[Imaging of hepatic tumors in children and adolescents]. / Bildgebung von Lebertumoren im Kindes- und Jugendalter.

BACKGROUND: Pediatric liver tumors are relatively rare, but thorough knowledge of their imaging features is still important. OBJECTIVES: Frequency and imaging features of benign and malignant liver masses during childhood and adolescence. MATERIALS AND METHODS: Discussion of relevant original articles, review manuscripts and expert recommendations concerning imaging of childhood liver tumors. RESULTS: The most common malignant tumors of the liver are hepatoblastoma, which usually occur in younger children, as well as in some regions hepatocellular carcinoma. In contrast to most benign masses, such as focal nodular hyperplasia, simple cysts or fatty liver infiltrations, their imaging morphology is not very characteristic. Radiologically, sonography and magnetic resonance imaging (MRI) are used for assessment. Both methods benefit from intravenous contrast agent administration. CONCLUSIONS: Childhood liver tumors show a broad spectrum of morphological manifestations. Some entities can be characterized using standard imaging, some require multimodal imaging or histological assessment. In addition to morphological imaging criteria, age and the medical history as well as laboratory data play an important role in establishing the correct diagnosis.

[Correction of hypospadias by the Snodgrass method. Indications and results]. / Hypospadiekorrektur nach Snodgrass. Indikationen und Ergebnisse.

Tubularisation of the urethral plate with a medial incision was popularized by Snodgrass in the late 1990s. Since then this procedure has emerged throughout the world as the method of choice for correction of primary hypospadias. The procedure is applied as the technique of choice for primary correction of hypospadias, regardless of the level of the hypospadic meatus and the width of the original urethral plate, and is also used in various situations for secondary hypospadias surgery.. The complication rate is about 5-10 % in primary cases and between 10% and 20% in revision surgery for hypospadias repair.

[Pelvic kidney in childhood. Specific features, concomitant pathologies and useful diagnostic investigations]. / Kindliche Beckenniere. Spezifika, Begleitpathologien und sinnvolle Diagnostik.

In a retrospective analysis we studied the case histories of 31 children who had been seen in our department for investigation of pelvic ectopic kidney between January 1994 and June 2005. The evaluation of each involved the medical history, ultrasound examination, VCUG, and DMSA scan or MAG3 diuresis renogram. Of the 31 children, 21 (67.7%) had initially been referred to our department for further investigation and clarification because renal agenesis was suspected. In the remaining 10 (32.3%) children the pelvic kidney was an incidental finding observed during investigation of various other conditions. Overall, 7 (22.6%) of the 31 were symptomatic (recurrent urinary tract infections, abdominal pain, hypertension, hydronephrosis), while 77.4% (24/31) were completely free of symptoms at the time of follow-up. Ultrasound revealed that the ectopic kidney was on the left in 64.5% (20/31) of these cases. Nuclear scans performed both at the time of the initial diagnosis and at follow-up were available for 11 of the 31 children and showed a mild improvement of the partial function of the pelvic kidney, from a mean of 25.6% to a mean of 34.6%. In conclusion, whenever renal agenesis is suspected on ultrasonographic examination, the investigator should first consider renal ectopia; ultrasound examination with the bladder full is the definitive diagnostic procedure. For asymptomatic cases we recommend regular ultrasound monitoring of the kidney -- at first every 6 months and later once a year. In cases with complex anatomy MRI is a suitable method for further diagnostic work-up.

[Urinary tract infections in children]. / Harnwegsinfekte bei Kindern.

Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).

Imaging of the neonatal CNS.

Imaging of the central nervous system is one of the major tasks of Paediatric Radiology, particularly in newborns, who present with a variety of conditions that need more or less urgent imaging. Imaging is usually performed primarily by bedside US, in rare cases supplemented by a skull or spine radiograph. For more detailed information and preoperatively, MRI has become the neuroimaging tool. Thus, CT today is only used for acute trauma assessment, for assessment of potential cerebral calcifications or when MRI is not available. In cases with vascular anomalies or unsuccessful punctures, image guided interventions (embolisation) or image guidance for access (lumbar puncture, puncture of skull collections ...) may become necessary. This article tries to give a brief overview on the common disease entities, their typical imaging features in the major modalities applied and the implications of imaging potential for indication and choice of imaging method. In general, acute assessment may become everywhere and major features of important diseases should be recognised not to miss conditions which need urgent treatment or referral to a dedicated paediatric unit. Many other conditions will only be seen at centres with a dedicated neonatal care unit and dedicated paediatric radiologist who then also will be able to provide proper imaging with adapted protocols and methods for these partially severely sick babies. As these specific features and adapted capabilities as well as dedicated training and clinical experience are necessary for providing best results and proper handling in neonates, many neonatal conditions will not be imaged at a peripheral site, but primarily should be referred to a paediatric (radiology) centre.

[The pediatric pelvic kidney--a retrospective analysis]. / Die kindliche Beckenniere--eine retrospektive Analyse.

OBJECTIVES: We evaluated children with pelvic kidney and their follow-up according to initial renal function and the appearance of concomitant urological pathologies. PATIENTS AND METHODS: In a retrospective analysis of our case notes, we studied 17 children (8 female, 9 male) who had been referred to our department for further investigation between 1994 and 2002 in whom we found a pelvic ectopic kidney. RESULTS: The mean age of the patients at the initial investigation was 72.5 months (range, 2 - 156 months); 10/17 were referred to our department for further investigation and clarification of a suspected renal agenesis, the remaining 7/17 children presented with urinary tract infection (1/17), nocturnal enuresis (3/17), hypertension (1/17) and phimosis (2/17). The nuclear medicine scan performed at the initial investigation in 14/17 children revealed that the function of the ectopic kidney had been reduced to one-third in contrast to two-thirds for the orthotopic kidney (p = 0.002). Overall global renal clearance was normal in all children. In 8/17 patients, the ongoing control nuclear investigations, on average 26.2 months later, revealed unchanged overall function of the kidney, we did, however, find a slight improvement of the ectopic renal function as compared to initial investigation which was not statistically significant (p = 0.683). In the period of this retrospective analysis, surgical correction of an accompanying pathology was performed in 23.5 % (4/17) of the children (vesico-ureteteric reflux operation in two cases, surgery for pelvic ureteric junction obstruction in one case, and nephroureterectomy in one case of a nonfunctioning-kidney). A left-sided pelvic kidney was seen in 64.7 % (11/17) of cases, a right-sided ectopic kidney in 23.5 % (4/17), a pelvic fused kidney in 11.7 % (2/17), and a solitary left-sided pelvic ectopia with right-sided agenesis in 5.8 % (1/17) of cases. CONCLUSION: In the event of suspected renal agenesis on ultrasonography, the possibility of a pelvic ectopic kidney should always be included in the range of diagnoses. On ultrasonography, the pelvic kidney is best visualized inferior to the iliac vessels, in the presence of a filled bladder. It is more frequently encountered on the left side. Nearly one-thirds of our patients presented with concomitant pathologies and one quarter needed surgical intervention. Although the function of the ectopic kidney alone was reduced by (2/3), the overall renal clearance was normal and remained stable in the course of the observation period.

[Pediatric outpatient surgery]. / Ambulantes Operieren im Kindesalter.

BACKGROUND: The number of outpatient surgeries for routine surgical interventions continues to increase, especially in adults. For many patients, there is no doubt that interventions like arthroscopy will be performed on an outpatient basis. Regarding urologic surgeries in adults (e.g., vasectomy, hydrecelectomy), outpatient treatment is well established. For adults such a procedure represents a well-calculable situation in most cases, as the patient can quite accurately imagine the events that will follow. In terms of pediatric outpatient surgery, the scenario is sometimes quite different. Parents are more anxious and uncertain because they must decide for the well-being of their children and they often do not exactly know what will happen during the procedure. In addition, they do not have to decide for themselves but for their children. DISCUSSION: Unfortunately, parents often lack information prior to surgery. Therefore, all persons involved in the treatment of children (e.g., urologists, anesthesiologists, nurses) must be trained and educated in giving adequate and appropriate information especially for parents. CONCLUSION: The purpose of this article is to provide different starting points for an optimized preparation and care of children and parents concerning outpatient surgery in pediatric urology.

[Vesico-ureteral reflux: Diagnosis and treatment recommendations]. / Vesikoureteraler Reflux : Diagnose und Therapieempfehlungen.

BACKGROUND: Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux. OBJECTIVES: Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage. THERAPY: The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies. CONCLUSION: Decisions on treatment should be made individually with parents taking into account all the findings available.

[Imaging in pediatric urology]. / Bildgebung in der Kinderurologie.

BACKGROUND: For many years, sonography and the intravenous pyelogram (IVP) were the most important examination methods for the evaluation of the urinary tract in children. Both methods have their pros and cons: sonography provides ideal visualization of normal kidneys and the evaluation of the pelvicalyceal system. For detection or exclusion of renal scarring, however, this method is not well suited. It provides no information regarding kidney function. METHODS: With an IVP, it is possible to evaluate urinary excretion and, thus, indirectly assess kidney function. As this examination method involves radiation exposure and the necessity of a contrast agent, it should be avoided in the examination of children. The CT is an excellent examination method that can diagnose nearly all urological diseases in children or answer urological questions; however, a CT scan applies the highest radiation dose of all discussed methods. For this reason, examination via MRI is of increasing importance in uroradiology. Initially only the T2 sequences for the visualization of the urinary tract in children were applied. CONCLUSION: The current technical developments as well as the use of the contrast agent gadolinium and the antidiuretic agent furosemide allow an all-in-one evaluation of the kidneys and urinary tract.

A new spacing material for interstitial implantation of radioactive seeds.

Poly-p-dioxanon sutures (PDS) have been common in surgery as an absorbable material for years. After hardening by a particular procedure we use PDS pins as spacer material in interstitial I-125 implantations. The advantages of PDS are the mechanical qualities in contrast to catgut which causes hazards because of its soft consistency. PDS supports the efforts in optimization of seed distribution and dose application in interstitial radiotherapy.

Three-dimensional ultrasound of the fetal spine.

OBJECTIVE: To describe normal fetal spinal anatomy displayed by three-dimensional ultrasound and to determine whether three-dimensional ultrasound improves visualization of specific spinal defects. METHODS: Fetuses (n = 28) (16 normal and 12 abnormal) were examined on standard two- and three-dimensional sonographic equipment. RESULTS: In 15 of 16 normal fetuses, the spine was visualized at least from the upper thoracic area to the lower sacrum in a single three-dimensional image, and in 14 normal fetuses continuity of the ribs and spine was depicted. Neural tube defects were identified on both two- and three-dimensional ultrasounds; however, three-dimensional ultrasound displayed the level of the defect more accurately in three of the five cases. Scoliosis was recognized easily on a single three-dimensional rendered image, whereas several two-dimensional redered image, whereas several two-dimensional images were needed for the examiner mentally to reconstruct the scoliosis. CONCLUSION: Three-dimensional ultrasound may become an important tool for imaging of the fetal spine. Additional studies are necessary to determine the efficacy and cost effectiveness of this technology. However, our preliminary data suggest that presentation of the spine as a continuous structure rather than in independent two-dimensional views makes visualization of the spatial relationship of the spinal anatomy and adjacent structures easier. The ability to review the volume data using techniques not available on two-dimensional ultrasound may enable physicians to determine the extent of neural tube defects with more accuracy.

Cerebral arteriovenous malformations: diagnostic value of echo-enhanced transcranial Doppler sonography compared with angiography.

BACKGROUND AND PURPOSE: The purpose of our study was to examine the clinical value of echo-enhanced transcranial power Doppler sonography (EE-TCD), including it ability to assess hemodynamic parameters of the intracranial vasculature, in patients with suspected cerebral arteriovenous malformations (AVMs) and to compare this method with angiography. METHODS: Sixteen patients with suspected cerebral AVMs were examined with EE-TCD and angiography. As an echo-enhancing agent, SHU 508A (Levovist) was administered intravenously by bolus injection in nine patients and by continuous infusion in seven. Sonograms were reviewed without knowledge of other imaging results and were correlated with angiographic findings. RESULTS: Angiography showed AVMs in 12 of 16 patients. Eleven lesions were located in the anterior or middle fossa and one was in the posterior fossa. EE-TCD was slightly less sensitive in the detection of AVMs (92%, 11/12 lesions), since in one patient the lacking acoustic window did not allow a transcranial examination. EE-TCD slightly underestimated AVM size compared with angiographic findings but showed feeding arteries with sufficient acoustic properties. In seven patients (58%), angiography revealed a coincidental blood supply from another intracranial or extracranial vessel, which was missed by EE-TCD in all cases. Assessment of peak systolic velocities and resistive indexes resulted in a higher (mean, 191.1 cm/s) and a lower (mean, 45.7%) value, respectively, in the feeding arteries as compared with the contralateral arteries (mean, 101.8 cm/s and 55.6%, respectively). Side-to-side differences were significantly higher in patients with AVMs than in those without a malformation. Signal enhancement was markedly longer with continuous infusion (mean, 520 seconds +/- 28.2) than with bolus injection (mean, 145 seconds +/- 10.5) of the contrast agent. CONCLUSION: In our limited study group, EE-TCD was a sensitive method for the detection of AVMs, and Levovist proved to be a safe and effective echo-enhancing substance.

CT findings in post-operative subphrenic abscess with teratomatous inclusions.

A 39-year-old woman presented with abdominal pain after tubal sterilization. CT showed a subphrenic abscess with fatty inclusions owing to laceration or rupture of a mature ovarian teratoma. Although subphrenic abscess is a well recognized post-operative complication, and ovarian teratomas are frequent, a teratomatous inclusion within a subphrenic abscess is a unique finding.

Conventional imaging in paediatric uroradiology.

OBJECTIVE: To briefly describe basic conventional imaging in paediatric uroradiology. METHOD: The state of the art performance of standard imaging techniques (intravenous urography (IVU), voiding cystourethrography (VCU), and ultrasound (US)) is described, with emphasis on technical aspects, indications, and patient preparation such as adequate hydration. Only basic applications as used in routine clinical work are included. RESULT AND CONCLUSION: Conventional imaging methods are irreplaceable. They cover the majority of daily clinical routine queries, with consecutive indication of more sophisticated modalities in those patients who need additional imaging for establishing the final diagnosis or outlining therapeutic options.

Imaging guided interventional procedures in paediatric uroradiology--a case based overview.

OBJECTIVE: To describe the potential and application of interventional image guided procedures in the paediatric urinary tract. PATIENTS AND METHODS: The different techniques are illustrated using case reports. The examples comprise established indications such as percutaneous nephrostomy for compromised kidneys in obstructive uropathy and infection, sonographic guided renal biopsy including monitoring or treatment of complications after biopsy, and evaluation and balloon dilatation of childhood renal artery stenosis. There are new applications such as treatment of stenosis in cutaneous ureterostomy or sonographically guided catheterism for deployment of therapeutic agents. RESULTS: Generally, the procedures are safe and successful. However, complications may occur, and peri-/post-interventional monitoring is mandatory to insure early detection and adequate management. Sometimes additional treatment such as percutaneous embolisation of a symptomatic post biopsy arterio-venous fistula, or a second biopsy for recurrent disease may become necessary. CONCLUSION: Imaging guided interventional procedures are performed successfully in a variety of diseases of the paediatric urinary tract. They can be considered a valuable additional modality throughout infancy and childhood.

Three dimensional ultrasound: display modalities in the fetal spine and thorax.

PURPOSE: To evaluate the display modalities of three dimensional ultrasound (3D US) in the prenatal assessment of the fetal spine and thorax. METHOD: Twenty prenatal spine examinations (mean gestational age: 21 weeks, 15 normal findings, five pathological cases) were performed with a commercially available 3D US device. The visualization of fetal spine and rib anatomy and pathology by 3D US display was evaluated using various rendering methods and the optimal method was determined in regard to comprehensive diagnostic display. RESULTS: Demonstration of continuity of both the spine and the ribs could be achieved by 3D US. Visualization of clavicles, scapula and iliac bone was possible on rendered images. CONCLUSION: 3D US offers an additional diagnostic tool for prenatal assessment of the fetal spine and ribs; it provides a continuous demonstration of curved or tortuous structures in the rendered image. It improves comprehension of complex anatomy by providing a simultaneous display of all orthogonal sectional planes.

[Accuracy of renal volume assessment in children by three-dimensional sonography]. / Nierenvolumetrie im Kindesalter: Genauigkeit der dreidimensionalen Sonographie im Vergleich zur konventionellen Sonographie und CT / MRT.

PURPOSE: Prospective evaluation of the accuracy of three-dimensional ultrasound (3DUS) to assess the renal parenchymal volume. MATERIALS AND METHODS: CT, MRI, 2DUS and 3DUS were used to measure the renal volume in 40 patients (range: neonate to 17 years; mean age: 8.95 years). The 3DUS was determined with a Voluson 730 (Kretztechnik, GE) or an external 3D-system (EchoTech, GE) using electromagnetic positioning sensors attached to conventional 2DUS-equipment. The 2DUS volume was calculated with the ellipsoid equation and the 3DUS volume computed with the system integrated software. For CT and MRI, planimetric analysis was used to determine the renal parenchymal volume, whereby the dilated collecting system of a hydronephrosis was subtracted to obtain the real renal parenchymal volume. The results of 2DUS and 3DUS were compared to the results of CT and MRI, and inter- and intraobserver variabilities were calculated. RESULTS: In 74 of 77 kidneys, the 3DUS study was of diagnostic quality. The accuracy of the 3DUS volumes compared well to the CT and MRI volumes with a mean difference of -1.8 +/- 4.6 % versus a mean difference of -2.4 +/- 15.4 % for 2DUS. In normal kidneys, the accuracy was -2.6 +/- 4.4 % for 3DUS and -3.8 +/- 14.7 % for 2DUS. In hydronephrosis, the accuracy was +4.0 +/- 5.9 % and +9.6 +/- 21.3 %, respectively, indicating that 3DUS is more accurate than 2DUS, particularly in kidneys with a dilated collecting system. Inter- and intraobserver variabilities were +/- 7.3 % and +/- 5.3 %. CONCLUSION: For assessing the renal parenchymal volume in children, 3DUS is feasible and comparable to CT and MRI.

Scintigraphy and sonography in reflux nephropathy: a comparison.

The evaluation of reflux nephropathy (RNP) is a major task in the following up of children with vesicoureteral reflux (VUR). Adequate monitoring of RNP development depends on the frequent use of sonographical and scintigraphical examinations. In order to evaluate the accuracy of sonography in monitoring RNP 63 patients suffering from VUR (mean age: 8.8 years, range: newborn to 18 years, male:female = 19:44) were examined prospectively. We calculated renal size sonographically and compared our data to static and dynamic renographic findings. Our results showed a good correlation between relative DMSA uptake and sonographically estimated relative renal size (r = 0.95, P < 0.001), whereas not unexpectedly the correlation between relative kidney function and sonographically estimated renal size was poor (r = 0.83, P < 0.01). We therefore believe, that in monitoring children with VUR, sonography can offer accurate information on questions about renal size and renal parenchymal structure as well as pelvic distention. With very small kidneys as well as with kidneys showing severe dilatation and above all for evaluating renal function, scintigraphy proved to be the better method.

[The conservative treatment of stress incontinence in women with midodrine]. / Die konservative Behandlung der weiblichen Stressinkonontinenz mit Midodrin.

This paper describes the aetiology and symptoms of stress incontinence in women and reports on the conservative therapy of this condition with midodrine, an alpha-sympathomimetic drug. Successful results were obtained in 80% of the cases, the side effects produced by midodrine were negligible.