, chronic retention with overflow or low process, such as by Dephi. compliance bladders) • Grade D “No recommendation possible” would 3. Exclusion of hydronephrosis in cases of urinary be used where the evidence is inadequate or incontinence associated with severe uterine pro- conflicting. lapse (Figure 2 a,b,c,d). 710 Figure 1a. Procidentia uteri. Figure 1 b. IVU: bilateral hydronephrosis. Left kidney is in sacral ectopia. Figure 2 a. MRI: complete urogenital prolapse. Figure 2-b. MRI: ureteral dilation Figure 2-c. MRI: ureteral dilation Figure 2-d. MRI bilateral hydronephrosis 711 currently contraindicate when creatinine levels II. TECHNIQUES exceed 2.0 mg/dL. A number of different conditions such as renal dysfunction, obstruction, congenital Upper tract imaging modalities include intravenous anomalies, fistula, stones and tumors may be detec- ultrasonography (USS), urogram (IVU), computeri- ted. zed tomography (CT scan), magnetic resonance ima- IVU is the appropriate first study in cases of extrau- ging (MRI), and isotope scanning. No data as to spe- rethral incontinence. When ectopic ureter is suspec- cificity, sensitivity, predictive value or reproducibili- ted (although this condition can also be responsible ty in connection with the diagnosis and management of urethral incontinence), delayed films and tomo- of urinary incontinence are available. The use of the graphy are important because the renal unit or moie- different imaging modalities also depend on availa- ty associated with an ectopic ureter is often poorly bility, expertise, and local management policies. functioning. In fact, IVU is sometimes unable to Generally speaking, low cost and low risk techniques such as USS should be preferred. Unless otherwise detect a small, malfunctioning moiety associated described, the following considerations regarding the with a duplication and ectopic ureter or a poorly different imaging modalities are based on expert opi- functioning or abnormally located kidney with a nion. single ectopic system [4-6]. In such cases where the diagnosis of ectopia is still suspected after IVU, ano- 1. ULTRASONOGRAPHY ther imaging modality such as CT, MRI (Figure 3 a,b) or isotope scanning [7-9] should be considered. Ultrasonography is the gold standard technique for IVU is the appropriate first imaging study when ure- primary imaging of the upper urinary tract because tero-vaginal fistula is suspected, usually after pelvic of the relatively low cost of the equipment and the- surgery.
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