Safety of retrograde pyelography for infected ureteral stones.

INTRODUCTION: Initial management of obstructing ureteral stones with concomitant urinary tract infection (UTI) includes prompt renal decompression and antibiotics. Some urologists theorize that performing retrograde pyelography (RGP) at the time of ureteral stent placement may cause pyelovenous backflow of bacteria thereby worsening clinical outcomes. We compared outcomes in patients with infected ureteral stones who underwent RGP versus no RGP prior to stent placement. MATERIALS AND METHODS: A retrospective chart review was conducted involving patients who presented between 2015 and 2017 with an obstructing ureteral stone and associated UTI. Computed tomography scans were evaluated for stone size and location. Operative reports were reviewed to determine whether the patient underwent RGP at time of ureteral stent placement. Demographics, perioperative information, intensive care unit (ICU) admission rate, and length of stay (LOS) were compared. RESULTS: Seventy-two patients were identified and stratified by severity of condition at presentation, including UTI without sepsis (n = 18), sepsis (n = 32), severe sepsis (n = 11), and septic shock (n = 11). Forty-three patients underwent RGP at the time of stent placement, and 29 did not. Between both patient cohorts, statistical analysis revealed no significant difference in postoperative ICU admission rate (p = 0.35) or LOS for patients with UTI without sepsis (p = 0.17), sepsis (p = 0.45), severe sepsis (p = 0.66), and septic shock (p = 0.25). CONCLUSION: The use of RGP prior to ureteral stent placement for an obstructing ureteral stone with concomitant UTI was not associated with unfavorable clinical outcomes in our retrospective series. While these findings support the safety of RGP in this setting, prospective trials are warranted.

Bilateral retrograde pyelography leading to anuria.

Retrograde pyelography (RGP) is done to evaluate the collecting system when intravenous contrast studies are contraindicated due to renal insufficiency or prior adverse reactions. We report a patient who developed acute renal shutdown following bilateral RGP in the same sitting done for evaluation of positive malignant cytology of urine. A 65-year-old man on treatment for left stroke and hypertension, with a baseline serum creatinine of 1.9 mg/dl presented with painless haematuria for 2 months. Plain computed tomogram revealed a small papillary growth on the posterior wall of the urinary bladder. Transurethral resection revealed inflammatory atypia. As the patient continued to have haematuria, he was taken up for bilateral ureteric washings for cytology and bilateral RGP. A 5-Fr universal ureteral catheter was used to cannulate the ureters, urine was aspirated for cytology and 6 ml of 76% meglumine diatrizoate (1:2) was injected, and sufficient opacification with no abnormality or pyelosinus/venous or lymphatic reflux was noted. In the immediate postoperative period, he developed anuria and the serum creatinine rose to 3.6 mg/dl on postoperative day 1 and to 7.5 mg/dl on day 5. He needed three sessions of haemodialysis. Ultrasonography showed no hydroureteronephrosis. Urine output improved and his serum creatinine stabilized at the preoperative level of 1.8 mg/dl. The patient is doing well with stable renal function at 12 months. Although RGP is useful, it needs to be done with caution if a bilateral procedure is contemplated. This entity is seldom reported, and routine double-J stenting following unilateral/bilateral RGP also needs evaluation.

Risk of Radiation from Computerized Tomography Urography in the Evaluation of Asymptomatic Microscopic Hematuria.

PURPOSE: The AUA (American Urological Association) guidelines for asymptomatic microscopic hematuria recommend that patients undergo computerized tomography urography, which is associated with high doses of ionizing radiation. To our knowledge the associated risk of secondary malignancy and mortality remains unknown. We modeled the risk of malignancy and associated mortality due to ionizing radiation from computerized tomography urography relative to the additional diagnostic benefit offered over renal ultrasound. MATERIALS AND METHODS: We performed a PubMed® based literature search to identify model inputs. We obtained estimates of age and gender specific radiation induced secondary malignancy and mortality rates from the BEIR (Biologic Effects of Ionizing Radiation) VII Phase 2 report with dose extrapolation using the linear no threshold model. RESULTS: Patients with asymptomatic microscopic hematuria had a 0.053% and 0.48% prevalence of upper tract urothelial carcinoma and renal cell carcinoma, respectively. Ultrasound had 77% sensitivity for upper tract urothelial carcinoma and 82% sensitivity for renal cell carcinoma. The effective radiation dose of computerized tomography urography was 31.7 mSv. Based on these inputs a population of 100,000 patients with asymptomatic microscopic hematuria would include 53.1 and 478 patients with upper tract urothelial carcinoma and renal cell carcinoma, respectively. On ultrasound alone 98.2 cases of upper urinary tract malignancy would be missed. An additional 149 cases of secondary malignancy would be caused by computerized tomography urography associated radiation with 101 fatalities. A total of 1,018.3 computerized tomography urography studies would need to be performed to detect an additional case of upper tract malignancy. CONCLUSIONS: Based on current risk models computerized tomography urography for asymptomatic microscopic hematuria may be associated with a small but significant risk of secondary malignancy relative to the additional diagnostic benefit offered.

"Allergic-like" reaction risk in patients undergoing non-intravenous contrast urography.

INTRODUCTION: Though widely performed, the safety of non-intravenous contrast (NIVC) urography in patients with documented intravenous, iodinated contrast allergic like reactions (ICA) is unclear. The purpose of this study was to determine the risk of "allergic-like" reaction (ALR) events in patients with ICA undergoing NIVC urography. MATERIALS AND METHODS: Patients undergoing contrast urography at a single institution were identified between 2011-2014. Patient charts were reviewed for documented ICA prior to index surgery, preoperative allergy prophylaxis with steroid or antihistamine, and acute allergic reactions identified by ICD codes within 24 hours of surgery. RESULTS: A total of 2,650 patients were included, 1,325 female (50%). Of these patients, 113 (4.2%) had an ICA. Overall 33% (37/113) of patient received preoperative allergy prophylaxis with a steroid or antihistamine. A potential ALR related ICD-9 code was identified in one patient (0.8%) with a prior IVC ALR without allergy prophylaxis within 24 hours preoperatively undergoing percutaneous nephrolithotomy (PCNL). This event was found to be an associated with a myocardial infarction and lacked ALR sequelae. CONCLUSION: Despite commonly voiced concerns, in this large series of over 2,500 patients, including 113 patients with a prior history of ICA undergoing contrast urography, only one patient was found to have a potential ALR event following PCNL. No patients undergoing a retrograde contrast urography with prior, documented ICA had a NIVC ALR event despite a low rate of pretreatment with corticosteroid or antihistamine.

Identifying and managing the risks of medical ionizing radiation in endourology.

INTRODUCTION: The risks of exposure to medical ionizing radiation is of increasing concern both among medical professionals and the general public. Patients with nephrolithiasis are exposed to high levels of ionizing radiation through both diagnostic and therapeutic modalities. Endourologists who perform a high-volume of fluoroscopy guided procedures are also exposed to significant quantities of ionizing radiation. The combination of judicious use of radiation-based imaging modalities, application of new imaging techniques such as ultra-low dose computed tomography (CT) scan, and modifying use of current technology such as increasing ultrasound and pulsed fluoroscopy utilization offers the possibility of significantly reducing radiation exposure. We present a review of the literature regarding the risks of medical ionizing radiation to patients and surgeons as it pertains to the field of endourology and interventions that can be performed to limit this exposure. MATERIALS AND METHODS: A review of the current state of the literature was performed using MEDLINE and PubMed. Interventions designed to limit patient and surgeon radiation exposure were identified and analyzed. Summaries of the data were compiled and synthesized in the body of the text. RESULTS: While no level 1 evidence exists demonstrating the risk of secondary malignancy with radiation exposure, the preponderance of evidence suggests a dose and age dependent increase in malignancy risk from ionizing radiation. Patients with nephrolithiasis were exposed to an average effective dose of 37mSv over a 2 year period. Multiple evidence-based interventions to limit patient and surgeon radiation exposure and associated risk were identified. CONCLUSION: Current evidence suggest an age and dose dependent risk of secondary malignancy from ionizing radiation. Urologists must act in accordance with ALARA principles to safely manage nephrolithiasis while minimizing radiation exposure.

Imaging for urolithiasis: standards, trends, and radiation exposure.

PURPOSE OF REVIEW: To discuss current trends in imaging for urolithiasis and review the recent scientific literature surrounding this topic. Specifically, to address the efforts urologist should be making to reduce the use of ionizing radiation and to examine alternatives to computerized tomography (CT) scan in diagnosing and managing patients with stones. RECENT FINDINGS: Although CT remains the gold standard for diagnosing urolithiasis, low-dose and ultralow-dose CT scans should be utilized more frequently. Imaging with ultrasound and digital tomosynthesis, especially in follow-up for urolithiasis, offers the dual benefit of reduced patient radiation exposure and acceptable diagnostic ability. SUMMARY: Urolithiasis is a prevalent and recurrent condition and patient radiation exposure throughout diagnosis and management of this disease needs to be considered. Imaging modalities that limit radiation and preserve diagnostic accuracy must be utilized.

Is top-down vs bottom-up radiological evaluation after febrile urinary tract infection really less stressful for the child and family? Challenging the dogma.

PURPOSE: We evaluated whether stress levels in children and parents during radiological evaluation after febrile urinary tract infection are really lower using the top-down approach, where (99m)technetium dimercaptosuccinic acid renal scintigraphy is used initially, than the bottom-up approach, where voiding cystourethrography is initially performed and repeated examinations are easier for all. MATERIALS AND METHODS: We prospectively evaluated 120 children 3 to 8 years old. Pain ratings were obtained using the Faces Pain Scale-Revised, and conversation during the procedure was evaluated using the Child-Adult Medical Procedure Interaction Scale-Revised by 2 independent observers. To evaluate parental anxiety, the State-Trait Anxiety Inventory form was also completed. Following a documented febrile urinary tract infection children were randomized to the top-down or bottom-up group. A third group of 44 children undergoing repeat voiding cystourethrography and their parents were also evaluated. RESULTS: Child ratings of pain using the Faces Pain Scale-Revised were not significantly different between the top-down group following (99m)technetium dimercaptosuccinic acid renal scintigraphy (2.99 on a scale of 10) and the bottom-up group following voiding cystourethrography (3.21). Also the Faces Pain Scale-Revised was not significantly different in the repeat voiding cystourethrography group (3.35). On the Child-Adult Medical Procedure Interaction Scale-Revised there was negative correlation between child coping and child distress, as well as rate of child distress and adult coping promoting behavior. Parental state anxiety scores were significantly less in the top-down and repeat voiding cystourethrography groups than in the bottom-up group. CONCLUSIONS: Although the top-down approach and repeat voiding cystourethrography cause less anxiety for caregivers, these values do not correlate to pain scale in children. This finding might be due to lack of appropriate evaluation tools of pediatric pain and anxiety. However, the theory that the top-down approach is less invasive, and thus less stressful, requires further research. The Child-Adult Medical Procedure Interaction Scale-Revised data indicate that influences in adult-child interaction are bidirectional.

Subsequent cancer risk of children receiving post voiding cystourethrography: a nationwide population-based retrospective cohort study.

BACKGROUND: To estimate the subsequent cancer risk of children receiving post voiding cystourethrography (VCUG), a nationwide population-based retrospective cohort study with the data from the Taiwan National Health Insurance Research Database (NHIRD) were used for the analysis. METHODS: In the VCUG cohort, 31,908 participants younger than 18 years of age who underwent VCUG between 1997 and 2008 were identified from the NHIRD. A comparison cohort, the non-VCUG cohort, was randomly selected among children without VCUG examination histories during 1997-2008, frequency matched for age (every 5 years), sex, geographic region area, parents' occupation, and index year based on a 1:4 ratio. Cox's proportional hazard regression analysis was conducted to estimate the subsequent cancer risk of children receiving VCUG. RESULTS: The overall cancer risk of the VCUG cohort is 1.92-fold (95 % CI = 1.34-2.74) higher than that of the non-VCUG cohort with statistical significance. The genital cancer and urinary system cancer risks of the VCUG cohort are respectively 6.19-fold (95 % CI = 1.37-28.0) and 5.8-fold (95 % CI = 1.54-21.9) higher than those of the non-VCUG cohort with statistical significance. The hazard ratios are higher in genital cancer, urinary system cancer (the major radiation exposure area), and cancer of the abdomen, except for the genitourinary system (the minor radiation exposure area), in sequence. CONCLUSIONS: Pediatric VCUG is associated with increased subsequent cancer risk, especially in the genitourinary system.

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.

Society for fetal urology recommendations for postnatal evaluation of prenatal hydronephrosis--will fewer voiding cystourethrograms lead to more urinary tract infections?

PURPOSE: There is no consensus on the extent and mode of postnatal imaging after a diagnosis of prenatal hydronephrosis. We validated the protocol of our practice, which parallels current Society for Fetal Urology (SFU) recommendations, in limiting voiding cystourethrogram, while examining its impact on the incidence of febrile urinary tract infections. A secondary goal was to examine predictors of postnatal intervention. MATERIALS AND METHODS: We evaluated a cohort of 117 infants with prenatal hydronephrosis and retrospectively reviewed outcomes. Excluded from study were 30 infants with anatomical abnormalities. Third trimester prenatal ultrasound was done to evaluate SFU grade, laterality and anteroposterior diameter. Cox proportional hazard model and chi-square analysis were used to assess predictors of resolution and surgical intervention. RESULTS: A total of 87 infants with a median followup of 33.5 months were included in analysis. Postnatal voiding cystourethrogram was done in 52 patients, of whom 7 had vesicoureteral reflux. In 6 infants (6.9%) a febrile urinary tract infection developed, which was diagnosed with a catheter specimen during followup. In 3 infants a urinary tract infection developed immediately after catheterization. Anteroposterior diameter 9 mm or greater and SFU grade 3 or greater independently predicted the need for postnatal intervention (p = 0.0014 and 0.001, respectively). CONCLUSIONS: With adherence to our protocol, voiding cystourethrogram was avoided in almost half of evaluated infants. No infant diagnosed with vesicoureteral reflux had a urinary tract infection. Catheterization was associated with a urinary tract infection in 50% of cases. An anteroposterior diameter of 9 mm or greater and a SFU grade of 3 or greater were associated with postnatal progression to surgery. Patients with a SFU grade of 4 progressed to surgical intervention at a faster rate than those with a grade of greater than 3.

Efficacy of a cartoon and photograph montage storybook in preparing children for voiding cystourethrogram.

BACKGROUND: Undergoing voiding cystourethrogram (VCUG) can be distressing for children. OBJECTIVE: To assess the efficacy of a cartoon and photograph montage storybook in preparing children for VCUG. MATERIALS AND METHODS: Outpatient children (ages 2-14 years) who had VCUGs between December 2011 and June 2012 were randomly assigned to two groups; one group received the storybook a week before the procedure. Parents and guardians were asked to complete an anonymous survey rating their child's tolerance of the exam from 1 to 5, worst to best, immediately after VCUG. The VCUG technologist also rated the child's tolerance. RESULTS: Children prepared for VCUG with the storybook had less distress than those without. Results were analyzed by Cochran-Mantel-Haenszel and Cochran-Armitage Trend exact tests, a P value of both tests of 0.0092 indicating a statistically significant difference between the tolerance scores of children prepared with the storybook and those without. Effects of gender and history of VCUG were not statistically significant. Two-thirds of all children had no other source of information. CONCLUSION: The cartoon and photograph montage storybook format of preparing children for VCUG was effective in increasing their tolerance for the procedure. The storybook should be mailed out in advance because the majority of families did not pursue information on preparing their children for VCUG.

Controversy in urinary tract infection management in children: a review of new data and subsequent changes in guidelines.

Controversy and lack of consensus have been encountered in the management of pediatric urinary tract infection (UTI), including its diagnosis, radiological investigations and the use of antibiotic therapy. In this review, we discuss the need for radiological investigations and the extent of their use as well as the need for prophylactic antibiotics in children with UTI and vesicoureteral reflux. Only a small proportion of children with first UTI and no history of antenatal renal abnormalities have clinically important malformations. Renal ultrasound should be performed in febrile infants and young children with UTI; a micturating cystourethrogram should not be performed routinely after the first febrile UTI. Long-term antibiotics appear to reduce the risk of recurrent symptomatic UTI in susceptible children, although the clinical benefit is marginal. Current recommendations encourage performing radiological investigations only in children at risk and discourage routine prophylactic antibiotic use.

Essentials of Computed Tomography Imaging of Hematuria.

Hematuria is defined usually as the presence of blood in the urine, either on voiding or in a catheterized specimen. Hematuria is broadly divided into microscopic and gross hematuria and may be symptomatic or asymptomatic. The causes of hematuria include a very wide spectrum of conditions. However, here, we have filtered the causes causing gross hematuria, including calculus, trauma, tumors, vascular, and miscellaneous causes. Plain X-rays of the kidney, ureter, and bladder; ultrasound; intravenous urography; computed tomography (CT); magnetic resonance imaging; retrograde ureterography and pyelography (RGP); cystoscopy; and ureteroscopy are techniques that are useful for diagnosis. In the past, one or a combination of several techniques was used to evaluate hematuria but recently, advances in CT urography mean that it can be used alone for this task. This article briefly reviews the common causes of gross hematuria in adults and their evaluation by CT-based urography. Gross hematuria is evaluated well with CT scan urography which includes an unenhanced scan, the nephrographic phase, and the excretory phase. Unenhanced scans are routinely performed to evaluate the basic parameters such as the size, shape, position, and outline of the kidneys and calculus disease, which is the most common cause of hematuria. Renal parenchymal diseases including masses are best visualized in the nephrographic phase along with other abdominal organs. Delayed excretory phases including the kidneys, ureters, and bladder are useful for detecting urothelial diseases. CT urography's protocol permits evaluations of hematuria through a single examination.

The efficacy of oral midazolam for decreasing anxiety in children undergoing voiding cystourethrogram: a randomized, double-blind, placebo controlled study.

PURPOSE: Voiding cystourethrogram is an invasive test that evokes anxiety. Our primary aim was to determine whether midazolam is beneficial in decreasing anxiety in children who undergo voiding cystourethrogram. Secondary aims were an examination of parent anxiety, health care professional perceptions and post-procedure behavioral outcomes in children after voiding cystourethrogram. MATERIALS AND METHODS: A total of 44 children were randomized to placebo or oral midazolam before voiding cystourethrogram in double-blind fashion. The Modified Yale Preoperative Anxiety Scale was used to evaluate child behavior before and during voiding cystourethrogram, and the Post Hospitalization Behavior Questionnaire was used to investigate any short-term and intermediate-term behavioral outcomes. The State-Trait Anxiety Inventory was used to evaluate parent personal anxiety during voiding cystourethrogram. A separate questionnaire was administered to radiology staff. Statistical analysis included the 2-sample t and Fisher exact tests. RESULTS: There was no difference in Modified Yale Preoperative Anxiety Scale scores in children randomized to midazolam or placebo. There was also no significant difference in parent anxiety. Radiology care providers identified no reliable benefit when blinded to sedation vs placebo. We did not note any post-procedural behavior issues after voiding cystourethrogram at up to 6 months of followup. CONCLUSIONS: Midazolam may not significantly help with child or parent anxiety during voiding cystourethrogram. No reliable benefit was noted according to radiology health care provider perception and there was no significant post-procedural behavior benefit. Midazolam may not provide a significant benefit in decreasing anxiety during voiding cystourethrogram.

Effects of parental soothing behavior on stress levels of 2-8 year old children during voiding cystourethrograms by phase of procedure.

Using the example of a voiding cystourethrogram (VCUG), a painful radiological procedure, this study investigated whether parental soothing behavior (reassuring comments like "it's almost over" or "You're O.K." and soothing by "sh, sh") in one phase of the procedure influenced the child's distress in the following phase. The sample was comprised of 68 2-8 year-old children and the accompanying parent(s). Child and parental behavior during the VCUG was coded using a standardized rating scale (CAMPIS-R). Parental reassurance during the anticipatory phase significantly increased the child's distress of the following phase, while parental "sh, sh" significantly reduced it. Both parental behaviors showed no significant effect on the child's distress of the following phase when applied during the procedure itself. Results underline the importance of differentiating between anticipatory and procedural phases of the VCUG. Counselling methods for parents on more appropriate strategies to assist their children during procedural phases of the VCUG are necessary.

Air vs contrast pyelogram for initial puncture access in percutaneous nephrolithotomy: a randomized controlled trial.

Percutaneous nephrolithotomy (PCNL) is a standard procedure for large renal stones. Contrast (traditionally) as well as air is being used to delineate pelvi-calyceal system (PCS) to perform initial puncture. Contrast, when used has certain disadvantages including poor differentiation of anterior and posterior calyces. In this interim analysis of 122 patients of a prospective study subjects were stratified in two groups: in group 1, contrast was used while in group 2, air was used to delineate PCS. Out of 122,103 patients underwent puncture by contrast or air exclusively while 19 patients required mix of contrast and air (14 patients failed puncture using contrast while 5 using air). Mean dosage of radiation exposure (8.43 vs. 14.26 mGy), duration of radiation exposure (0.66 vs. 1.02 min), access time (3.72 vs. 5.84 min), were less in group 2 as compared to group 1. 84.5% of patients underwent puncture in single attempt in group 2 as compared to 56.25% in group 1. Five patients had post-operative fever and one had trans-pleural tract dilation. Complete stone clearance was seen in 94.8% of patients using air to only 75% of patients using contrast. Conclusion: Air pyelogram is a feasible, safe, cost effective and efficient access alternative to contrast pyelogram and in difficult situation a mixture of both is better than using one.

Evaluation and follow-up of patients with urinary lithiasis: minimizing radiation exposure.

As unenhanced computed tomography (CT) has supplanted other modalities (eg, intravenous urography, ultrasonography) as the "test of choice" for evaluation of stone disease, patients have been exposed to higher doses of ionizing radiation in both primary evaluation and follow-up. There has been progressive recognition that low doses of radiation in the range of conventional CT may increase the long-term risk of cancer in exposed patients; these data have been extrapolated from longitudinal and ongoing study of atomic bomb survivors. There have been mounting efforts to develop alternative approaches to conventional CT (eg, low-dose protocols, substitution of ultrasound/plain X-ray) to provide comparable data while reducing total radiation exposure. It is essential that urologists collaborate with radiologists, emergency room physicians, and other providers to appropriately balance the theoretical risks and practical benefits of ionizing radiation in the diagnosis of stone disease.

Intranasal fentanyl versus placebo for pain in children during catheterization for voiding cystourethrography.

BACKGROUND: Voiding cystourethrogram (VCUG) is a common procedure at pediatric tertiary care centres that can be painful as it involves a urinary catheter. Currently there are no widely utilized protocols for non-topical medications to decrease pain that children feel during catheterization. OBJECTIVE: To determine if intranasal (IN) fentanyl is effective at decreasing pain that children feel during catheterization of VCUG when compared with sterile water. MATERIALS AND METHODS: We performed a double-blind randomized controlled trial, using IN fentanyl (2 microg/kg) compared to placebo (sterile water,) in children 4-8 years of age scheduled for elective VCUG in one urban pediatric tertiary center. RESULTS: Using the Face Pain Score-Revised, children receiving IN fentanyl scored 2.58 (1.93-3.25 95% CI) while those receiving sterile water scored 2.86 (2.20-3.51 95% CI) showing no statistically significant difference. There were no adverse events. CONCLUSIONS: Although we were unable to show a statistically significant difference between our study and control groups, we believe that this may be due to technique (positioning, delivery device) and timing of administration of IN fentanyl as well as multi-factorial causes of distress during VCUG. Future studies investigating alternative delivery techniques of IN fentanyl for analgesia during VCUG may yield more promising results.

Reflex Anuria Following Retrograde Pyelography: A Case Report and Literature Review.

A case of acute kidney injury due to reflex anuria that was caused by retrograde pyelography and required temporary hemodialysis is reported. An 83-year-old Japanese woman presented with anuria 2 days after undergoing bilateral retrograde pyelography for the investigation of gross hematuria. Retrograde pyelography showed no apparent abnormality, such as malignancy or urolithiasis, but pyelorenal extravasation of contrast medium was remarkable. Her anuria improved promptly after hemodialysis, allowing her treatment to conclude with only one hemodialysis session, and a normal renal function was restored with no sequelae. The details of this case and a review of the relevant literature are presented.

Radiation exposure in the acute and short-term management of urolithiasis at 2 academic centers.

PURPOSE: Diagnostic imaging has a central role in the evaluation and management of urolithiasis. A variety of modalities are available, each with benefits and limitations. Without careful consideration of imaging modalities in quantity and type patients may receive excessive doses of radiation during initial diagnostic and followup evaluations. Therefore, we determined the effective radiation dose associated with an acute stone episode and short-term followup. MATERIALS AND METHODS: A multicenter retrospective study of all patients who presented with an acute stone episode was performed. The analysis included all imaging studies related to stone disease performed within 1 year of the acute event. Using accepted effective radiation dose standards for each of these examinations, the total radiation dose administered was calculated and compared by patient characteristics including stone location, stone number and intervention strategy. The primary outcome assessed was a total radiation dose greater than 50 mSv, the recommended yearly dose limit for occupational exposure by the International Commission on Radiological Protection. RESULTS: We identified 108 patients who presented to our respective institutions with a primary acute stone episode between 2000 and 2006. The mean age in our cohort was 48.6 years and 50% of the patients were men. Patients underwent an average of 4 radiographic examinations during the 1-year period. Studies performed included a mean of 1.2 plain abdominal films of the kidneys, ureters and bladder (range 0 to 7), 1.7 abdominopelvic computerized tomograms (range 0 to 6) and 1 excretory urogram (range 0 to 3) during the first year of followup. The median total effective radiation dose per patient was 29.7 mSv (IQR 24.2, 45.1). There were 22 (20%) patients who received greater than 50 mSv. Analysis of stone location, number of stones, stone composition, patient age, sex and surgical intervention indicated no statistically significant difference in the probability of receiving a total radiation dose greater than 50 mSv. CONCLUSIONS: A fifth of patients receive potentially significant radiation doses in the short-term followup of an acute stone event. Radiographic imaging remains an integral part of the diagnosis and management of symptomatic urolithiasis. While debate exists regarding the threshold level for radiation induced fatal malignancies, urologists must be cognizant of the radiation exposure to patients, and seek alternative imaging strategies to minimize radiation dose during acute and long-term stone management.