Bahramnezhad F, et al Exercise and Chronic Heart Failure GMJ. 2013;2(2):54-59 www.gmj.ir Comparison of Renal Ultrasound and Voiding Cystourethrography in the Detection of Vesicoureteral Reflux Sedigheh Ebrahimi Department of Pediatrics, Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran Abstract Background: This study evaluates the accuracy of renal ultrasonography (US) in the detection of vesicoureteral reflux (VUR) compared to voiding cystourethrography (VCUG). Martials and Methods:We retrospectively reviewed the medical records of 131 children with urinary tract infection. Ultrasound findings were considered to be suggestive of VUR if a “pelvocaly- ceal dilatation”‚ “retrovesical ureteral dilatation” and/or an “increase in one or both kidneys’ size” were reported.Results: Ultrasound findings were positive for VUR in 5 of 24 patients with confirmed VUR on VCUG, and were negative in all of 107 patients without VUR on VCUG. Altogether, of the 131 children‚ 24 had reflux on VCUG, 19 (79%) of who had no sonographic findings suggestive for reflux. The sensitivity and specificity of ultrasound in Suggesting VUR were 20% and 100%, respectively.Conclusion: The results of this study showed that ultraso- nography cannot accurately detect or predict vesicoureteral reflux. This outcome should be mentioned by clinicians in evaluation of patients with complaints which are suggestive for VUR.[GMJ.2013;2(2):54-59] Keywords: Vesicoureteral reflux; Ultrasonography; Voiding cystourethrography (VCUG) Introduction an increased risk for urinary tract infections, hypertension, and progressive kidney dam- esicoureteral reflux (VUR) is a common age. The association between VUR, UTI, and Vurinary tract disorder in children. In nor- renal scarring has produced a strong argument mal kidney-bladder function, urine flows only in favor of diagnosing reflux [2]; albeit, there from the kidneys to the bladder. VUR is an is a little dispute regarding the need for some abnormal backward flow of urine from the forms of imaging studies. Thus, in medical bladder toward the ureters. The term “reflux practice, the early recognition and careful nephropathy” is described as sustained injury monitoring of VUR are considered to be very of kidneys with concomitant gross pathologic important. The standard evaluation of an in- changes as a consequence of VUR and urinary fant or young child after the first documented tract infection (UTI) [1]. febrile urinary tract infection (UTI) includes Some individuals with untreated VUR are at renal ultrasonography (US) and voiding cys- Correspondence to: GMJ Sedigheh Ebrahimi MD.; Associate professor of ©2013 Galen Medical Journal Pediatrics. Department of Medical Ethics, Shiraz Fax: +98 731 2227091 University of Medical Sciences, Shiraz, Iran 53 GMJ. 2013;2(2):49-53 PO Box 7461686688 Telephone Number: +98917-1129908 Email:[email protected] www.gmj.ir Email Address :[email protected] Ebrahimi S, et al Comparison of Renal Ultrasound and VCUG in the Detection of Vesicoureteral Reflux tourethrography (VCUG). The latter is used sidered if a “pelvocalyceal dilatation”‚ “retro- mostly as the method of choice to confirm the vesical ureteral dilatation” and/or an “increase diagnosis of VUR. A Dimercaptosuccinic acid in one or both kidneys’ size” could be detect- (DMSA) renal scan is also used to assess any ed. Normal and abnormal sonographic find- renal abnormalities. In clinical practice, these ings were compared with detection of reflux recommendations and methods of diagnosis by VCUG. VUR grade was classified accord- are often extended to older children [2]. ing to the International Reflux Study guide- Based on what mentioned above, primar- lines in Children [6]. ily, the diagnosis and follow-up of VUR is Since the differentiation of Grades 4 and 5 based on VCUG despite having the main dis- of reflux has no clinical significance, these advantages of significant gonadal radiation groups were combined and described as grade exposure and catheterization complications 4–5 in this report. Accuracy of diagnostic test [3]. Additionally, all of these interventions were calculated with confidence intervals of might be stressful to the child and the family. about 95% for each test. Thus, over the past two decades, in an attempt The efficiency of US was assessed by the abil- to provide comfort for child and the family ity to detect VUR. The statistical indices used and also to eliminate the radiation exposure for evaluation of this diagnostic method, were caused by these methods, many efforts have sensitivity, specificity, and predictive values been made to use ultrasonography for the non- (positive and negative). Considering VCUG invasive diagnosis of VUR which avoids the results as the gold standard test, sensitivity need for urethral catheterization, and which was described as the proportion of patients avoids the anxiety of parents and patients that with the disorder (VUR) in who the renal leads many families to refuse such evaluation ultrasound was affirmative; Specificity was [1,4]. Ultrasound (US) is an appealing imag- explained as the proportion of those without ing test for the urinary tract in children due the disorder in who the test was negative. The to its accessibility, noninvasiveness, and lack positive predictive value in this study was the of radiation. Several studies have looked at its probability that confirmed VUR in children value in the detection of VUR demonstrating with dilatation noted on the US. The negative low accuracy compared to VCUG as the gold predictive value was the probability that the standard [5]. However, there is still a chal- subject does not have VUR in children with lenge among clinicians regarding the accu- any dilatation noted in US. racy of diagnosis with US in VUR in children. The collected data were analyzed after encod- The goal of this study was to compare the ing by using statistical computing SPSS soft- diagnostic accuracy of sonography with that ware (version 16.0). of VCUG in VUR diagnosis in children with UTI. Results Materials and Methods A total of 131 charts of patients (age 1 month to 14years) with a final diagnosis of UTI, This study was carried out to evaluate the reli- were investigated for VUR using US before ability and usefulness of renal sonography in VCUG. Of the subjects, 96 (73%) were fe- the diagnosis of VUR in children. We retro- males and 35 (27%) were males. The patients spectively reviewed the charts of 131 children were divided into 3 age groups; the age of under 14 years old with UTI who underwent the 73 subjects (56 %) was“1 month to two renal US examinations and were followed by years”, while the age group of “2 to 5 years” VCUG within two weeks apart. Renal collect- included 31 children (24%) and subjects aged ing system and ureter of each kidney was re- 5 years and older were 27 children (21%). In garded separately and defined as a renal unit this study, VUR were found in thirty three RU (RU). Subjects with history of urinary tract through VCUG, of which 9 cases (7%) were surgery and kidney anomalies were excluded. bilateral, 9 cases (7%) were only in left side In this study, by means of US, VUR was con- and 6 cases (5%) were only in the right side 55 GMJ. 2013;2(2):54-59 www.gmj.ir Ebrahimi S, et al Comparison of Renal Ultrasound and VCUG in the Detection of Vesicoureteral Reflux Comparison of Renal Ultrasound and VCUG in the Detection of Vesicoureteral Reflux Ebrahimi S, et al and 107 cases (82%) were normal. Among bilateral hydronephrosis on US, in VCUG 24 patients with abnormal findings 22 cases were reported as bilateral reflux grade 3, And (91%) were females. Table-1 shows the distri- a patient with dilatation of calyceal system bution of the patients with VUR on VCUG by and hydronephrosis in the left side, showed grade and table-2 shows comparative results grade 5 of reflux on the same side in VCUG. of US and VCUG considering examinations Considering the total of 131 patients, VUR of RUs. was documented in 24 patients (18.3%) on Descriptively, patients’ US examinations were VCUG (33RUs). US results suggested the reported as follows: 113 normal, 13 cases of presence of VUR in only 5 (3.8%) patients. In bladder inflammation (cystitis), 1 person none of 107 subjects with normal VCUG, US showed ureteral dilatation, 1 with right ureter- criteria for VUR, were found. al dilatation with cystitis, one patient with in- Results of calculations performed for detec- creased size of right kidney, one patient with tion of VUR by means of US are as follows: bilateral hydronephrosis, and one showed uni- sensitivity with confidence interval about 95 lateral hydronephrosis with ipsilateral ureteral percent: 20.83%; specificity with confidence dilatation. interval about 95 percent: 100%; positive Out of 113 subjects whom reported US were predictive value: 100%; negative predictive completely normal, VCUG showed the pres- value: 84.93%; percentage of false negative: ence of VUR in 11 RUs in the right and 13 79.2%; percentage of false positive: 0.0; test RUs in the left (grade 1 to 3). VCUG results Diagnostic accuracy: 32.7%. US was not suf- suggested the presence of VUR in 3 RUs of ficiently sensitive for detecting VUR since the 13 patients who were sonographically there was 25% missed diagnosis of refluxing indicated only with cystitis; of them one kidneys or the grade of reflux. was in right side (grade 2) and two on the left (grade 3). In one patient who had left Discussion ureteral dilatation on US, VCUG reported re- flux grade 3 in the same side. In one patient UTI is a common pediatric problem. Most with dilatation of the right ureter and cystitis cases of VUR are diagnosed after UTI occurs. in US, VCUG reported grade 1 reflux in the The reported frequency of VUR ranges from same side.