Contrast media reactions during voiding cystourethrography or retrograde pyelography

Exploring Gadolinium-Based Contrast Media for Retrograde Pyelography in the Context of Iodine Allergy

Iodinated contrast media can rarely cause severe allergic reactions during nonvascular urologic imaging procedures. Alternatives like gadolinium-based contrast may help mitigate this risk in susceptible patients. A 66-year-old woman with a documented iodine allergy presented with an obstructing stone in the right ureter. To avoid the risk of an allergic reaction, the decision was made to use an alternative non-iodinated contrast agent for retrograde pyelography prior to ureteral stent placement. Gadobenate dimeglumine, an MRI contrast agent, was diluted 50:50 with saline and utilized successfully to provide adequate opacification for safe stent placement without adverse reaction. The patient underwent repeat pyelography with gadobenate dimeglumine one month later during ureteroscopy without complication. This case demonstrates that diluted gadobenate can serve as an effective alternative to iodinated contrast media in patients at high risk of reaction to iodine-containing agents. While severe reactions to iodinated contrast are uncommon in nonvascular urologic procedures, they can still occur even with premedication. Gadolinium-based agents have been reported to provide sufficient opacification for most urologic interventions, though inferior radiographically to iodinated contrast. Further study on gadolinium efficacy and safety in this setting is warranted. However the present case supports gadobenate dimeglumine as a viable option for retrograde pyelography when allergy risk precludes iodinated contrast use.

Intraperitoneal Rupture of Urinary Bladder during Micturating Cystourethrography in a Child

Micturating cystourethrography (MCUG) is a very commonly performed diagnostic procedure in pediatric urology. Although considered to be simple, safe, and cost-effective, it can incur some complications. Bladder rupture during MCUG is a very rare complication and only a handful of cases have been reported in world literature. We report the case of a 2.5-month-old boy who had intraperitoneal bladder rupture during an MCUG needing surgical repair. At operation, the child had a bladder tear at the dome of the bladder which was repaired successfully. The postoperative recovery was uneventful and the child is doing well in follow-up. Although individual management of bladder rupture may differ, a majority of infants need surgery for the same. Thorough vigil and attention to the technique are a must to prevent such incidents in children.

Outcomes in patients with known contrast allergy undergoing contrast-enhanced endourological procedures: a retrospective cohort study

BACKGROUND

Intravenous administration of iodinated contrast agents carries the risk of allergic reaction, yet this risk is unclear with administration into the urinary tract. We sought to evaluate patients with known contrast, iodine, or shellfish allergies for allergic response when undergoing urologic imaging requiring intraluminal, urinary tract contrast administration.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients undergoing endourologic procedures from 2010 to 2015 at our institution. Clinical records were reviewed for demographics, medical history, allergies, procedure details, fluids administered, anesthetic and pharmacologic agents administered, and continuous monitoring parameters. Patients with known allergies to iodine, shellfish, and/or contrast were identified and evaluated for clinical or hemodynamic signs of allergy. A convenience sample of 50 patients without allergy history was used as a comparison group.

RESULTS

We identified 1,405 procedures involving 1,000 consecutive patients. Procedures included retrograde pyelograms and antegrade nephrostograms. Eighty-six cases involving 58 patients with contrast, iodine, or shellfish allergies were identified. Of those with contrast allergy history, 18 (20.1%) cases involved patients with a history of anaphylactic reaction. Of these, 11 (61%) received steroid prophylaxis. No patients in either group (Allergy, No Allergy) were identified as having an allergic reaction during the procedure. There were no statistically significant differences in intraoperative intravenous fluids (p=0.931), procedure duration (p=0.747), or vasopressor use (p=0.973) between groups. Due to the zero event rate of contrast allergy, we used the Hanley and Lippman-Hand method, which places true population risk (95% confidence interval) of a significant event at less than 3.5%.

CONCLUSIONS

In 86 cases involving patients with a history of contrast allergy, we found no evidence of clinically significant allergic reaction to intraluminal endourologic contrast administration under continuous anesthesia monitoring. The risk of significant reactions to contrast administered within the urinary tract appears to be low in these patients, regardless of prophylaxis.

Anaphylactoid Reactions After Instillation of Contrast Material Into the Urinary Tract: A Survey of Contemporary Practice Patterns and Review of the Literature

OBJECTIVE

To assess drug reactions (ADRs) encountered by practicing urologists for contrast instilled into the urinary collecting system, and to describe current practice patterns regarding contrast administration into the urinary tract for patients with known contrast allergies.

METHODS

Endourological Society members were e-mailed a web-based survey about their prior experience with contrast-related ADRs and practices for contrast administration into the urinary tract among patients with known intravenous contrast allergies. Chi-squared analysis was used to compare management patterns between patients with established allergies and those without.

RESULTS

An estimated 2300-2500 e-mails were reached, resulting in an estimated response rate of 6.3%-8%. Over 75% of respondents were fellowship trained. Average time in practice was 16 years, and respondents performed a mean of 6.7 urologic contrast studies per week. Among respondents, 32.6%, 14.7%, and 4.0% had treated at least 1 patient with a mild, moderate, or severe reaction, respectively. Contrast-related ADRs were most commonly associated with retrograde pyelogram (50%). For patients with known contrast allergies, 5.4% pursue additional work-up before administering contrast in the urinary tract. Pretreatment with antihistamine or steroids is used by 24.8% and 23.4%, respectively. When performing retrograde pyelograms for such patients, urologists are more likely to use dilute contrast (P = .003), but otherwise do not significantly alter technique.

CONCLUSION

Contrast ADRs are encountered not infrequently among practicing urologists. There is notable practice variation in the management of patients with known contrast allergies, though the overall perceived risk of contrast use in these patients is low, provided good technique is used.

Delayed severe anaphylactoid reaction following retrograde pyelogram: A case report

Retrograde pyelography is used to evaluate upper collecting system in patients with hematuria who have contrast allergy. Reported here is a patient who developed severe, late-onset anaphylactoid reaction after retrograde pyelography. Premedication is commonly used to reduce risk of allergic reaction but has limited evidence to support its efficacy. Caution should be used when evaluating microhematuria with retrograde pyelography in patients with prior anaphylactoid reaction to intravenous contrast.

Off-label-use of sulfur-hexafluoride in voiding urosonography for diagnosis of vesicoureteral reflux in children: A survey on adverse events

AIM

To evaluate the risk profile of sulfur hexafluoride in voiding urosonography (VUS) based on a large cohort of children.

METHODS

Since 2011 sulfur hexafluoride (SH, SonoVue^®, Bracco, Italy) is the only ultrasound contrast available in the European Union and its use in children has not been approved. Within a 4-year-period, 531 children with suspected or proven vesicoureteral reflux (f/m = 478/53; mean age 4.9 years; 1 mo-25.2 years) following parental informed consent underwent VUS with administration of 2.6 ± 1.2 mL SH in a two-center study. A standardized telephone survey on adverse events was conducted three days later.

RESULTS

No acute adverse reactions were observed. The survey revealed subacute, mostly self-limited adverse events in 4.1% (22/531). The majority of observed adverse events (17/22) was not suspected to be caused by an allergic reaction: Five were related to catheter placement, three to reactivated urinary tract infections, five were associated with perineal disinfection before voiding urosonography or perineal dermatitis and four with a common cold. In five patients (0.9%) hints to a potential allergic cause were noted: Perineal urticaria was reported in three interviews and isolated, mild fever in two. These were minor self-limited adverse events with a subacute onset and no hospital admittance was necessary. Ninety-six point two percent of the parents would prefer future VUS examinations with use of SH.

CONCLUSION

No severe adverse events were observed and indications of self-limited minor allergic reactions related to intravesical administration of SH were reported in less than 1%.

Paediatric Urinary Tract Infection: A Hospital Based Experience

INTRODUCTION

Paediatric Urinary Tract Infection (UTI) is one of the commonly encountered entities by paediatricians. Studies have shown easy vulnerability of paediatric urinary tract in any acute febrile illness and a miss in diagnosis could have long term consequences like renal scaring with its adverse effects. Bearing these evidence based preludes in view we designed our study to know the prevalence of UTI in Kashmir province.

AIM

Aim of the present study was to know the prevalence of UTI in febrile children and to know the sensitivity of different imaging modalities like Renal and Urinary Bladder Ultrasonography (RUS), Voiding Cystourethrography (VCUG) and Dimercaptosuccinic Acid (DMSA) scan in diagnosing UTI.

MATERIALS AND METHODS

A total of 304 patients, between 2 months to 10 years, with axillary temperature of ≥ 100.4^oF (38^oC), who did not have a definite source for their fever and who were not on antibiotics were included in the study. Detailed history and through clinical examination was done to rule out any potential or definite focus of infection as per the predesigned proforma. Routine urine examination with culture and sensitivity, followed by RUS and VCUG was done in all patients where routine urine examination was suggestive of UTI. DMSA was done in only culture proven cases after 6 months to document the renal scarring.

RESULTS

Out of 304 children, 140 were males and 164 were females, UTI was present in 40 patients who had fever without any apparent cause giving a prevalence of 13.2%. Escherichia coli (E. coli) were the commonest isolated organism, followed by Klebsiella and Citrobacter species. Renal and Urinary Bladder Ultrasonography (RUS) detected Vesicoureteral Reflux (VUR) in 25% (10/40) while VCUG showed VUR in 55% (22/40) giving a RUS sensitivity of 45% for detecting VUR. DMSA done only after 6 months in UTI diagnosed patients showed a renal scarring in 25% (10/40) patients.

CONCLUSION

Missing a febrile paediatric UTI, can prove a future catastrophe if not timely diagnosed and treated.

Urinary bladder rupture during voiding cystourethrography

Voiding cystourethrography (VCUG) is a commonly performed diagnostic procedure for the evaluation of vesicoureteral reflux with urinary tract infection or congenital renal diseases in children. The procedure is relatively simple and cost-effective, and complications are very rare. The iatrogenic complication of VCUG range from discomfort, urinary tract infection to bacteremia, as well as bladder rupture. Bladder rupture is a rare complication of VCUG, and only a few cases were reported. Bladder rupture among healthy children during VCUG is an especially uncommon event. Bladder rupture associated with VCUG is usually more common in chronically unused bladders like chronic renal failure. Presented is a case of bladder rupture that occurred during a VCUG in a healthy 9-month-old infant, due to instilled action of dye by high pressure. This injury completely healed after 7 days of operation, and it was confirmed with a postoperative cystography. The patient's bladder volume, underlying disease, velocity of the contrast media instilled, catheter size, and styles of instillation are important factors to prevent bladder rupture during VCUG. Management of bladder rupture should be individualized, but the majority of infants are treated with the operation. In conclusion, bladder rupture is a rare complication, however, delicate attention is needed in order to prevent more dire situations.

Anaphylactoid reaction after retrograde pyelography despite preoperative steroid preparation

A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years' duration. The patient was scheduled to undergo cystoscopy with bilateral retrograde pyelography, because this is considered a safe alternative to intravenous pyelography or computed tomography. Because of her contrast allergy, the patient completed a 13-hour steroid preparation before the procedure. However, within minutes of extubation, she developed an anaphylactoid reaction and, despite appropriate management, required reintubation and subsequent transfer to the intensive care unit. The patient was subsequently extubated 8 hours later and recovered completely.

Allergy-like reactions to iodinated contrast agents. A critical analysis

Allergy-like reactions may occur following administration of iodinated contrast media (CM), mostly in at-risk patients (patients with history of previous reaction, history of allergy, co-treated with interleukin-2 or beta-blockers, etc.) but remain generally unpredictable. Severe and fatal reactions are very rare events. All categories of CM may induce such reactions, although first generation (high osmolar CM) have been found to induce a higher rate of adverse events than low osmolar CM. However, no differences were found between the two categories of CM with respect to mortality. Delayed reactions can also occur. There are no differences between the various categories of CM except for non-ionic dimers, which are more likely to induce such effect. Numerous clinical studies have evaluated the prophylactic value of drugs (mostly antihistamines and corticosteroids). Results are unclear and highly variable. Any prevention depends upon the mechanism involved. However, the mechanism of CM-induced allergy-like reaction remains disputed. Relatively recent data revived the hypothesis of a type-I hypersensitivity mechanism. Positive skin tests to CM have been reported. However, the affinity of IgE towards CM has been found to be very low in the only study which actually evaluated it. Other pathophysiological mechanisms (involving direct secretory effects on mast cells or basophils, or activation of the complement system associated or not with the plasma contact system) are also much debated. Anaphylaxis and anaphylactoid reactions are, in the end, clinically undistinguishable.

Complications of voiding cystourethrography in the evaluation of infants with prenatally detected hydronephrosis

PURPOSE

We determined complications in infants undergoing voiding cystourethrography as part of the evaluation for prenatally detected hydronephrosis.

MATERIALS AND METHODS

We retrospectively reviewed the records of infants referred to our institution for the evaluation of prenatal hydronephrosis from 1992 to 1997. Infants with a prenatal history of bilateral hydronephrosis, bladder distention and oligohydramnios, oligohydramnios only or a prenatal abnormality involving any other organ system were excluded from study. Of 206 patients 129 male and 49 female infants underwent postnatal voiding cystourethrography at our institution. Chart review and a telephone interview with the parents were done to assess lower urinary tract infection, pyelonephritis, hospital admission for urosepsis, gross hematuria, urinary retention or skin rash.

RESULTS

Postnatal voiding cystourethrography was normal in 138 patients but it diagnosed bilateral vesicoureteral reflux in 15, unilateral vesicoureteral reflux in 20, ureterocele in 4 and refluxing megaureter in 1. Of the 129 male infants evaluated 101 had undergone circumcision as a newborn, 14 were uncircumcised and the circumcision status of 14 was unknown. At voiding cystourethrography suppressive antibiotics were administered to 166 infants, 7 were not on suppressive antibiotics and antibiotic status was unknown in 5. No patient had a lower urinary tract infection, pyelonephritis or urosepsis. In addition, there were no episodes of urinary retention, gross hematuria or skin rash.

CONCLUSIONS

While the reported rate of new or recurrent infection associated with voiding cystourethrography is as high as 6%, we did not identify any infectious or other complications in infants undergoing voiding cystourethrography for prenatal hydronephrosis. When properly performed, we believe that voiding cystourethrography is safe and presents little risk in these patients.

Complications of voiding cystourethrography in the evaluation of infants with prenatally detected hydronephrosis

PURPOSE

We determined complications in infants undergoing voiding cystourethrography as part of the evaluation for prenatally detected hydronephrosis.

MATERIALS AND METHODS

We retrospectively reviewed the records of infants referred to our institution for the evaluation of prenatal hydronephrosis from 1992 to 1997. Infants with a prenatal history of bilateral hydronephrosis, bladder distention and oligohydramnios, oligohydramnios only or a prenatal abnormality involving any other organ system were excluded from study. Of 206 patients 129 male and 49 female infants underwent postnatal voiding cystourethrography at our institution. Chart review and a telephone interview with the parents were done to assess lower urinary tract infection, pyelonephritis, hospital admission for urosepsis, gross hematuria, urinary retention or skin rash.

RESULTS

Postnatal voiding cystourethrography was normal in 138 patients but it diagnosed bilateral vesicoureteral reflux in 15, unilateral vesicoureteral reflux in 20, ureterocele in 4 and refluxing megaureter in 1. Of the 129 male infants evaluated 101 had undergone circumcision as a newborn, 14 were uncircumcised and the circumcision status of 14 was unknown. At voiding cystourethrography suppressive antibiotics were administered to 166 infants, 7 were not on suppressive antibiotics and antibiotic status was unknown in 5. No patient had a lower urinary tract infection, pyelonephritis or urosepsis. In addition, there were no episodes of urinary retention, gross hematuria or skin rash.

CONCLUSIONS

While the reported rate of new or recurrent infection associated with voiding cystourethrography is as high as 6%, we did not identify any infectious or other complications in infants undergoing voiding cystourethrography for prenatal hydronephrosis. When properly performed, we believe that voiding cystourethrography is safe and presents little risk in these patients.

Iodinated contrast material in uroradiology. Choice of agent and management of complications

Many conditions seen by urologists require imaging examinations with iodinated radiographic contrast material as a key part of the primary evaluation of the patient. A basic understanding of contrast media, risks of administration, choice of agents, and premedication regimens for high-risk patients, is beneficial in helping patients prepare for their examinations. Urologists may be the primary physicians administering contrast material or may be working with radiologists in the care of patients receiving contrast agents. Because contrast reactions may occur unexpectedly, even during examinations in which the agents are not given intravenously, urologists should be able to recognize and treat the various types of adverse reactions.

Spurious rise in total carbon dioxide and chloride with negative anion gap after cystogram

We report a case of spurious hyperchloraemia, elevated total carbon dioxide and negative anion gap 9 days following a voiding cystourethrogram (VCU) in a patient with bladder exstrophy and obstructive uropathy. We believe that the spurious laboratory results were due to analytical interference of the absorbed iodine with the method of bicarbonate and chloride measurement. The absorbed iodine was retained in the circulation for an extended period because of associated renal impairment. Our patient was also on piperacillin which might have interfered with iodine clearance. Physicians and laboratory pathologists should be aware of this effect when interpreting laboratory results of patients who have undergone a VCU in association with obstructive uropathy and impaired renal function.

The appropriateness of use and the clinical impact of micturating cystourethrography in paediatric practice

STUDY OBJECTIVE

To determine the appropriateness of use and the clinical impact of micturating cystourethrography (MCU) in paediatric practice.

DESIGN

Retrospective medical record review.

SETTING

A major teaching children's hospital in the Trent region.

PATIENTS

Consecutive sample of 120 children undergoing MCU during 1991-1992, identified from the radiology records.

MAIN OUTCOME MEASURES

The referring clinician's reasons for requesting an MCU; the clinical management plan pursued before and after the MCU, and the change in management initiated by the result of the examination; the appropriateness of use of the test, as determined by the presence or absence of a valid indication for MCU in the specific clinical situation.

RESULTS

The change in patient management attributable to the MCU result could be categorized as: no change (19%); decision to end the imaging investigation of the patient (33%); decision to end all investigations, and prophylactic or therapeutic interventions (16%); decision to discontinue chemoprophylaxis (2%); decision to end the imaging investigation and introduce chemoprophylaxis and follow-up for bacteriuria (6%); decision to continue the imaging investigation and introduce chemoprophylaxis and follow-up for bacteriuria (13%); and decision to operate or help in planning the surgical treatment required (11%). Inappropriate use of the test was observed in 20% of the cases.

CONCLUSIONS

This study provides a basis for understanding the use of MCU in paediatric practice. The findings that 19% of the cystourethrograms had no appreciable effect, and that 20% of the examinations were used inappropriately show the need for increased effort to minimize overuse of the test.