The impact of the distal ureteral diameter ratio, bladder volume at onset of vesicoureteral reflux, and/or grade in predictive models of clinical outcomes in children with vesicoureteral reflux.

PURPOSE: Vesicoureteral reflux (VUR) grade has been used as a primary factor in assessing a child's risk of clinical outcomes. Unfortunately, grade has poor inter-observer reliability. We hypothesized that more objective and reliable VCUG parameters including the distal ureteral diameter ratio (UDR) and volume at onset of VUR (Vol) may either augment or replace the current grading system to provide more reliable prediction of clinical outcomes. MATERIALS AND METHODS: Multivariate clinical outcome models were analyzed to assess the impact on predictive accuracy by the addition of voiding cystourethrogram (VCUG) data including grade, UDR, and Vol, alone or in combinations. Clinical variables from retrospective review of 841 children's records included age, gender, presentation, VUR laterality, bowel and bladder dysfunction, history of febrile urinary tract infection (UTI), and number of UTIs. The primary outcomes assessed included VUR resolution or persistence and need for operative intervention. RESULTS: Grade, UDR, and Vol were independent predictors of resolution and operative intervention. Vol increased predictive accuracy in resolution models with grade or UDR alone; however, no significant difference occurred in models with the substitution of grade with UDR. CONCLUSIONS: A more reliable classification system for VUR, with improved predictive accuracy regarding clinical outcomes, may be developed incorporating UDR and Vol. Whether VUR grade can be completely replaced by Vol and UDR measurements requires further evaluation with larger number of patients.

Radiation exposure in pediatric videourodynamics: An evaluation of safety in comparison to voiding cystourethrogram.

INTRODUCTION: Children with spina bifida (SB) undergo a videourodynamic study (VUDS) or urodynamic study and voiding cystourethrogram (VCUG). A standardized protocol for imaging during a pediatric VUDS has not been established. Our aim is to quantify radiation exposure and establish a baseline for children with spina bifida (SB) undergoing VUDS in current practice at our institution. METHODS: This is a retrospective study from 2013 to 2020 of consecutive pediatric SB patients undergoing VUDS by a single provider. Patients were categorized into three groups based on age; group 1 (0-2 YR), group 2 (2-10 YR), group 3 (>10 YR). Radiation data was reported as mean air kerma (AK), dose area product (DAP) and exposure time (seconds). Effective dose (ED) was calculated based on radiation quantity (Air Kerma, AK) and organ sensitivity. The lifetime attributable risk (LAR) was calculated based on AK and a risk coefficient. Data points calculated for patients undergoing VUDS were then compared to age matched institutional VCUG data in the same age groups. RESULTS: 398 patients undergoing VUDS met inclusion criteria and 262 independent patients underwent VCUG. ED increased with age in both VUDS and VCUG. All VCUG groups were found to have a higher ED than VUDS. The LAR for VUDS groups 1-3 was 0.001, 0.002, and 0.006, respectively. Reported in percentages, there is a 0.1%, 0.2%, and 0.6% chance, respectively, of age groups 1, 2 and 3 developing cancer as a result of the radiation exposure from a VUDS. DISCUSSION: Our study found that ED was low across all age groups for VUDS, comparing favorably to the VCUG groups. VCUG was selected as a benchmark comparison for its diagnostic similarities and, at times, overlapping indications. Few studies have described ED with respect to VUDS or extrapolate the ED of VUDS into LAR in the pediatric population. We recognize that we have not determined the true ED of the gonads and bladder, rather we have overestimated, as the data is based on an international reference point proximal to the exposed individual. However, LAR was calculated for each age group and revealed that patients are at a negligible increased risk of developing malignancy secondary to exposure compared to the general population. CONCLUSION: Our current practice for pediatric VUDS has exhibited consistently low radiation exposure amongst all age groups. Moving forward, we have the foundation and flexibility to create an imaging protocol for pediatric VUDS, while taking more calculated steps toward incorporating ALARA, as low as reasonably achievable, principles. A protocol adhering to the ALARA principle could provide consistency across institutions and aid in multi-institutional studies.

Modified three-layer vesicourethral reconstruction in robot-assisted radical prostatectomy can change cystography pattern and improve early recovery of continence.

BACKGROUND AND OBJECTIVES: To determine early continence outcomes after three-layer vesicourethral reconstruction during robot-assisted radical prostatectomy (RARP) and the role of postoperative cystography pattern. METHODS: Between May 2015 and January 2019, a total of 170 consecutive patients with localized prostate cancer who underwent RARP, were divided into one- and three-layer groups based on the method of vesicourethral reconstruction. Continent status, preoperative, intraoperative, postoperative, clinicopathological variables, and cystography parameters were analyzed. The patients were followed up for at least 12 months. RESULTS: Of the 170 consecutive patients, 85 with one-layer vesicourethral anastomosis, and 85 with three-layer reconstruction. The continence rates immediately after catheter removal, 4, 12, and 24 weeks after RARP were 47.1%, 75.3%, 92.9%, and 98.8% in the three-layer group; compared to 15.3%, 60%, 78.8%, and 90.6% in the one-layer group, respectively. In the multivariate analysis, three-layer reconstruction was the only independent variable with a 42% risk reduction of postprostatectomy incontinence (hazard ratio (HR): 0.58, 95% confidence interval (CI) = 0.42-0.80, p = 0.001). Cystography in the three-layer group revealed less anastomotic leakage, less sharp bladder neck angle, and higher bladder neck level category. CONCLUSIONS: Three-layer anatomical reconstruction demonstrated promising early continence outcomes, and postoperative cystography revealed a specific pattern more associated with continence.

Bladder height to width ratio as a surrogate marker for non-physiological storage pressures in children with spinal dysraphism.

INTRODUCTION: Spinal dysraphism is the most frequent cause of neurogenic bladder. Urodynamic study (UDS) is an important component of the follow-up of a child with neurogenic bladder. However, it suffers from a lack of widespread availability and is further hampered by technical difficulties and difficulty in its interpretation in children. A neurogenic bladder often appears vertically elongated; only limited and sparse literature is available regarding objectively defining the bladder shape and the urodynamic parameters in the cohort. OBJECTIVES: This study aimed to investigate the usefulness of the bladder's height-to-width ratio (HWR) on cystogram as a screening tool for identifying "non-physiological" bladder pressures in children with spinal dysraphism. A prospective study was undertaken to evaluate children operated for spinal dysraphism. Cystogram, ultrasonography and UDS evaluation were performed. HWR was calculated by the ratio of the maximum height to the maximum bladder width at maximum cystometric capacity (MCC), where MCC was calculated using standard Koff's formula, given by (age in years + 2) *30 ml in children more than one year and weight *7 ml for infants. The children were categorised into groups based on maximum detrusor pressure (MDP) into two groups (MDP ≥ 30 cmH2O and MDP < 30 cmH2O). A receiver-operative characteristic curve was constructed to analyse the sensitivity and specificity of HWR in predicting the MDP. RESULTS: A total of 53 children, operated for spinal dysraphism, met the study criteria during the study period, from March 2021 to September 2022. The median age of children was 4 years (IQR-3-5.5 years). The HWR ratio was compared between the two groups and was significantly higher for the non-physiological pressure bladders than for physiological pressure bladders (mean of 1.55 vs 1.26, p = 0.001). On evaluating the sensitivity and specificity of HWR for discerning children with non-physiological bladder pressures were 87.5% and 48.28%, respectively. The area under the curve (AUC) was 0.781, with a cut-off value of 1.3. DISCUSSION: We attempted to evaluate the HWR based on bladder shape objectively. We demonstrated a moderate correlation between the bladder shape and the bladder pressures. An HWR of 1.3 or higher could be significant for identifying a non-physiological bladder storage pressure. CONCLUSION: The height to width ratio of the bladder on cystogram is a useful tool as a surrogate marker for non-physiological storage pressures in bladders of children with spinal dysraphism.

Comparison of maximum voided volume and maximum bladder capacity in voiding diary, uroflowmetry and cystometrography in children with non-neurogenic lower urinary tract dysfunction.

BACKGROUND: Maximum voided volumes (MVV) and maximum bladder capacities (MBC) are important parameters in the evaluation of lower urinary tract functions in children. However, consistency of MVV and MBC measurements between voiding diary (VD), uroflowmetry (UF) and cystometrography (CMG) in children with non-neurogenic lower urinary tract dysfunction (LUTD) has not been addressed specifically. OBJECTIVE: We aimed to compare the MVV in VD and UF and MBC in CMG in children with non-neurogenic LUT dysfunction and investigate for possible factors for discrepancies. MATERIALS AND METHODS: Children with non-neurogenic LUTD were retrospectively evaluated with a focus on VD, UF, and CMG. VD applied for 2 days and MVV recorded except for first urine in morning. UF repeated in children with <50% of expected bladder capacity (EBC) for age. Highest value and post voiding residual urine (PVR) was recorded. CMG was performed if these conditions were present: High PVR or LUT dysfunction resistant to standard urotherapy (conservative management with biofeedback) and medical therapy (oral anticholinergics) or LUT dysfunction accompanied by VUR or recurrent UTI. MBC in CMG was recorded according to International Children Continence Society (ICCS) standards. MVV and MBC in VD, UF, CMG were compared and possible factors for discrepancy were investigated. RESULTS: 54 children (median age: 10 (4-17) years) were included in the study. 39 (72.2%) were girls, 15 (27.8%) were boys. Median MVV was 232.50 (20-600) ml in VD, 257.50 (69-683) ml in UF and MBC was 184 (31-666) ml in CMG (p = 0.012) (Summary Table). In the subgroup analysis, it was shown that the bladder capacities obtained from all three tests were not compatible with each other in children younger than 10 years of age, in girls, in those with recurrent urinary tract infection, detrusor overactivity, high PVR and normal flow pattern (p = 0.003, p = 0.016, p = 0.029, p < 0.001, p = 0.045, p = 0.03, respectively). DISCUSSION: There is a discrepancy between bladder capacities obtained from VD, UF and CMG In children with non-neurogenic LUT dysfunction. In particular, the lower capacity obtained from invasive urodynamic tests may be related to the poor compliance of children during the procedure. Therefore, when invasive urodynamics is required in these cases, we recommend that maximum cystometric capacity to be evaluated by comparing with voided volumes at UF, VD and other clinical signs and symptoms, and urodynamic parameters in more detail. CONCLUSION: MVV in VD and UF are comparable, but MBC in CMG is lower in children with non-neurogenic LUTD selected for invasive urodynamic studies. More attention should be paid to bladder capacity obtained from urodynamic studies in children exhibiting the characteristics identified in the subgroup analysis. We believe that evaluating bladder capacity values, especially obtained from invasive studies, in conjunction with clinical findings can prevent misdiagnosis, over investigation and overtreatment in children with non-neurogenic LUTD.

[Voiding cystourethrography : Indications, fluoroscopy technique and radiation protection]. / Miktionszysturethrographie : Indikationen, Durchleuchtungstechnik und Strahlenschutz.

BACKGROUND: Voiding cystourethrography continues to be the gold standard in the diagnostics of a wide range of diseases of the urinary tract in children. MATERIAL AND METHODS: Indications, implementation of voiding cystourethrography in terms of preparation, materials used, dealing with the child and the parents as well as the standardized examination technique are presented. In particular, the technical aspects of fluoroscopy devices and criteria for good image quality are discussed. Case studies are used to illustrate the problems of frequent urological diseases. DISCUSSION: The three standard examinations for the detection of vesicoureteral reflux (VUR), radionuclide cystography, contrast-enhanced voiding urosonography and voiding cystourethrography are compared. Their potential for detecting VUR and additional urological pathologies is discussed in detail. Furthermore, the optimized examination technique of voiding cystourethrography is presented. The applicability of the current dose reference values of the German Federal Office for Radiation Protection (BfS) in the daily routine is discussed and the feasibility of the dose reference values is explained.

The accuracy of cystography under general anesthesia in children with vesicoureteral reflux.

PURPOSE: To examine the accuracy of cystography under general anesthesia in children with vesicoureteral reflux (VUR). MATERIALS AND METHODS: A prospective study of children who had VUR on cystography without general anesthesia (i.e., the gold-standard), and who are candidates for endoscopic VUR repair surgery. All children subsequently underwent a cystography under general anesthesia before injection using standardized method, which was compared to the gold-standard cystography. χ2 and Mann-Whitney U tests were used to compare proportions and medians between groups. RESULTS: Between 2017 and 2021, 126 renal units in 13 boys and 50 girls were included. Median age was 3.4 years (interquartile range [IQR] 1.5-6.5). Median time from cystography without to cystography with general anesthesia was 3.8 months (IQR 2.7-6). Of the 126 renal units, 96 had VUR on cystography without general anesthesia. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative and positive predictive values of cystography under general anesthesia were 47% (45/96), 87% (26/30), 34% (26/77) and 92% (45/49), respectively. Accuracy was 56.3%; Cohen's Kappa coefficient was 0.22, indicating poor agreement. In subgroup analysis, the sensitivity of cystography under general anesthesia was significantly lower in primary VUR (20% vs. 55% in secondary VUR, p = 0.01) and active VUR (14% vs. 52% in passive VUR, p = 0.008). CONCLUSION: Cystography under general anesthesia was poorly correlated to cystography performed while the child was awake or lightly sedated. Clinical decision relying on this cystography is questionable.

Contrast-enhanced voiding urosonography (CEVUS) as a safe alternate means of assessing vesicoureteral reflux in pediatric kidney transplant patients.

BACKGROUND: Although voiding cystourethrogram (VCUG) is currently the gold standard in VUR evaluation, there is ionizing radiation exposure. Contrast-enhanced voiding urosonography (CEVUS) uses ultrasound contrast agents to visualize the urinary tract and has been reported to be safe and effective in VUR evaluation in children. CEVUS application has yet to be specifically described in VUR evaluation in the pediatric kidney transplant population. The purpose of this study was to report the use of CEVUS and VCUG in evaluating and managing VUR in pediatric renal transplant patients. METHODS: Retrospective review was conducted for pediatric kidney transplant patients (18 years and younger) who underwent VCUG or CEVUS to assess for transplant VUR from July 2019 through June 2021. Demographic information, reason for VUR evaluation, fluoroscopy time, and postimaging complications were evaluated. Costs of imaging modalities were also considered. RESULTS: Eight patients were evaluated for transplant VUR during the study period. Of the 3 patients who underwent VCUG, all 3 had VUR (median grade 3). Median fluoroscopy time was 18 s and dose-area product was 18.7 uGy*m2 . Of the 5 patients who underwent CEVUS, 4 had VUR (median grade 4). There were no complications for either modality. Based on clinical and radiographic findings, patients were recommended no intervention, behavioral modification, or ureteral reimplantation. The total cost of CEVUS was $800 less than that of VCUG. CONCLUSION: CEVUS can provide an alternate means of safely evaluating VUR in kidney transplant patients with similar outcomes, potentially lower costs, and no exposure to ionizing radiation.

Accuracy of contrast-enhanced voiding urosonography using Optison™ for diagnosis of vesicoureteral reflux in children.

BACKGROUND: There is limited quality of evidence regarding the accuracy of contrast-enhanced voiding urosonography (ceVUS) for diagnosis of vesicoureteral reflux (VUR) compared to fluoroscopic voiding cystourethrography (VCUG), and minimal data on the use of the ultrasound contrast agent Optison™ for this purpose. OBJECTIVE: To compare the accuracy of ceVUS using Optison™ to VCUG, and to assess inter-rater agreement regarding presence and grading of VUR. STUDY DESIGN: In this retrospective investigation, all sequential ceVUS with Optison™ and VCUG studies performed in children between 2014 and 2017 were reviewed. Two raters independently graded all ceVUS studies using a 5-point scale. CeVUS sensitivity and specificity were estimated separately for each rater using the VCUG report as the ground truth for presence and degree of VUR. Logistic and ordinary linear regression models assessed rater-report agreement and inter-rater agreement for each kidney, Optison™ dose, and referral diagnosis. RESULTS: 97 children (51 females) with 101 paired studies were included. Sensitivity and specificity of ceVUS for VUR detection were identical for both raters: right kidney 75%/90.9%; left kidney 85.7%/78.9% (Figure). There was no statistically significant difference in disagreement between raters and the VCUG report for the right or left kidney. Inter-rater agreement on ceVUS grading was 90% and 88% for right and left kidneys, respectively. There was a significant negative association between fetal hydronephrosis vs urinary tract infection and disagreement between Rater 2 and the VCUG report for the left kidney. There were no other significant associations with respect to either kidney, Optison™ dose, or referral diagnosis. DISCUSSION: Our study showed that detection of VUR with ceVUS and Optison™ is comparable to fluoroscopic VCUG. Based on the VCUG reports, the incidence of VUR in our patient population was substantially lower than in the meta-analysis of Chua et al. and in the study of Kim et al. The explanation for the large discrepancy in VUR incidence may reflect differences in the patient populations, and in our reporting of VUR with respect to kidney number rather than to pelviureteral units. Study limitations include its retrospective nature and potential bias in terms of patient selection. Since VUR is an intermittent phenomenon, sequential rather than simultaneous performance of the ceVUS and fluoroscopic studies might have influenced VUR detection. CONCLUSION: A blinded comparison of ceVUS performed with Optison™ to fluoroscopic VCUG showed moderate-good sensitivity and specificity for diagnosis of VUR.

Multi-institutional Validation of Improved Vesicoureteral Reflux Assessment With Simple and Machine Learning Approaches.

PURPOSE: Vesicoureteral reflux grading from voiding cystourethrograms is highly subjective with low reliability. We aimed to demonstrate improved reliability for vesicoureteral reflux grading with simple and machine learning approaches using ureteral tortuosity and dilatation on voiding cystourethrograms. MATERIALS AND METHODS: Voiding cystourethrograms were collected from our institution for training and 5 external data sets for validation. Each voiding cystourethrogram was graded by 5-7 raters to determine a consensus vesicoureteral reflux grade label and inter- and intra-rater reliability was assessed. Each voiding cystourethrogram was assessed for 4 features: ureteral tortuosity, proximal, distal, and maximum ureteral dilatation. The labels were then assigned to the combination of the 4 features. A machine learning-based model, qVUR, was trained to predict vesicoureteral reflux grade from these features and model performance was assessed by AUROC (area under the receiver-operator-characteristic). RESULTS: A total of 1,492 kidneys and ureters were collected from voiding cystourethrograms resulting in a total of 8,230 independent gradings. The internal inter-rater reliability for vesicoureteral reflux grading was 0.44 with a median percent agreement of 0.71 and low intra-rater reliability. Higher values for each feature were associated with higher vesicoureteral reflux grade. qVUR performed with an accuracy of 0.62 (AUROC=0.84) with stable performance across all external data sets. The model improved vesicoureteral reflux grade reliability by 3.6-fold compared to traditional grading (P < .001). CONCLUSIONS: In a large pediatric population from multiple institutions, we show that machine learning-based assessment for vesicoureteral reflux improves reliability compared to current grading methods. qVUR is generalizable and robust with similar accuracy to clinicians but the added prognostic value of quantitative measures warrants further study.

Voiding cystourethrogram: Who gets a cyclic study and does it matter?

BACKGROUND: Voiding cystourethrogram (VCUG) images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when vesicoureteral reflux (VUR) is present. Given the variation in VCUG technique and reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016, which included the recommendation of at least 2 voiding cycles to identify intermittent VUR and/or ureteral ectopia. STUDY DESIGN: VCUG were assessed for adherence to performance of cyclic study. Children who underwent cyclic evaluation were compared to those who underwent a single cycle VCUG. Radiation dosage was also analyzed. Studies performed on patients >18 years of age and those obtained as part of a trauma evaluation were excluded from study. RESULTS: Two hundred and eighty-four VCUGs were analyzed, 97 (34.2%) were positive for VUR on the initial cycle. Of the remaining 187 studies, 116 (62%) had multiple filling-voiding cycles while in 71 (38%) only a single cycle was performed. One hundred and sixty-one (86.1%) were negative for vesicoureteral reflux. Twenty-six (13.9%) children were diagnosed with VUR after the initial filling-voiding cycle: 6 were diagnosed with grade I, 2 grade II, 11 grade III, 2 grade IV and 5 grade V. Of the 123 total children found to have VUR, 26 (21.2%) were diagnosed after an initial negative cycle. Younger children were significantly more likely to have a cyclic study performed; mean age of patients undergoing a cyclic study was 1.09 ± 2.16 years versus 3.86 ± 4.5 years (p ≤ 0.0001). Categorically, 74.1% of children less than 1 year of age underwent a cyclic study compared to 6.9% of children older than 5 years of age (p ≤ 0.0001). There was no difference based on sex with 49.1% of males and 50.9% of females (p = 0.667) undergoing cyclic evaluation. Children undergoing a cyclic study had lower median radiation dose 2.15 microGy m2 (range 0.09-111) compared to 4.41 (range 1.3-104) [p = 0.01]. DISCUSSION: Vesicoureteral reflux may occur intermittently and cyclic VCUG is thought to enhance the ability to detect reflux. In our cohort, 26 children (9.2%) were only diagnosed after an additional cycle - ie 21.1% of reflux would have been missed had a cyclic study not been performed. The majority of these patients (69.2%, 18 of 26) were found to have dilating, and thus perhaps more clinically significant, reflux. Our study highlights the importance of obtaining as much information as possible and adhering to the standardized VCUG protocol. CONCLUSION: Younger children are more likely to undergo cyclic VCUG. While most reflux is detected with the initial filling-voiding cycle, 26 (21.2%) patients were diagnosed after an initial negative cycle with the majority being dilating VUR.

Evaluating the accuracy of simplified VCUG in comparison with traditional VCUG for diagnosis of urinary-reflux in children: Radiation dose reduction.

INTRODUCTION: Voiding cystourethrogram (VCUG) is an imaging technique for diagnosing urinary-reflux. VCUG requires X-ray exposure, increasing the risk of malignancies induced by ionizing radiation, especially in children. Considering the importance of early diagnosis of urinary-reflux using VCUG to prevent kidney complications and the significance of reducing the radiation dose during this imaging, this study intends to reduce the imaging views of VCUG and evaluate the urinary-reflux, using a reduced number of images. MATERIAL AND METHODS: Children referred to a University hospital who underwent VCUG participated in this study. The routine VCUG procedure contained five images. Two images of full-bladder and post-void of each patient were considered a simplified procedure and were evaluated by two radiologists to determine reflux and its grade. The sensitivity and specificity of simplified VCUG were determined. RESULTS: 182 patients with a mean age of 5.36±4.95 years old participated in this study. There were 90% and 82% agreement between routine and simplified VCUG results in the left and right kidneys. The simplified VCUG had 87.2% and 100% sensitivity and specificity in detecting the left-side reflux, 83 .9% and 100%, to detect the right-side reflux. CONCLUSION: The results showed that using two images instead of five can effectively diagnose and grade urinary-reflux. The simplified VCUG had a relatively good and acceptable agreement in comparison to the routine cystourethrogram. It can effectively reduce the patient's radiation dose, especially in patients who need to perform serial bladder imaging for follow-up after operation.

A machine learning-based approach for quantitative grading of vesicoureteral reflux from voiding cystourethrograms: Methods and proof of concept.

INTRODUCTION: The objectivity of vesicoureteral reflux (VUR) grading has come into question for low inter-rater reliability. Using quantitative image features to aid in VUR grading may make it more consistent. OBJECTIVE: To develop a novel quantitative approach to the assignment of VUR from voiding cystourethrograms (VCUG) alone. STUDY DESIGN: An online dataset of VCUGs was abstracted and individual renal units were graded as low-grade (I-III) or high-grade (IV-V). We developed an image analysis and machine learning workflow to automatically calculate and normalize the ureteropelvic junction (UPJ) width, ureterovesical junction (UVJ) width, maximum ureter width, and tortuosity of the ureter based on three simple user annotations. A random forest classifier was trained to distinguish between low-vs high-grade VUR. An external validation cohort was generated from the institutional imaging repository. Discriminative capability was quantified using receiver-operating-characteristic and precision-recall curve analysis. We used Shapley Additive exPlanations to interpret the model's predictions. RESULTS: 41 renal units were abstracted from an online dataset, and 44 renal units were collected from the institutional imaging repository. Significant differences observed in UVJ width, UPJ width, maximum ureter width, and tortuosity between low- and high-grade VUR. A random-forest classifier performed favourably with an accuracy of 0.83, AUROC of 0.90 and AUPRC of 0.89 on leave-one-out cross-validation, and accuracy of 0.84, AUROC of 0.88 and AUPRC of 0.89 on external validation. Tortuosity had the highest feature importance, followed by maximum ureter width, UVJ width, and UPJ width. We deployed this tool as a web-application, qVUR (quantitative VUR), where users are able to upload any VCUG for automated grading using the model generated here (https://akhondker.shinyapps.io/qVUR/). DISCUSSION: This study provides the first step towards creating an automated and more objective standard for determining the significance of VUR features. Our findings suggest that tortuosity and ureter dilatation are predictors of high-grade VUR. Moreover, this proof-of-concept model was deployed in a simple-to-use web application. CONCLUSION: Grading of VUR using quantitative metrics is possible, even in non-standardized datasets of VCUG. Machine learning methods can be applied to objectively grade VUR in the future.

Feasibility of Dual-Energy Computed Tomography Imaging of Gadolinium-Based Contrast Agents and Its Application in Computed Tomography Cystography: An Exploratory Study to Assess an Alternative Option When Iodinated Contrast Agents Are Contraindicated.

OBJECTIVE: The aim of this study was to compare the contrast enhancement differences between gadolinium-based and iodine-based contrast agents at different single-energy tube potentials and dual-energy-based virtual monochromatic energies. In addition, we describe the application of a gadolinium-based contrast agent in computed tomography (CT) cystography for a patient with contraindications to iodine. METHODS: A phantom study was performed using 3 iodine samples (concentrations: 5, 10, and 15 mgI/mL) and 3 gadolinium samples (concentrations: 3.3, 6.6, and 9.9 mgGd/mL). The prepared phantom was scanned by a dual-energy CT (DECT) at 80, 100, 120, and 140 kV in the single-energy mode and at 100/Sn140 kV in the dual-energy mode. Virtual monoenergetic images (VMIs) at 50 keV were generated from the DECT scan. In addition, a DECT cystogram was performed using a gadolinium-based contrast agent in a patient with contraindications to iodinated contrast. RESULTS: Strong linear correlations between mean signal of contrast enhancement and mass concentration were found for both iodine and gadolinium samples across all single-energy CT (SECT) and DECT scan conditions. The VMI at 50 keV provided the highest contrast enhancement for both types of contrast samples at each concentration level, and single-energy CT scans at low-energy beams showed higher contrast enhancement than higher beam energies. In addition, the contrast enhancement for pure gadolinium solution was constantly higher than pure iodine solution at an identical mass concentration level. The DECT cystogram was performed with excellent technical success. The urinary bladder was appropriately distended with intravesical contrast measuring 606 Hounsfield units and no evidence of bladder leak or fistula. CONCLUSIONS: Imaging of gadolinium-based contrast agents is improved using a DECT technique, with VMI at 50 keV providing the highest contrast enhancement among our tested parameters. Dual-energy CT cystography using a gadolinium-based agent can be a safe and effective alternative when iodinated agents are contraindicated.

Top-Down versus Bottom-Up Approach in Children Presenting with Urinary Tract Infection: Comparative Effectiveness Analysis Using RIVUR and CUTIE Data.

PURPOSE: The initial imaging approach to children with urinary tract infection (UTI) is controversial. Along with renal/bladder ultrasound, some advocate voiding cystourethrogram (VCUG), ie a bottom-up approach, while others advocate dimercaptosuccinic acid (DMSA) scan, ie a top-down approach. Comparison of these approaches is challenging. In the RIVUR/CUTIE trials, however, all subjects underwent both VCUG and DMSA scan. Our objective was to perform a comparative effectiveness analysis of the bottom-up vs top-down approach. MATERIALS AND METHODS: We simulated 1,000 hypothetical sets of 500 children using RIVUR/CUTIE data. In the top-down approach, patients underwent initial DMSA scan, and only those with renal scarring underwent VCUG. In the bottom-up approach, the initial study was VCUG. We assumed all children with vesicoureteral reflux (VUR) received continuous antibiotic prophylaxis (CAP). Outcomes included recurrent UTI, number of VCUGs and CAP exposure. We assumed a 25% VUR prevalence in children with initial UTI with sensitivity analysis using 40% VUR prevalence. RESULTS: Median age of the original RIVUR/CUTIE cohort was 12 months. First DMSA scan was performed at a median of 8.2 weeks (IQR 5-11.8) after the index UTI. In the simulated cohort, slightly higher yet statistically significantly recurrent UTI was associated with the top-down compared with the bottom-up approach (24.4% vs 18.0%, p=0.045). On the other hand, the bottom-up approach resulted in more VCUG (100% vs 2.4%, p <0.001). Top-down resulted in fewer CAP-exposed patients (25% vs 0.4%, p <0.001) and lower overall CAP exposure (5 vs 162 days/person, p <0.001). Sensitivity analysis was performed with 40% VUR prevalence with similar results. CONCLUSIONS: The top-down approach was associated with slightly higher recurrent UTI. Compared to the bottom-up approach, it significantly reduced the need for VCUG and CAP.

Is there a need for endoscopic evaluation in symptomatic boys with an unsuspicious urethra on VCUG? A consideration of secondary radiologic signs of posterior urethral valves.

INTRODUCTION: A significant proportion of PUV becomes symptomatic after the perinatal period. Voiding cystourethrography (VCUG) often fails to identify PUVs. This study evaluates the relationship between the radiological appearance of the posterior urethra, potential secondary radiological signs and endoscopically documented PUV in boys with febrile UTIs, VUR, refractory symptoms of bladder overactivity or suggestive sonography findings. PATIENTS AND METHODS: Data on VCUG findings and endoscopy from 92 boys (mean age 27 months) who underwent endoscopic PUV incision between 2012 and 2017 following a VCUG were reviewed. 24 boys with endoscopically unsuspicious urethras were included as control group (mean age 27.5 months). Statistical analysis was performed using Fisher's exact test. RESULTS: In patients with PUV, the urethra was suspicious on a preoperative VCUG in 45.7%, whereas it appeared normal in 54.3%. Abortive forms of PUV were more frequently found in patients with a radiologically unsuspicious urethra (30%vs.16.7%, p = 0.15). Bladder neck hypertrophy on VCUG (16.7%vs.60.9%, OR 7.5, p < 0.001), a trabeculated bladder on VCUG (72%vs.37.5%, OR 4.3, p < 0.001) and a hypertrophied musculus interuretericus (38%vs.4.2%, OR 11.7, p < 0.001) were more common in patients with PUV and urethras appearing normal on VCUG as compared to controls. CONCLUSION: Unsuspicious findings of the urethra on VCUG cannot exclude a relevant PUV and implicate a risk of disregarding abortive forms. The presence of secondary radiologic signs of infravesical obstruction on a VCUG despite an unsuspicious posterior urethra in boys with recurrent UTI's as well as refractory symptoms of bladder overactivity or suggestive signs on sonography must be further clarified endoscopically.

Diagnostic accuracy of pneumo-CT-cystography in the detection of bladder rupture in patients with blunt pelvic trauma.

PURPOSE: To evaluate the diagnostic utility of bladder air distension (pneumo-CT-cystography) in the detection of bladder rupture in patients with blunt pelvic trauma. MATERIALS AND METHODS: 843 patients with blunt pelvic trauma were evaluated. Intravenous contrast-enhanced CT was performed for trauma staging. 97 of 843 patients had clinical and radiological signs of possible bladder injury and underwent retrograde air distension. RESULTS: Among 97 patients, 31/97 showed CT signs of bladder rupture, of which 5/31 (16%) intraperitoneal, 25/31 (81%) extraperitoneal and 1/31 (3%) combined. 23 of these patients underwent surgery, which confirmed bladder injury in 100% of cases. The other 8 patients were managed conservatively, and follow-up studies showed disappearance of free air. Among the 66/97 patients with no signs of bladder injury, 38/66 had surgery, which confirmed bladder integrity, while 28/66 were managed conservatively and showed no signs of bladder rupture at clinico-radiological follow-up examinations. CONCLUSIONS: CT evaluation of urinary bladder after retrograde air distension (pneumo-CT-cystography) may be a reliable diagnostic tool in the detection of bladder rupture in patients with blunt pelvic trauma. This technique is faster, cheaper and allows to overcome some of the limitations of conventional CT-cystography.

The Importance of Cystoscopy in Diagnosis and Treatment of Urethral Stricture Following Transurethral Prostatectomy.

BACKGROUND: Transurethral prostatectomy is the gold standard surgical treatment of bladder outlet obstruction due to benign enlargement of the prostate, with more than 30,000 procedures performed annually in the United States alone. The success rate of this minimally invasive procedure is high and the results are durable. The development of urethral stricture is a long-term complication of the procedure and is noted in about 2% of patients. The stricture narrows the urethral lumen, leading to re-appearance of obstructive urinary symptoms. Traditionally, the evaluation of the stricture was performed by retrograde urethrography. Advancements in the fields of flexible endoscopy allowed rapid inspection of the urethra and immediate dilatation of the stricture in selected cases. OBJECTIVES: To compare the efficacy of urethrography versus cystoscopy in the evaluation of urethral strictures following transurethral prostatectomy. METHODS: A retrospective review was conducted of a series of 32 consecutive patients treated due to post-transurethral resection of prostate (TURP) urethral stricture. RESULTS: Twenty patients underwent both tests. In 16 there was concordance between the two tests. Four patients had no pathological findings in urethrography but had strictures in cystoscopy. All strictures were short (up to 10 mm) and were easily treated during cystoscopy, with no complaints or re-surgery needed in 24 months follow-up. CONCLUSIONS: Cystoscopy was superior to urethrography in the evaluation of post-TURP strictures. Strictures where often short and treated during the same procedure. We recommend that cystoscopy be the procedure of choice in evaluating obstructive urinary symptoms after TURP, and retrograde urethrography be preserved for selected cases.

Bladder Herniation as an Auto-Augmentation Technique in Bladder Exstrophy: Initial Experience in Patients with Small Bladder Plate.

OBJECTIVE: To present our long-term experience of bladder plate herniation technique in patients with bladder exstrophy epispadias complex (BEEC) and inadequate bladder plate. METHODS: Ten BEEC patients with inadequate bladder plates were referred. The bladder underlying fascia was opened and the exstrophic bladder was fixed above the peritoneal cavity to herniate the peritoneal contents beneath the bladder plate so that the abdominal pressure would be directly transferred to the posterior bladder wall; causing gradual bladder expansion and auto-augmentation. In 5 patients, the inguinal hernia was fixed to increase the pressure transferred to the exstrophic bladder. The bladder capacity was measured while the patient was crying and when the bladder was enlarged. Cystometry and voiding cystourethrogram were performed before the application of this technique and during the next 6 to 8 months, to determine the bladder capacity for further primary bladder closure. RESULTS: The bladder was enlarged during straining/crying without any complications. The average bladder capacity was increased about 2.5 to 3 times after 8 months of follow-up so that it was suitable for undergoing primary closure. None of the children needed bladder augmentation following the single-stage total BEEC reconstruction. CONCLUSION: This technique seems to be safe, effective, and feasible in patients with small-sized bladder and may be performed before the primary closure to increase the success rate. This technique may be effective in increasing the bladder capacity for staged bladder closure and bladder neck reconstruction without further need for bladder augmentation.