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Fetzer Et Al, Contrast Enhanced Ultrasound for Antegrade ORIGINAL RESEARCH Impact of Implementing Contrast- Enhanced Ultrasound for Antegrade Nephrostogram After Percutaneous Nephrolithotomy David T. Fetzer, MD , Jennifer Flanagan, MSRS, RRA, RT(R), Ali Nabhan, MSRS, RRA, RT(R)(CT), Kim Pongsatianwong, RDMS, RVT, Jodi Antonelli, MD, Margaret Pearle, MD, PhD, Kanupriya Vijay, MD, Lori Watumull, MD Objectives—To report results from a quality improvement (QI) project evaluat- ing diagnostic performance, hospital resource use, and patient response data for postoperative contrast-enhanced ultrasound (CEUS) antegrade nephrostogram after percutaneous nephrolithotomy. Received September 5, 2019, from the Department Methods—For this Health Insurance Portability and Accountability Act–compli- of Radiology (D.T.F., J.F., A.N., K.V., L.W.) and – fi Urology (J.A., M.P.), University of Texas South- ant, Institutional Review Board approved study, QI data were deidenti ed and western Medical Center, Dallas, Texas, USA; and analyzed. On the first postoperative day after percutaneous nephrolithotomy, Imaging Services, University of Texas Southwestern patients underwent both CEUS and fluoroscopic antegrade nephrostogram. For Medical Center, William P. Clements Jr University fl Hospital, Dallas, Texas, USA (K.P.). Manuscript CEUS, 1.0 mL of Lumason (sulfur hexa uoride lipid type A microspheres; accepted for publication June 3, 2020. Bracco Diagnostics, Inc, Monroe Township, NJ) was injected via an indwelling We thank the Imaging Services Administration nephrostomy tube, with ureteral patency confirmed by identifying intravesical at the University of Texas Southwestern Medical Cen- ultrasound (US) contrast. Diagnostic performance for ureteral patency and con- ter, William P. Clements Jr University Hospital, for fl support of the associated quality improvement project trast extravasation was calculated (with uoroscopy as the reference standard). from which data were collected, as well as the hospital The examination time, room time, physician time, hospital costs, and patient sonographers for their dedication to high-quality imag- response data were compared. The mean, standard deviation, 95% confidence ing and patient care; in particular, we thank Kelly fi Albury RDMS, RVT, Sandra Richardson RDMS, interval, differences in mean, and 95% con dence interval of differences were RVT,andSkyeSmolaRDMS,RVT.Finally,we calculated. thankYinXi,PhD,assistantprofessor,Departmentof Radiology, University of Texas Southwestern Medical Results—Eighty-one examinations were performed in 73 patients during the QI Center, for statistical advice and services. Dr Fetzer period. The sensitivity and specificity of CEUS for ureteral patency were 96% has research agreements with Philips Healthcare and fi Siemens Healthineers and serves on the speakers and 57%, respectively. There was no signi cant difference in time metrics bureaus of Philips Healthcare and Siemens between modalities, and the cost analysis showed lower direct and indirect costs Healthineers. All of the other authors of this article for CEUS. Patient responses revealed lower levels of comfort for CEUS relative have reported no disclosures. to fluoroscopy, without significant differences in reported pain or effort levels. Address correspondence to David T. Fetzer, MD, Department of Radiology, University of Texas Conclusions—Contrast-enhanced US showed very high sensitivity for ureteral Southwestern Medical Center, 5323 Harry Hines patency; the relatively low specificity may have resulted from false-negative Blvd, Dallas, TX 75390-9316, USA. results in fluoroscopy. The hospital costs and resource use of CEUS compared E-mail: [email protected] favorably to fluoroscopy. Contrast-enhanced US also offers inherent advantages, Abbreviations including portability and lack of ionizing radiation. CEUS, contrast-enhanced ultrasound; CI, confi- dence interval; CPT, Current Procedural Key Words—contrast-enhanced ultrasound; fluoroscopy; nephrolithiasis; Terminology; ncCT, noncontrast computed nephrostogram; pyelography; urolithiasis tomography; NPV, negative predictive value; PCN, percutaneous nephrostomy; PCNL, per- cutaneous nephrolithotomy; PPV, positive pre- ercutaneous nephrolithotomy (PCNL) is the procedure of dictive value; QI, quality improvement; US, 1–3 ultrasound choice for treating large or complex renal calculi. P Although some patients are left without external drainage doi:10.1002/jum.15380 or with only a ureteral stent after surgery, in many cases, a © 2020 American Institute of Ultrasound in Medicine | J Ultrasound Med 2021; 40:101–111 | 0278-4297 | www.aium.org Fetzer et al—Contrast-Enhanced US for Antegrade Nephrostogram After PCNL – percutaneous nephrostomy (PCN) catheter, with or patency in post-PCNL patients.17 19 Although the without a ureteral stent, is left in place.4,5 Postsurgical feasibility and accuracy have been shown, to the best imaging may include noncontrast computed tomo- of our knowledge, no publication has described the graphy (ncCT) of the abdomen and pelvis to identify impact on hospital resource use or on patient accep- postoperative complications and assess for residual tance. The purpose of this article is to report results – stone fragments.6 11 Fluoroscopic antegrade nephros- from a hospital quality improvement (QI) project, togram is often performed to confirm ureteral patency designed to evaluate diagnostic accuracy, hospital before PCN or ureteral stent removal. These resource use, and patient survey data, undertaken examinations subject a patient to ionizing radiation when CEUS was implemented as an alternative to and may be uncomfortable, particularly considering standard-of-care fluoroscopy at our institution. the design of most fluoroscopic tables. Additionally, fluoroscopy subjects radiology staff to scatter radia- tion. Materials and Methods As a relatively low-cost, portable technology with a high safety profile, ultrasound (US) is an ideal modal- For this Health Insurance Portability and Account- ity for evaluating a wide variety of conditions and can ability Act–compliant study, hospital resource use and be found in many care environments such as in operat- patient preference data were initially collected under ing rooms, emergency departments, intensive care a hospital QI project. After project completion, data units, and primary care clinics. Contrast-enhanced were deidentified, following an Institutional Review ultrasound (CEUS), which has been widely available Board–approved protocol for retrospective review of 12,13 throughout Europe and Asia for many years, is clinical data. A wavier of informed consent was quickly gaining acceptance in the United States with granted. No funding was received for this work. the Food and Drug Administration approval of Lumason (sulfur hexafluoride lipid type A micro- Patient Data and Work Flow spheres; Bracco Diagnostics, Inc, Monroe Township, From December 21, 2017, to August 17, 2018, adult NJ) for focal liver lesion characterization in both adults patients scheduled for postoperative antegrade fluoro- and children and for vesicoureteral reflux in children. scopic nephrostogram after PCNL were enrolled. With the addition of CEUS-specific category 1 Current Standard practice at our institution is for patients to Procedural Terminology (CPT) codes, physicians can undergo ncCT on the first postoperative day to iden- get reimbursed for these examinations. tify residual stone fragments and to detect clinically – Contrast-enhanced voiding urosonography has important postoperative complications.7 9,11 After the become an accepted alternative to fluoroscopy in pediat- ncCT, fluoroscopic antegrade nephrostogram is used ric patients in whom vesicoureteral reflux is suspected,14 to confirm ureteral patency before removal of the comparing favorably to standard fluoroscopic cysto- balloon-tipped drainage tube (PCN) and ureteral urethrography, without the associated radiation risks.15 stent left in situ after stone removal. Ultrasound contrast agents are well tolerated with few During the evaluation period, the standard-of-care contraindications, low allergic reaction rates, and no ncCT was performed. Then, a CEUS examination was known toxicity compared to iodinated and gadolinium performed immediately after the ncCT, before fluoros- agents.16 These agents are composed of microbubbles, copy. Both CEUS nephrostogram, using a microbubble measuring approximately 2 to 3 μm in size (similar in contrast agent, and fluoroscopic antegrade nephrostogram, size to red blood cells), too large to cross endothelial- or using an iodinated contrast agent, were performed using epithelial-lined spaces. Therefore, intravascular micro- the indwelling PCN for injection of microbubble and bubbles remain within the vascular space, whereas iodinated contrast agents, respectively; as there is no cross- intracavitary microbubbles remain within the space in reactivity between these contrast agents, both can be which they are injected, making CEUS particularly useful administered on the same day without concern. Survey for vesicoureteral reflux.14,16 responses (described below) were obtained immediately Recently, CEUS has been described as an addi- after each examination. Imaging and demographic data tional imaging tool for the assessment of ureteral were recorded from the electronic medical record. 102 J Ultrasound Med 2021; 40:101–111 Fetzer et al—Contrast-Enhanced US for Antegrade Nephrostogram After PCNL Imaging Protocol Ultrasound imaging was performed with either The CEUS antegrade nephrostogram was performed an EPIQ 7G system (Philips
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