[Assessing the impact of bladder ultrasound on catheter-associated urinary tract infections and health-care costs: an observational pre-post study]. / Valutazione dell'impatto dell'ecografia vescicale sulle infezioni del tratto urinario associate al catetere e sui costi sanitari: uno studio osservazionale pre-post.

. Assessing the impact of bladder ultrasound on catheter-associated urinary tract infections and health-care costs: an observational pre-post study. INTRODUCTION: The placement of a urinary catheter is a standard procedure, but it can cause discomfort, increase the risk of infections and costs. Pelvic ultrasound is a non-invasive assessment of the bladder and bladder catheter placement that can be performed by nurses. AIM: To assess the appropriateness of urinary catheter placement using bladder ultrasound, to monitor urinary catheter-associated urinary tract infections and costs associated with catheter use. METHODS: A single-centre pre-post observational study was conducted from September 2021 to August 2022 in patients aged >18 years requiring urinary monitoring; the first 6 months patients were assessed without the use of bladder ultrasound (control group), while the last 6 months with bladder ultrasound. RESULTS: 189 patients were included in the pre-ultrasound group and 175 patients in the post-ultrasound group; the demographic and clinical characteristics of the two groups were comparable. The rate of inappropriate catheterisation was 22.6% in the pre-group, whereas no inappropriate catheterisation was performed in the post-group. There was a 2.2% of absolute reduction in the rate of urinary tract infections (from 8.5% to 6.3%). Costs associated with the use of urinary catheters were reduced by 74.2% (from 173 to 44.8 euros). CONCLUSIONS: Bladder ultrasound in clinical practice is feasible and reduced the inappropriate use of bladder catheters, reducing patient risks and healthcare costs.

Cost-Effectiveness of Screening Ultrasound after a First, Febrile Urinary Tract Infection in Children Age 2-24 Months.

OBJECTIVE: To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics. STUDY DESIGN: We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY). RESULTS: Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group. CONCLUSIONS: Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

Contemporary Practice Patterns of Voiding Cystourethrography Use at a Large Tertiary Care Center in a Single Payer Health Care System.

PURPOSE: Voiding cystourethrogram involves radiation exposure and is invasive. Several guidelines, including the 2011 AAP (American Academy of Pediatrics) guidelines, no longer recommend routine voiding cystourethrogram after the initial urinary tract infection in children. The recent trend in voiding cystourethrogram use remains largely unknown. We examined practice patterns of voiding cystourethrogram use and explored the impact of these guidelines in a single payer system in the past 8 years. MATERIALS AND METHODS: We identified all voiding cystourethrograms performed at a large pediatric referral center between January 2008 and December 2015. Patients 2 to 24 months old who underwent an initial voiding cystourethrogram for the diagnosis of a urinary tract infection in the first 6 months of 2009 and 2014 were identified. Medical records were retrospectively reviewed. RESULTS: During the study period 8,422 voiding cystourethrograms were performed and the annual number declined over time. In the pre-AAP and post-AAP cohorts 233 and 95 initial voiding cystourethrograms were performed, respectively. While there was no statistically significant difference in the vesicoureteral reflux detection rate between 2009 and 2014 (37.3% vs 43.0%, p = 0.45), there was a threefold increase in high grade vesicoureteral reflux in 2014 (2.6% vs 8.4%, p = 0.03). CONCLUSIONS: A clear trend toward fewer voiding cystourethrograms was noted at our institution. This decrease started before 2011 and cannot be attributed to the AAP guidelines alone. While most detected vesicoureteral reflux remains low grade, there was a greater detection rate of high grade vesicoureteral reflux in 2014 compared to 2009. This may reflect a favorable impact of a more selective approach to obtaining voiding cystourethrograms.

Cost and radiation exposure in the workup of febrile pediatric urinary tract infections.

BACKGROUND: Technetium-99m dimercaptosuccinic acid (DMSA) scans are often used in the evaluation of pediatric patients with febrile urinary tract infections (UTIs). Given the prevalence of febrile UTIs, we sought to quantify the cost, radiation exposure, and clinical utility of DMSA scans when compared with dedicated pediatric renal ultrasounds (RUSs). MATERIALS AND METHODS: An institutional review board approved retrospective study of children under the age of 18 years evaluated at our institution for febrile UTIs between the years 2004-2013 was conducted. The patients had to meet all of the following inclusion criteria: a diagnosis of vesicoureteral reflux, a fever >38°C, a positive urine culture, and evaluation with a DMSA scan and RUS. A chart review was used to construct a cost analysis of technical and professional fees, radiographic results, and radiation dose equivalents. RESULTS: Overall, 104 children met the inclusion criteria. A total of 122 RUS and 135 DMSA scans were performed. The technical costs of a DMSA scan incurred a 35% cost premium as compared to an RUS. The average effective radiation dose of a single DMSA scan was 2.84 mSv. New radiographic findings were only identified on 7% of those patients who underwent greater than 1 DMSA scan. CONCLUSIONS: The utility of the unique information acquired from a DMSA scan as compared to a RUS in the evaluation of febrile UTI must be evaluated on an individual case-by-case basis given the increased direct costs and radiation exposure to the patient.

Sonographic assessment of the effect of vesicoureteral reflux and urinary tract infections on growth of the pediatric solitary kidney.

INTRODUCTION: Perusal of recent guidelines relating to proper evaluation of infants and children with urinary tract infection (UTI) suggests that the occurrence of vesicoureteral reflux (VUR) may not have the clinical import previously ascribed to this anatomic abnormality. Patients with a solitary kidney uniquely allow investigation of the effects of both vesicoureteral reflux (VUR) and urinary tract infection (UTI) on renal growth unencumbered with the inevitable questions of laterality that confound analysis in patients with two kidneys. Several previous studies with conflicting results have addressed whether vesicoureteral reflux (VUR) impacts ultimate renal size in children with a solitary kidney. Few published studies have considered the occurrence of both urinary tract infection (UTI) and VUR on the degree of compensatory hypertrophy. This is the largest series to date investigating the effect of both UTI and VUR on the degree of compensatory hypertrophy with time. OBJECTIVE: Our objective was to analyze sonographically determined renal growth in patients with a solitary kidney, stratifying for both the occurrence and severity of UTIs and the occurrence and severity of VUR. STUDY DESIGN: We retrospectively reviewed the clinical history (including bladder and bowel dysfunction (BBD)) and radiology reports of 145 patients identified as having either a congenital or acquired solitary kidney in our pediatric urology practice from the prior 10 years. UTIs were tabulated by severity, where possible, and the grade of VUR was recorded based on the initial cystogram. Sonographically determined renal length was tabulated for all ultrasounds obtained throughout the study. Based on a mixed-effects model, we investigated the influence of UTI and VUR on renal growth. RESULTS: Of the 145 patients analyzed, 105 had no VUR and 39 had VUR (16 = Gr I&II, 11 = GIII, 12 = GIV&V). Comparison showed that there was no difference in the occurrence of UTI between those without VUR (27/105 with UTI) and those with VUR (15/39 with UTI; p = 0.14). There was no difference in the occurrence of BBD in patients with VUR (15/39) and those without VUR (36/106, p = 0.62). While neither VUR nor UTI alone affected renal growth in the solitary kidney, the three-way interaction term among age, VUR, and UTI was significant (p = 0.016). The growth of the kidneys in the various patient groups is depicted in the table. From the analysis, a refluxing solitary kidney with UTI showed a significantly lower growth rate than the other groups (p < 0.001). DISCUSSION: This study is limited by the inherent selection bias of retrospective studies. Additionally, the variability of sonographic renal measurement is well recognized. Lastly, our sample size did not allow us to incorporate the severity of the UTIs and the grades of VUR in our final regression model. Nevertheless, the overall patterns suggest that when both VUR and UTI are present, the solitary kidney demonstrates less renal growth with time. Study of larger cohorts of patients with solitary kidneys will be necessary to confirm our observations and discern what, if any, are the consequences of high-grade VUR and upper tract UTI in these patients. CONCLUSION: In the largest series to date we were able to discern no independent effect of either VUR or UTI on sonographically determined renal growth in patients with a solitary kidney. However, UTI and VUR together result in kidneys that are smaller than other solitary kidneys not so affected. Follow-up studies of larger cohorts seem warranted to confirm these findings and discern the clinical import of these smaller kidneys.

[Ultrasound assessment in renal infections]. / L'ecografia nelle infezioni del rene.

Urinary tract infections (UTIs) are a common clinical problem, especially among women. Ultrasound assessment is indicated in case of complicated UTIs, in particular in children, pregnant women and patients with chronic kidney disease. Even though B-mode imaging alone is rarely diagnostic in case of particular kidney infections such as focal and multifocal acute pyelonephritis, Doppler and power-Doppler (PD) techniques are able to increase its sensitivity. Contrast-enhanced ultrasound (CEUS) further improves the signal-to-noise ratio, thus increasing the diagnostic accuracy of ultrasound in case of renal infectious disease. Recent studies performed on kidney transplant recipients have indeed demonstrated the high sensitivity and specificity of CEUS in diagnosing acute pyelonephritis. Moreover, ultrasonography is a useful diagnostic tool in case of kidney abscesses, emphysematous pyelonephritis, early phases of pyonephrosis, and in the evaluation and monitoring of echinococcal cysts. Ultrasound imaging is less specific in diagnosing xanthogranulomatous pyelonephritis, malacoplakia and renal tuberculosis. Finally, several authors recommend routine ultrasound assessment in HIV patients, given the high incidence of renal complications in this population of patients.

Economic and radiation costs of initial imaging approaches after a child's first febrile urinary tract infection.

BACKGROUND. The traditional initial imaging approach following pediatric urinary tract infection is the "bottom-up" approach (cystogram and renal ultrasound). Recently, the "top-down" approach (nuclear renal scan followed by cystogram for abnormal scans only) has gained increasing attention. The relative cost and radiation doses of these are unknown METHODS. The authors used a decision model to evaluate these imaging approaches. Cost and effective radiation dose estimates, including sensitivity analyses, were based on one-time imaging only. RESULTS. Comparing hypothetical cohorts of 100 000 children, the top-down imaging approach cost $82.9 million versus $59.2 million for the bottom-up approach. Per-capita effective radiation dose was 0.72 mSv for top-down compared with 0.06 mSv for bottom-up. CONCLUSIONS. Routine use of nuclear renal scans in children following initial urinary tract infection diagnosis would result in increased imaging costs and radiation doses as compared to initial cystogram and ultrasound. Further data are required to clarify the long-term clinical implications of this increase.

Static renal scintigraphy with 99mTc-DMSA for the assessment of renal damage after therapy for acute lymphoblastic leukemia in children.

INTRODUCTION: Acute lymphoblastic leukemia (ALL) and its treatment may adversely affect kidney function. The aim of the present study was to determine whether 99mTc-DMSA static renal scintigraphy can be used to disclose kidney damage at the end of therapy for ALL in children. MATERIAL AND METHODS: The study group consisted of 48 ALL patients aged 6.6-22.9 years, with a mean time of continuous complete remission of 51 months. Static renal scintigraphy with 99mTc-DMSA was performed in all patients. RESULTS: Minor scars in the renal cortex were diagnosed with scintigraphy in 6 (13%) patients. A significant correlation was found between renal scarring and a history of urinary tract infection. CONCLUSIONS: No clinically significant kidney damage was found after completion of treatment of ALL. Static renal scintigraphy may be a valuable noninvasive method for visualization of renal cortex pathology.

Lower urinary tract dysfunction and ultrasound assessment of bladder wall thickness in children with cerebral palsy.

OBJECTIVES: To evaluate lower urinary tract dysfunction (LUTD) based on questionnaire symptom scoring and ultrasound assessment of bladder wall thickness (BWT) in children with cerebral palsy (CP). METHODS: A total of 97 children with CP were enrolled in the study. The patients were either symptomatic or asymptomatic with respect to lower urinary tract symptoms. All children underwent a urinary questionnaire and renal ultrasonography. Ultrasound assessment of BWT was completed in 72 cases. RESULTS: A total of 47 patients were female and 50 were male. The mean age was 8 years 8 months (SD 3 years 1 month), with a range of 5-18 years. Urinary incontinence was present in 43 patients (44.3%). Based on the questionnaire, LUTD was found in 59 patients (60.8%). The mean BWT was 2.30 mm. There was no statistically significant difference between continent and incontinent children (2.46 vs 2.19 mm) or between children with and without LUTD (2.43 vs 2.12 mm). CONCLUSIONS: LUTD is common in children with CP and occurred in 60.8% of the patients assessed. BWT did not correlate with the presence of bladder dysfunction or incontinence. Ultrasound assessment of BWT was not relevant for diagnosis of lower urinary tract dysfunction.

Factors associated with variability in outcomes for children hospitalized with urinary tract infection.

OBJECTIVES: To describe the variability in outcomes and care processes for children hospitalized for urinary tract infection (UTI), and to identify patient and hospital factors that may account for variability. STUDY DESIGN: Retrospective cohort of children 1 month to 12 years of age hospitalized for UTI at 25 children's hospitals from 1999 to 2004. We measured variability in length-of-stay (LOS), cost, readmission rate, intensive care unit admission, and performance of renal ultrasound and voiding cystourethrogram and identified patient and hospital factors associated with these outcomes. RESULTS: The cohort included 20,892 children. There was significant variation in outcomes and processes of care across hospitals (eg, mean LOS, 2.1-5.0 days; patients with both imaging tests performed, 0.3%-72.9%). Older children had shorter LOS and were less likely to undergo imaging. Patients hospitalized at high volume hospitals were more likely to undergo imaging. Hospitals with high percentage of Medicaid patients had longer LOS and were less likely to perform imaging tests. Hospitals with a clinical practice guideline for UTI had shorter LOS and decreased costs per admission. CONCLUSIONS: The variability across hospitals may represent opportunities for benchmarking, standardization, and quality improvement. Decreased LOS and costs associated with clinical practice guidelines support their implementation.

Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury.

AIMS: The vast majority of spinal cord lesions cause neurogenic bladder disorders. Detrusor hyperreflexia presents a major risk factor for renal damage in these patients. We evaluated the long-term results of patients with spinal cord injury treated at our institution. METHODS: Eighty spinal cord injury patients (60 male, 20 female; mean age 29.6 years) with at least one follow-up visit a year for a minimum of five consecutive years, were included in this retrospective analysis. Follow-up included urodynamic evaluation, sonography of the upper and lower urinary tract, urine examination, and evaluation of renal function. Treatment modifications were based on the urodynamic findings. RESULTS: Mean follow-up was 67.3 months (range 60-103 months). At initial presentation, 51 patients performed intermittent catheterization, 7 had indwelling catheters, 10 utilized reflex voiding, 2 patients presented with a Brindley stimulator, 10 patients used abdominal straining. At the end of our study, no patient had signs of renal damage. To achieve that goal, 8 patients underwent sphincterotomy, 3 received a Brindley stimulator, 3 underwent bladder augmentation, one Kock pouch was performed, and 12 patients were treated with botulinum-A-toxin injections in the detrusor. Twenty-two patients received intravesical anticholinergic therapy. In merely three patients, treatment was not modified during the entire follow-up. CONCLUSIONS: In the long term, treatment strategy of neurogenic bladder dysfunction in patients with spinal cord injury had to be modified in almost all patients. 18.8% underwent surgery. For protection of the upper urinary tract and maintenance of continence, regular urodynamic follow-up is warranted.

Compliance with guidelines for the medical care of first urinary tract infections in infants: a population-based study.

BACKGROUND: No population-based studies have examined the degree to which practice parameters are followed for urinary tract infections in infants. OBJECTIVE: To describe the medical care of children in their first year of life after a first urinary tract infection. METHODS: Using Washington State Medicaid data, we conducted a retrospective cohort study of children with a urinary tract infection during their first year of life to determine how many of these children received recommended care based on the most recent guidelines from the American Academy of Pediatrics. Recommended care included timely anatomic imaging, timely imaging for reflux, and adequate antimicrobial prophylaxis. Multivariate logistic-regression models were used to evaluate if hospitalization for first urinary tract infection, young age at time of diagnosis, gender, race, primary language of parents, having a managed care plan, and rural location of household residence were associated with recommended care. RESULTS: Less than half of all children diagnosed with a urinary tract infection in their first year of life received the recommended medical care. Children who were hospitalized for their first urinary tract infection were significantly more likely than children who were not hospitalized to receive anatomic imaging (relative risk [RR]: 1.38; 95% confidence interval [CI]: 1.20-1.57) and imaging for reflux (RR: 1.62; 95% CI: 1.34-1.90). CONCLUSIONS: There is poor compliance with guideline-recommended care for first urinary tract infections in infants in a Medicaid population. Given the trend toward increased outpatient management of urinary tract infections, increased attention to outpatient imaging may be warranted.

Introital and transvaginal ultrasound as the main tool in the assessment of urogenital and pelvic floor dysfunction: an imaging panel and practical approach.

This article reviews the different applications of ultrasound in benign urogynecological diseases. The findings presented here were obtained by introital and transvaginal ultrasound, both of which can be performed with the same equipment (5-7-MHz sector transducer, emission angle of at least 90 degrees; for introital sonography, the transducer is placed over the external urethral orifice with the transducer axis corresponding to the body axis). Female voiding dysfunction, including urge symptoms, recurrent urinary tract infections and urinary incontinence, may occur secondary to morphological and topographical changes of the urogenital organs. Findings such as urethral diverticula, periurethral masses, funneling of the urethra and distension cystoceles are identified by introital ultrasound. Transvaginal ultrasound enables the detection of pathologies of the bladder and uterus including its appendages. Ultrasound as part of the diagnostic work-up of stress urinary incontinence and genitourinary prolapse allows for the morphological and dynamic assessment of the lower urinary tract. It is possible, for example, to classify sonographically identified changes of the endopelvic fascia as lateral (distraction cystocele, funneling of the urethra) and central (pulsation cystocele) defects as well as to determine the reactivity of the pelvic floor muscles. Ultrasound has replaced radiography in yielding information on the abnormal morphology of the urogenital organs, which should be taken into account in planning the treatment of urogynecological conditions.

Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography.

AIMS: To address some of the issues in the ongoing debate over the optimal diagnostic imaging following childhood urinary tract infection (UTI), by determining the risk of missing renal cortical scarring which would be detected on a technetium-99m dimercaptosuccinic acid (DMSA) gold standard if ultrasound alone were used, factoring for clinical features (upper or lower tract), UTI recurrence, and age group (infants, preschool, or school age). METHODS: Details of UTI clinical features and recurrence were recorded for 990 children with a proven UTI, and their DMSA and ultrasound results were compared for each kidney. RESULTS: The risks of missing DMSA scarring varied between 0.4% (school age children with solitary lower tract UTI) and 11.1% (infants with recurrent upper tract UTI). CONCLUSIONS: UTI clinical features are important in assessing the need for DMSA imaging. Current UK imaging guidelines are endorsed, although preschool children with solitary lower tract UTI remain a controversial group and more attention needs to focused on children with recurrent UTI.

Assessment of infective urinary tract disorders.

Urinary tract infection (UTI) is common in children, particularly in the youngest age groups. There is a risk for progressive deterioration of renal function in these children if aggravating factors such as gross reflux and/or outflow obstruction of the urinary tract are present. In this review the pros and cons of available scintigraphic and radiological imaging techniques for the work-up of these children are presented. Ultrasound can be used in the acute phase to exclude obstruction but can not reliably show transient or permanent parenchymal lesions. The presence of reflux can be established with X-ray or direct nuclide cystography. The X-ray technique gives good morphological information and has a grading system with prognostic relevance. Both techniques are invasive and great care must be taken to keep the radiation burden down with the X-ray technique. Indirect nuclide cystography following a renographic study is non-invasive but has a lower sensitivity than direct techniques. More experience is needed with the indirect technique to evaluate the consequences of its apparently low sensitivity. Urography has a limited place in the acute work-up of urinary tract infection but can be used to look for renal scarring 1-2 years after an acute pyelonephritis. The 99mTc dimercaptosuccinic acid (DMSA) scan can be used during the acute UTI to show pyelonephritic lesions with good accuracy and/or during the follow-up after six months to show permanent lesions. The acute DMSA scan can be omitted. An early treatment is more important than an early scan!

Using a portable bladder scan to reduce the incidence of nosocomial urinary tract infections.

An innovative technology, BladderScan, was introduced to reduce urinary tract infections and care costs in hospitalized adults. Evaluation revealed reductions in infection rates and overall benefits exceeding costs.

[Usefulness of renal scintigraphy in the assessment of the first febrile urinary infection in children]. / Utilidad de la gammagrafía renal en la valoración de la primera infección urinaria febril en la edad pediátrica.

OBJECTIVE: The objective of this study was to compare the findings of renal ultrasonography and 99mTc-DMSA renal scintigraphy in children with their first acute febrile urinary tract infection to determine which method is better in detecting patients at risk of renal injury or reflux. PATIENTS AND METHODS: Thirty-three children between 0.2 and 12.3 years of age with their first acute febrile urinary tract infection were studied by means of clinical and laboratory assessment, renal ultrasonography and 99mTc-DMSA renal scintigraphy. In 24 patients (72.7%) a voiding cystourethrography was made. The patients were divided into two groups, those under 2 years of age (n = 14) and those over 2 years old (n = 19). RESULTS: Cortical scintigraphy showed renal changes in 23 patients (69.7%) and ultrasonography showed renal changes in 2 (6.1%; p < 0.05). Children over 2 years of age had a higher incidence of renal lesions than did younger children (84.2% vs 50%; p < 0.05). There were no differences between girls and boys. Reflux was demonstrated in 13 patients (54.2%). Among those kidneys which presented abnormal cortical scintigraphy, vesicoureteral reflux was present in 76.5% of the studies. Furthermore, of those with abnormal ultrasonography vesicoureteral reflux was present in 17.6%. CONCLUSIONS: We found a high incidence of renal involvement in children with their first acute febrile urinary tract infection. The cortical scintigraphy is more sensitive than ultrasonography in detecting renal changes. The incidence of vesicoureteral reflux in febrile urinary tract infection is high. When there is a renal cortical defect the risk of reflux is higher. This suggests that cortical scintigraphy should be added to the initial examination of children with their first acute febrile urinary tract infection and this could be supplemented by voiding cystourethrography alone, with ultrasonography having a secondary role.

Sonographic assessment of renal length in children: a reappraisal.

Ultrasonography (US) has largely replaced the intravenous urogram as the first modality for the evaluation of the kidneys in children suspected of having urinary tract abnormalities. Because many renal disorders are associated with changes in the sizes of the kidneys, normative standards for assessing renal size have been developed. These standards rely upon comparison of the renal lengths or calculated volumes or both, with various assessments of overall body size, including body surface area, weight, height, and chronological age. We discuss some of the limitations of US in assessing renal size in children. Practical recommendations are offered for optimizing the measurement and interpretation of sonographic renal sizes in children.