CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Establishing a Standard Protocol for the Voiding Cystourethrography Dominic Frimberger, MD, Maria-Gisela Mercado-Deane, MD, FAAP, SECTION ON UROLOGY, SECTION ON RADIOLOGY The voiding cystourethrogram (VCUG) is a frequently performed test to abstract diagnose a variety of urologic conditions, such as vesicoureteral refl ux. The test results determine whether continued observation or an interventional procedure is indicated. VCUGs are ordered by many specialists and primary care providers, including pediatricians, family practitioners, nephrologists, hospitalists, emergency department physicians, and urologists. Current protocols for performing and interpreting a VCUG are based on the This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have International Refl ux Study in 1985. However, more recent information fi led confl ict of interest statements with the American Academy provided by many national and international institutions suggests a need of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of to refi ne those recommendations. The lead author of the 1985 study, R.L. Pediatrics has neither solicited nor accepted any commercial Lebowitz, agreed to and participated in the current protocol. In addition, involvement in the development of the content of this publication. a recent survey directed to the chairpersons of pediatric radiology of 65 Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external children’s hospitals throughout the United States and Canada showed that reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations VCUG protocols vary substantially. Recent guidelines from the American or government agencies that they represent. Academy of Pediatrics (AAP) recommend a VCUG for children between 2 and The guidance in this report does not indicate an exclusive course of 24 months of age with urinary tract infections but did not specify how this treatment or serve as a standard of medical care. Variations, taking test should be performed. To improve patient safety and to standardize the into account individual circumstances, may be appropriate. data obtained when a VCUG is performed, the AAP Section on Radiology and All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, the AAP Section on Urology initiated the current VCUG protocol to create a revised, or retired at or before that time. consensus on how to perform this test. DOI: 10.1542/peds.2016-2590 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2016 by the American Academy of Pediatrics INTRODUCTION FINANCIAL DISCLOSURE: The authors have indicated they do The voiding cystourethrogram (VCUG) and the nuclear cystogram are not have a fi nancial relationship relevant to this article to the accepted tests in national and international institutions to diagnose disclose. vesicoureteral reflux (VUR). The VCUG aims to image the urinary tract, FUNDING: No external funding. including the urethra, bladder, ureters, and kidneys, during bladder filling and emptying. The VCUG has many components that can be POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to individually reviewed on the basis of evidence, but no evidence-based disclose. protocol for the VCUG per se is available. The International Reflux Study in 1985 1 is the only published protocol. However, a recent survey To cite: Frimberger D, Mercado-Deane MG, AAP SECTION directed to the chairpersons of pediatric radiology of 65 children’s ON UROLOGY, AAP SECTION ON RADIOLOGY. Establishing a Standard Protocol for the Voiding Cystourethrography. hospitals in the United States and Canada showed that VCUG protocols Pediatrics. 2016;138(5):e20162590 vary substantially. 2 The use of different VCUG protocols raises concerns Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 138 , number 5 , November 2016 :e 20162590 FROM THE AMERICAN ACADEMY OF PEDIATRICS about patient safety and does not technique and skill of the surgeon sedation or immobilization. These allow valid comparison of data and but also of the specific VCUG imaging controversies lead to different outcomes between individuals and technique. protocols among institutions, institutions. Unlike the VCUG, most Many components of the VCUG are making it problematic to compare imaging studies are performed by universally accepted and performed outcomes even when the details of using protocols that have national equally throughout different the technique are reported. and often international consensus institutions. Little discussion exists Standard evidence-based protocols in that allow the comparison of regarding the necessity to empty the medicine are important to minimize results across centers and achieve bladder before the test and to use a patient risk and to improve the a uniform level of patient safety. small nonballoon catheter for filling. validity of comparing data and Recent guidelines from the American The use of more than 1 bladder filling outcomes between individuals and Academy of Pediatrics (AAP) is a common standard, because several institutions. Great efforts were made recommend a VCUG for children groups showed that cyclic filling to ensure that the renal scan protocol between 2 and 24 months of age increases the reliability to detect VUR.8, 9 used in the Randomized Intervention with a urinary tract infection but did It is also well established that several for Children with VesicoUreteral not specify how this test should be voiding cycles may be necessary to Reflux (RIVUR) Study was uniform performed.3 Ward et al 4 compared detect the presence of an ectopic, across the participating centers.15 the radiation exposure and effective refluxing ureter. 10 The documented However, the very test that evaluated dose in children undergoing VCUG. relationship between bladder volume the presence and grade of VUR was They found an 8 times reduced at the onset of VUR and outcome not standardized. To improve our radiation exposure when using causes many pediatric urologists to understanding of VUR, a standardized grid-controlled, variable-rate pulsed ask their radiology departments to protocol of how to perform the fluoroscopy versus conventional note the bladder volume when VUR diagnostic VCUG study is necessary. continuous fluoroscopy. To strike first occurs. Bladder volume when Because the VCUG is ordered by many the balance between obtaining VUR first occurs is important, because different pediatric specialties and the high-quality images and minimizing previous studies have shown that VUR test results are used to determine radiation exposure, radiology occurring at lower bladder volumes treatment of the individual patient, departments should observe and pressure has a tendency to resolve this statement disseminates the the “as low as (is) reasonably spontaneously less often, independent current protocol to reach the broad achievable” (ALARA) and Image of grade.11 In addition, Alexander et al8 community of pediatric health care Gently guidelines. Image Gently is an verified that bladder volume at the providers. Medical circumstances can initiative of the Alliance for Radiation onset of VUR is an independent risk make it necessary to alter the protocol Safety in Pediatric Imaging. Both factor for breakthrough febrile urinary to accommodate a patient’s specific promote radiation protection for the tract infection. patient and radiologic personnel.5, 6 needs; in those cases, the reasons The VCUG can be a traumatizing test should be documented and the Differences in individual test for patients and parents alike. Sedation changes noted in the report. can be used as long as the effects do not parameters can have a significant effect VCUG TEMPLATE on the outcome of the test and have alter the voiding phase and therefore the potential to influence management the outcome of the test. However, Patient Name; Date of Birth; protocols for individual patients. In a patient and parent education, Medications; Medical Record Number study in 183 patients after minimally along with providing a comfortable invasive ureteral injection therapy, environment with well-trained staff Date of Study 60% of patients with a postoperative and the addition of child life specialists positive VCUG result did not show when available, is of great importance Reason for Examination: Information 12,13 VUR until the bladder was filled over to minimize stress. Provided by Ordering Physician 7 the age-adjusted bladder capacity. The multitude of data on the effect of Comparison: Previous Studies If an alternative protocol had been the VCUG technique on test outcome used that filled the bladder just to the has caused many departments to Technique age-adjusted capacity, those patients adapt similar parameters of the Informed consent is obtained and would have had a negative study result, VCUG in their protocols, such as the documented in the patient’s record. and their surgery would have been practice guidelines of the American considered successful. Therefore, the College of Radiology. 14 However, 1. Observe ALARA and Image postoperative success