1
|
Luithle T, Obermayr F, Dittmann H, Engel C, Etzler A, Kosch F, Menke IT, Schäfer M, Schuster T, Younsi N, Fuchs J. Determination of tissue tracer transit of Technetium-99m-mercaptoacetyltriglycine diuretic renography in infants with suspected ureteropelvic junction obstruction - A multicenter prospective observational study. J Pediatr Urol 2023; 19:780.e1-780.e7. [PMID: 37718234 DOI: 10.1016/j.jpurol.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION There is an ongoing controversy regarding management of ureteropelvic junction obstruction in infants, with a shift towards a non-operative approach. However, precise predictors of outcome are lacking. Recent studies postulated a high prognostic value of Technetium-99m-mercaptoacetyltriglycine tissue tracer transit with regard to the development of an impaired differential renal function and its potential improvement following pyeloplasty. OBJECTIVE To evaluate the prognostic value of Technetium-99m-mercaptoacetyltriglycine tissue tracer transit for the occurrence of changes in differential renal function in infants with suspected unilateral ureteropelvic junction obstruction in a prospective observational multicenter study. STUDY DESIGN Infants below 3 months of age with a unilateral isolated hydronephrosis ≥ grade 3 received ultrasound and Technetium-99m-mercaptoacetyltriglycine diuretic renography at two different time points (timepoint 1 and timepoint 2). Data were analyzed at local centers and at the study center and were collected in an internet-based database system. Tissue tracer transit was determined for each diuretic renography, inter-observer variation for tissue tracer transit and standard parameters for judgement of differential renal function development were assessed. RESULTS Thirty-seven patients were analyzed. Median age was 11 weeks (7-15) at timepoint 1 and 26 weeks (19-33) at timepoint 2. A delayed tissue tracer transit at timepoint 1 was not associated with deterioration of differential renal function at timepoint 2 in both, locally (10/37 cases) and centrally (4/37) analyzed cases. However, sensitivity and specificity were poor. The intraclass correlation coefficient comparing local and central findings of tissue tracer transit and renal drainage demonstrated poor or fair agreement. Analysis of standard parameters for differential renal function development revealed a prognostic value only for the dichotomized anteroposterior renal pelvic diameter (APD, p = 0.03, 95%-CI 1.2-22.2). DISCUSSION Regarding the primary endpoint of our study, we could not confirm the hypothesis that delayed tissue tracer transit reliably predicts a subsequent decline in differential renal function in the cohort of patients studied. Whether the low age of the patients, technical problems in the correct assessment of tissue tracer transit by the investigator in early infancy, the study design, or the parameter itself played a role is debated. CONCLUSION In the presented setting tissue tracer transit was not useful as a predictive parameter for deterioration of differential renal function in infants with suspected unilateral ureteropelvic junction obstruction. Sensitivity and specificity of tissue tracer transit were not sufficient for risk stratification. Improved utility of tissue tracer transit as a marker might be achieved using a different study setting.
Collapse
Affiliation(s)
- Tobias Luithle
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany.
| | - Florian Obermayr
- Faculty of Medicine, University of Marburg, Baldingertrasse, 35043 Marburg, Germany.
| | - Helmut Dittmann
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, Otfried-Müller-Str.14, 72076 Tuebingen, Germany.
| | - Corinna Engel
- Center for Pediatric Clinical Studies (CPCS), University Children's Hospital Tuebingen, Frondsbergstr. 23, 72070 Tuebingen, Germany.
| | - Andrea Etzler
- Department of Pediatric Surgery and Pediatric Urology, Klinikum Bremen-Mitte, St.-Jürgen-Str. 1, 28205 Bremen, Germany.
| | - Ferdinand Kosch
- Department of Pediatric Surgery, Städtisches Klinikum Karlsruhe, Moltkestr. 90, 76131 Karlsruhe, Germany.
| | - Ines Theresa Menke
- Department of Pediatric Surgery and Pediatric Urology, Medical Center Dortmund, Beurhausstr. 40, 44137 Dortmund, Germany.
| | - Mattias Schäfer
- Department of Pediatric Surgery and Pediatric Urology, Cnopf'sche Kinderklinik, St. Johannis-Mühlgasse 19, 90419 Nuremberg, Germany.
| | - Tobias Schuster
- Department of Pediatric Surgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany.
| | - Nina Younsi
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Joerg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany.
| |
Collapse
|
2
|
Li B, Ramesh S, McGrath M, Braga LH. Association of the Hydronephrosis Severity Score With Likelihood of Pyeloplasty: A Large Prospective Database Analysis. Urology 2023; 177:162-168. [PMID: 37088315 DOI: 10.1016/j.urology.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To apply and reproduce this scoring system in our prenatal hydronephrosis population with ureteropelvic junction obstruction (UPJO)-like hydronephrosis (HN), specifically looking at determining better HHS cutoffs that would allow for stratification into three risk categories: spontaneous HN resolution, observation, and surgery. METHODS A prospectively collected prenatal hydronephrosis database was reviewed to extract UPJO-like HN patients. Children with vesicoureteral reflux, primary megaureter, bilateral HN, and other associated anomalies were excluded. Only patients who had an ultrasound and mercaptoacetyltriglycine renal scan at a minimum of 2-time points were included. Hydronephrosis Severity Score was calculated at the initial, interim, and last follow-up clinic visits. Scores were analyzed regarding its usefulness to determine which patients would have been more likely to undergo pyeloplasty. RESULTS Of 167 patients, 131 (78%) were male, 119 (71%) had left UPJO-like, and 113 (67%) had a pyeloplasty. The median age at baseline was 2months (interquartile range 1-4). According to initial (first clinic visit) Hydronephrosis Severity Score, 5/36 (14%) patients with a 0-4 score, 93/116 (80%) with a 5-8 score, and 15/15 (100%) with a 9-12 score underwent pyeloplasty, respectively (P < .01). CONCLUSION The proposed HHS system for UPJO-like HN patients is reproducible, however, cut-off values need to be reassessed to accurately reflect true risk categories, as the purpose of this system is to differentiate those who have HN severe enough to require intervention from those who can be managed nonsurgically. Changing risk groups to mild (0-3), moderate (4-6), and severe (7-12) allowed for better discrimination between patients who underwent surgical intervention from those who did not in our dataset.
Collapse
Affiliation(s)
- Bruce Li
- Division of Urology, Department of Surgery, Western University, London, Ontario, Canada
| | - Smruthi Ramesh
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melissa McGrath
- McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, Ontario, Canada
| | - Luis H Braga
- McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, Ontario, Canada; Division of Urology, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
3
|
Chirurgische Intervention bei der kindlichen Ureterabgangsstenose. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
4
|
Brink A. Pitfalls of Radionuclide Renal Imaging in Pediatrics. Semin Nucl Med 2022; 52:432-444. [DOI: 10.1053/j.semnuclmed.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 01/23/2023]
|
5
|
Brink A, Libhaber E, Levin M. Renogram image characteristics and the reproducibility of differential renal function measurement. Nucl Med Commun 2021; 42:866-876. [PMID: 33741865 PMCID: PMC8279895 DOI: 10.1097/mnm.0000000000001408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/16/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Patient factors such as age and glomerular filtration rate (GFR), have been implicated as causes for poor reproducibility of differential renal function (DRF) estimates on 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) renography. This study aims to investigate factors associated with the reproducibility of DRF measurements. METHODS The association between age, GFR and imaged derived image characteristics and reproducibility of repeated DRF estimates calculated using the area under the curve method and the Rutland Patlak method was analysed for cohort 1 (n = 127). The association between these variables and reproducibility of DRF was tested with univariate linear regression. The univariate linear regression results were used to plan the multiple linear regression combinations.The associations between variables identified and reproducibility of DRF values were then tested in a second cohort (n = 227). RESULTS The R2 values for goodness-to-fit for the multiple regression models ranged from 0.33 to 0.49 for cohort 1 and from 0.17 to 0.22 for cohort 2. Left kidney to background ratio (LKTBR) was significant in all the multiple linear regression combinations (P < 0.05). Right kidney to background ratio (RKTBR), right renal margins well defined, right renal margins poorly visualised, time visualisation right calyces and age were significant in most combinations. The reproducibility of DRF measurement was decreased when the kidney to background ratio (KTBR) was ≤2. CONCLUSION Only LKTBR, RKTBR, right renal margins well defined, time visualisation right calyces and age predicted reproducibility for the measurement of DRF on 99mTc-MAG3 renograms. The KTBR should be incorporated into the renal processing software as a quality control step. The DRF values should be interpreted with caution if the KTBR is ≤2.0.
Collapse
Affiliation(s)
- Anita Brink
- Division of Nuclear Medicine, Department of Paediatrics, University of Cape Town, Cape Town
| | - Elena Libhaber
- Department of Research Methodology and Statistics, Faculty of Health Sciences, School of Clinical Medicine and Health Sciences Research Office, University of Witwatersrand, Braamfontein, Johannesburg
| | - Michael Levin
- Division of Paediatric Allergy, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
6
|
Sharma GR, Panda A, Sharma AG. Renal cortical transit time in the evaluation of prenatally detected presumed pelvi ureteric junction like obstruction: A systematic review. Indian J Urol 2021; 37:116-124. [PMID: 34103793 PMCID: PMC8173951 DOI: 10.4103/iju.iju_236_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/12/2020] [Accepted: 08/09/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Differentiating nonobstructive from obstructive dilatation of the kidney is a clinical dilemma in prenatally detected hydronephrosis. Many radionuclide renogram parameters have been used to differentiate obstructed from non-obstructed units, including cortical transit time (CTT). We evaluate the role of CTT in identifying obstruction through a systematic review. Methods A literature search of the MEDLINE, MEDLINE In-Process, and MEDLINE Epub Ahead of Print, EMBASE, Google scholar, Pub Med, and Cochrane Library was done using key words - radionuclide renogram, CTT, parenchymal transit time, cortical transit, renography to identify articles on the subject. The identified articles were assessed for appropriateness and reviewed. Results The initial search yielded a total of 1583 articles, after adding the articles from references and applying the inclusion and exclusion criteria a total of 28 articles were selected. CTT showed good inter observer agreement in identifying obstruction. The use of CTT as a single parameter for determining the need for surgery and to identify those kidneys which will have functional improvement after surgery has been evaluated and has been found to be useful. CTT is best used in conjunction with ultrasonography to make clinical decisions. Conclusion The commonly used visual method of estimating the CTT, is a promising parameter for the evaluation of prenatally detected pelviureteric junction obstruction. Further well-designed multicenter prospective studies are needed to establish it as the most specific parameter to differentiate obstructive from nonobstructive dilatation of the pelvicalyceal system.
Collapse
Affiliation(s)
| | - Arabind Panda
- Department of Urology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | | |
Collapse
|
7
|
Devarakonda CKV, Shearier ER, Hu C, Grady J, Balsbaugh JL, Makari JH, Ferrer FA, Shapiro LH. A novel urinary biomarker protein panel to identify children with ureteropelvic junction obstruction - A pilot study. J Pediatr Urol 2020; 16:466.e1-466.e9. [PMID: 32620509 PMCID: PMC7529974 DOI: 10.1016/j.jpurol.2020.05.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVE Reliable urinary biomarker proteins would be invaluable in identifying children with ureteropelvic junction obstruction (UPJO) as the existing biomarker proteins are inconsistent in their predictive ability. Therefore, the aim of this study was to identify consistent and reliable urinary biomarker proteins in children with UPJO. METHODS To identify candidate biomarker proteins, total protein from age-restricted (<2 years) and sex-matched (males) control (n = 22) and UPJO (n = 21) urine samples was analyzed by mass spectrometry. Proteins that were preferentially identified in UPJO samples were selected (2-step process) and ranked according to their diagnostic odds ratio value. The top ten proteins with highest odds ratio values were selected and tested individually by ELISA. The total amount of each protein was normalized to urine creatinine and the median with interquartile ranges for control and UPJO samples was determined. Additionally, fold change (UPJO/Control) of medians of the final panel of 5 proteins was also determined. Finally, we calculated the average + 3(SD) and average + 4(SD) values of each of the 5 proteins in the control samples and used it as an arbitrary cutoff to classify individual control and UPJO samples. RESULTS In the first step of our selection process, we identified 171 proteins in UPJO samples that were not detected in the majority of the control samples (16/22 samples, or 72.7%). Of the 171 proteins, only 50 proteins were detected in at least 11/21 (52.4%) of the UPJO samples and hence were selected in the second step. Subsequently, these 50 proteins were ranked according to the odds ratio value and the top 10 ranked proteins were validated by ELISA. Five of the 10 proteins - prostaglandin-reductase-1, ficolin-2, nicotinate-nucleotide pyrophosphorylase [carboxylating], immunoglobulin superfamily-containing leucine-rich-repeat-protein and vascular cell adhesion molecule-1 were present at higher levels in the UPJO samples (fold-change of the median protein concentrations ranging from 2.9 to 9.4) and emerged as a panel of biomarkers to identify obstructive uropathy. Finally, the order of prevalence of the 5 proteins in UPJO samples is PTGR1>FCN2>QPRT>ISLR>VCAM1. CONCLUSION In summary, this unique screening strategy led to the identification of previously unknown biomarker proteins that when screened collectively, may reliably distinguish between obstructed vs. non-obstructed infants and may prove useful in identifying informative biomarker panels for biological samples from many diseases.
Collapse
Affiliation(s)
- Charan Kumar V Devarakonda
- Center for Vascular Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| | - Emily R Shearier
- Center for Vascular Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| | - Chaoran Hu
- Biostatistics Center, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| | - James Grady
- Biostatistics Center, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| | - Jeremy L Balsbaugh
- Proteomics and Metabolomics Facility, Center for Open Research Resources and Equipment, University of Connecticut, Storrs, CT, 06269, USA.
| | - John H Makari
- Department of Surgery, Division of Urology, University of Nebraska, Omaha, NE, 68918, USA.
| | - Fernando A Ferrer
- Center for Vascular Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA; Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
| | - Linda H Shapiro
- Center for Vascular Biology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| |
Collapse
|
8
|
Li B, McGrath M, Farrokhyar F, Braga LH. Ultrasound-Based Scoring System for Indication of Pyeloplasty in Patients With UPJO-Like Hydronephrosis. Front Pediatr 2020; 8:353. [PMID: 32714886 PMCID: PMC7343702 DOI: 10.3389/fped.2020.00353] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/28/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Previous scoring systems have used renal scan parameters to assess severity of ureteropelvic junction obstruction-like hydronephrosis (UPJO-like HN), however this information is not always reliable due to protocol variation across centers and renogram limitations. Therefore, we sought to evaluate the Pyeloplasty Prediction Score (PPS), which utilizes only baseline ultrasound measurements to predict the likelihood of pyeloplasty in infants with UPJO-like. Methods: PPS was developed using three ultrasound parameters, Society of Fetal Urology (SFU) grade, transverse anteroposterior (APD), and the absolute percentage difference of ipsilateral and contralateral renal lengths at baseline. PPS was evaluated using prospectively collected prenatal hydronephrosis data (n = 928) of patients with UPJO-HN. Children with vesicoureteral reflux. primary megaureter, other associated anomalies, bilateral HN and <3 months of follow-up were excluded. Scores were analyzed regarding its usefulness in predicting which patients would be more likely to undergo pyeloplasty. Sensitivity, specificity, likelihood ratios (LR) and receiver operating characteristic (ROC) curve were determined. Results: Of 353 patients, 275 (78%) were male, 268 (76%) had left UPJO-like HN, and 81 (23%) had a pyeloplasty. The median age at baseline was 3 months (IQR 1-5). The PPS system was highly accurate in distinguishing patients who underwent pyeloplasty using baseline ultrasound measurements (AUC: 0.902). PPS of 7 and 8 were found to have a sensitivity of 85 and 78%, and specificity of 81 and 90%, respectively. PPS of 8 was associated with a LR of 7.8, indicating that these patients were eight times more likely to undergo pyeloplasty. Conclusion: Overall, PPS could detect patients more likely to undergo pyeloplasty using baseline ultrasound measurements. Those with a PPS of eight or higher were eight times more likely to undergo pyeloplasty.
Collapse
Affiliation(s)
- Bruce Li
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Melissa McGrath
- McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, ON, Canada.,Division of Urology, McMaster University, Hamilton, ON, Canada.,McMaster Children's Hospital Foundation, Hamilton, ON, Canada
| | - Forough Farrokhyar
- McMaster Children's Hospital Foundation, Hamilton, ON, Canada.,Department of Health Research, Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Luis H Braga
- McMaster Pediatric Surgical Research Collaborative, McMaster University, Hamilton, ON, Canada.,Division of Urology, McMaster University, Hamilton, ON, Canada.,McMaster Children's Hospital Foundation, Hamilton, ON, Canada.,Department of Health Research, Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
9
|
Sharma G, Maheshwari P. Re: Elbaset MA, Ezzat O, Elgamal M, Sharaf MA, Elmeniar AM, Abdelhamid A et al. Supernormal differential renal function in adults with ureteropelvic junction obstruction: Does it really exist? Indian J Urol 2020;36:205-11. Indian J Urol 2020; 36:334-335. [PMID: 33376280 PMCID: PMC7759165 DOI: 10.4103/iju.iju_422_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/06/2020] [Indexed: 11/23/2022] Open
|
10
|
Abstract
The crucial point for prompt diagnostics, ideal therapeutic approach, and follow-up of hydronephrosis associated with UPJ anomalies in children is the severity of hydronephrosis. Such many hydronephrosis grading systems as AP diameter, SFU, radiology, UTD, and Onen have been developed to evaluate hydronephrosis severity in infants. Unfortunately, it is still an ongoing challenge and there is no consensus between different disciplines. AP diameter is a very dynamic parameter and is affected by many factors (hydration, bladder filling, position, respiration). More importantly, its measurement is very variable and misleading due to different renal pelvic configurations. The radiology grading system has the same grades 1, 2, and 3 as the SFU grading system with addition of the AP diameter for the first 3 grades. This grading system divides parenchymal loss into two different grades. Grade 4 represents mild parenchymal loss while grade 5 suggests severe parenchymal loss. However, it is operator dependent, is not decisive, and does not differentiate grades 4 and 5 clearly. All grades of SFU are very variable between operators and clinicians. UTD classification aims to put all significant abnormal urinary findings together including the kidney, ureter, and bladder and thus determines the risk level for infants with any urinary disease. Different renal deterioration risks occur depending on the mechanism of hydronephrosis. Therefore, SFU and UTD classification may result in significant confusion and misleading in determining the severity of hydronephrosis. SFU-4 and UTD-P3 represent a considerable range of severity of hydronephrosis. Both represent minimal thinning of the medullary parenchyma and severe thinning of the cortical parenchyma (cyst-like hydronephrotic kidneys) at the same grade. The wide definition of SFU-4 and UTD-P3 fails to indicate accurately the severity of hydronephrosis and thus significantly misleads from a prompt treatment. They do not suggest who need surgical treatment and who can safely be followed non-operatively. The anatomy and physiology of the 4 suborgans of the kidney (renal pelvis, calices, medulla, and cortex) are completely different from each other. Therefore, each part of the kidney affect and behave differently as a response to UPJ-type hydronephrosis (UPJHN) depending on the severity of hydronephrosis. The upgraded Onen hydronephrosis grading system has been developed based on this basic evidence both for prenatal and post-natal periods. The Onen grading system determines specific detailed findings of significant renal damage, which clearly show and suggest who can safely be followed conservatively from who will need surgical intervention for UPJHN. Neither AP diameter nor radiology, SFU, or UTD classification is the gold standard in determining the severity of hydronephrosis. All these grading systems are based on subjective parameters and are affected by many factors. They do not determine the exact severity of UPJHN and thus cause permanent renal damage due to a delay in surgical decision in some infants while they may cause an unnecessary surgery in others. The Onen grading system has resolved all disadvantages of other grading systems and promises a safer follow-up and a prompt treatment for UPJHN. It is an accurate and easily reproducible grading that has high sensitivity and specificity.
Collapse
Affiliation(s)
- Abdurrahman Onen
- Section of Pediatric Urology, Department of Pediatric Surgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| |
Collapse
|
11
|
Interobserver reproducibility of mercaptoacetyltriglicine renography in children and adults with suspected obstruction: parameters of drainage and function calculated by International Atomic Energy Agency software. Nucl Med Commun 2019; 41:96-103. [PMID: 31860527 DOI: 10.1097/mnm.0000000000001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this study was to estimate interobserver reproducibility of Tc-99m mercaptoacetyltriglycine renography in children and adults by assessing the parameters of the International Atomic Energy Agency (IAEA) software for the analysis of dynamic renal studies. METHODS The renograms of 65 children and 65 adults covered a wide age range, different quality of drainage, overall function and differential renal function (DRF). Three observers were processing parameters of the IAEA software. Normalized residual activity at 20 min (NORA20), NORA on the postmicturition acquisition (NORApm), PM to maximum renal count ratio (PM/max), output efficiency at 20 min (OE20), OE 20 min after diuretic stimulation (OEF + 20), whole kidney mean transit time (MTT) and DRF by integral and Rutland-Patlak were calculated by observers. RESULTS The overall agreement between three observers was almost perfect [the average intraclass correlation coefficient (ICC) above 0.99] in children and adults, with no significant difference between the parameters of renal drainage, transit and DRF. ICCs for all parameters were higher than 0.980 in children under 12 months, even slightly greater for PM/max and OEF+20. In children with poor/incomplete drainage and DRF below 40%, ICCs were above 0.98. In the subgroup of adults with impaired overall tubular extraction rate, level of reproducibility was almost perfect. Slightly lower but still insignificant values of ICC were presented in adults with poor/incomplete drainage. CONCLUSION Our results indicate an excellent interobserver reproducibility for all quantitative parameters of IAEA software in both pediatric and adult patients.
Collapse
|
12
|
Vemulakonda VM, Hamer MK, Kempe A, Morris MA. Surgical decision-making in infants with suspected UPJ obstruction: stakeholder perspectives. J Pediatr Urol 2019; 15:469.e1-469.e9. [PMID: 31239100 PMCID: PMC6884651 DOI: 10.1016/j.jpurol.2019.05.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/22/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Although there are significant demographic and clinical variations in treatment decisions for infants with high-grade hydronephrosis concerning for ureteropelvic junction obstruction (UPJO), there has been little research on the roles of parents and surgeons in the surgical decision-making (DM) process. OBJECTIVE The purpose of this study was to understand parents' and surgeons' perceived roles in the surgical DM process for infants with high-grade hydronephrosis. STUDY DESIGN Semistructured interviews were conducted with pediatric urologists from three regionally diverse tertiary referral sites and parents of infants diagnosed and treated for unilateral Society for Fetal Urology grade 3 or 4 hydronephrosis at one tertiary pediatric urology practice. Purposive sampling was used to ensure adequate representation of parents based on treatment choice, patient gender, race/ethnicity, and distance from the practice. Survey domains included (1) discussions about diagnosis and treatment options, (2) factors guiding treatment choice, and (3) participants' role in the DM process. Transcribed data and field notes were analyzed using a team-based, inductive grounded theory qualitative approach. RESULTS Thirteen physicians and 32 parents were interviewed between November 2016 and November 2017. Parents and surgeons agreed that the surgeon was best equipped to guide treatment decisions because of their clinical knowledge and experience. Parents reported that their trust in the surgeon was the primary factor in their decisions. Surgeons reported tailoring discussions with parents to not only educate them about treatment options but also to develop an ongoing relationship with parents. Both parents and surgeons reported being satisfied with their roles in the DM process. DISCUSSION This study suggests that parental trust in the surgeon and surgeon recommendations drive DM. This may be due to a lack of explicit discussion of options or of parental values and preferences for care. Limited discussions may also impact parental understanding of risks and potential complications. These findings are similar to those of prior studies in adults and children considering elective surgery. CONCLUSIONS In this study, parents and surgeons reported that surgeon recommendations, rather than parent preferences, guide treatment choices for infants with suspected UPJO. Both parents and surgeons are satisfied with a physician-driven approach to DM, suggesting that, in situations where the perceived risk is low and parental knowledge is limited, parents may find a physician-led approach beneficial. Data gleaned from this study will be used to inform future quantitative studies evaluating factors guiding surgeon recommendations for treatment and their associations with underlying treatment variation.
Collapse
Affiliation(s)
- V M Vemulakonda
- Department of Pediatric Urology, Children's Hospital Colorado; Division of Urology, Department of Surgery, University of Colorado School of Medicine, USA.
| | - M K Hamer
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, USA
| | - A Kempe
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, USA
| | - M A Morris
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, USA
| |
Collapse
|
13
|
Suriyanto S, Ng EYK, Ng CED, Yan XS, Verma NK. 99mTc-MAG 3 diuresis renography in differentiating renal obstruction: Using statistical parameters as new quantifiable indices. Comput Biol Med 2019; 112:103371. [PMID: 31404720 DOI: 10.1016/j.compbiomed.2019.103371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/25/2019] [Accepted: 07/25/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to research, develop and assess the feasibility of using basic statistical parameters derived from renogram, "mean count value (MeanCV) and "median count value (MedianCV)", as novel indices in the diagnosis of renal obstruction through diuresis renography. SUBJECTS AND METHODS First, we re-digitalized and normalized 132 renograms from 74 patients in order to derive the MeanCV and MedianCV. To improve the performance of the parameters, we extrapolated renograms by a two-compartmental modeling. After that, the cutoff points for diagnosis using each modified parameter were set and the sensitivity and specificity were calculated in order to determine the best variants of MeanCV and MedianCV that could differentiate renal obstruction status into 3 distinct classes - i) unobstructed, ii) slightly obstructed, and iii) heavily obstructed. RESULTS The modified MeanCV and MedianCV derived from extended renograms predicted the severity of the renal obstruction. The most appropriate variants of MeanCV and MedianCV were found to be the MeanCV50 and the MedianCV60. The cutoff points of MeanCV50 in separating unobstructed and obstructed classes as well as slightly and heavily obstructed classes were 0.50 and 0.72, respectively. The cutoff points of MedianCV60 in separating unobstructed and obstructed classes as well as slightly and heavily obstructed classes were 0.35 and 0.69, respectively. Notably, MeanCV50 and MedianCV60 were not significantly influenced by either age or gender. CONCLUSIONS The MeanCV50 and the MedianCV60 derived from a renogram could be incorporated with other quantifiable parameters to form a system that could provide a highly accurate diagnosis of renal obstructions.
Collapse
Affiliation(s)
- S Suriyanto
- NTU Institute for Health Technologies, Interdisciplinary Graduate School, Nanyang Technological University, Singapore; School of Mechanical and Aerospace Engineering, College of Engineering, Nanyang Technological University, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| | - E Y K Ng
- School of Mechanical and Aerospace Engineering, College of Engineering, Nanyang Technological University, Singapore.
| | - C E David Ng
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore.
| | - Xuexian Sean Yan
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore.
| | - N K Verma
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| |
Collapse
|
14
|
Simal CJR. 99mTc-DTPA Diuretic Renography with 3 hours late output fraction in the evaluation of hydronephrosis in children. Int Braz J Urol 2018; 44:577-584. [PMID: 29368879 PMCID: PMC5996805 DOI: 10.1590/s1677-5538.ibju.2017.0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 11/15/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: Dynamic renal scintigraphy complemented by late gravity assisted postvoid images to 60 minutes is a frequently used diagnostic test in the evaluation of hydrone- phrosis. The objective of this study is to evaluate the effectiveness in acquiring images at 180 minutes to calculate the late output fraction (LOF) of 99mTc-DTPA in the diagno- sis of ureteropelvic junction obstruction (UPJO). Materials and Methods: A retrospective study of 177 patients (196 renal units) of sus- pected cases of clinical UPJO was conducted. The patients were submitted to at least two dynamic renal scintigraphies of 99mTc-DTPA, with the addition of furosemide (F0), with a mean age of 4.3±3.8 years for the first study, and a follow-up of 2.7±2.5 years. Results: For diagnosis based on renal curves, a 100% sensitivity, 82.2% specificity, positive predictive value (PPV) of 10.4% and negative predictive value (NPV) of 100% were estimated. For diagnosis based on LOF, a 100% sensitivity, 96.3% specificity, PPV of 35.7% and NPV of 100% were estimated. Conclusion: A LOF <10% is indicative of UPJO, and a LOF ≥15% is indicative of no UPJO. The data demonstrate that LOF presents equivalent sensitivity and NPV, and higher specificity and PPV in comparison to diagnosis based on renal curves, and is useful in the evaluation and follow-up of suspected cases of UPJO.
Collapse
Affiliation(s)
- Carlos J. R. Simal
- Universidade Federal de Minas Gerais, Brasil; Hospital Felicio Rocho, Brasil
| |
Collapse
|
15
|
Blum ES, Porras AR, Biggs E, Tabrizi PR, Sussman RD, Sprague BM, Shalaby-Rana E, Majd M, Pohl HG, Linguraru MG. Early Detection of Ureteropelvic Junction Obstruction Using Signal Analysis and Machine Learning: A Dynamic Solution to a Dynamic Problem. J Urol 2018; 199:847-852. [DOI: 10.1016/j.juro.2017.09.147] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Emily S. Blum
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, D. C
- Division of Urology, Children’s National Health System, Washington, D. C
| | - Antonio R. Porras
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, D. C
| | - Elijah Biggs
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, D. C
| | - Pooneh R. Tabrizi
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, D. C
| | - Rachael D. Sussman
- Division of Urology, MedStar Georgetown University Hospital, Washington, D. C
| | - Bruce M. Sprague
- Division of Urology, Children’s National Health System, Washington, D. C
| | - Eglal Shalaby-Rana
- Department of Radiology, Children’s National Health System, Washington, D. C
| | - Massoud Majd
- Department of Radiology, Children’s National Health System, Washington, D. C
| | - Hans G. Pohl
- Division of Urology, Children’s National Health System, Washington, D. C
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, D. C
- Departments of Radiology and Pediatrics, School of Medicine and Health Science, George Washington University, Washington, D. C
| |
Collapse
|
16
|
Otero HJ, Cerrolaza JJ, Loomis J, George A, Biggs E, Jago J, Linguraru MG. Feasibility and Quality Determinants of 3D Sonography in Children With Hydronephrosis. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2018. [DOI: 10.1177/8756479317717201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective was to determine the image quality of 3D diagnostic medical sonography (DMS) in children with hydronephrosis. 3D DMS was assessed based on 24 pediatric patients. Image quality was evaluated by two radiologists and a sonographer in terms of rib shadowing, cut-off parenchymal edges, motion artifact, and overall quality. The interreader reliability and relation between image quality and other variables were calculated. The results were based on images of 32 hydronephrotic kidneys. The average quality scoring of the images was quite high. Rib shadowing, cut-off edges, and motion artifact were present in the majority of the cases. The interreader reliability for overall quality, rib shadowing, cut-off, and motion was quite high. There was a correlation between the Society for Fetal and Neonatal Urology’s hydronephrosis grade and higher cut-off edges. Larger kidneys were more likely to show cut-off, motion, and lower quality scores. In this cohort of infants and toddlers with hydronephrotic kidneys, 3D DMS demonstrated good image quality; however, artifacts were attributed to kidney size and severity of hydronephrosis.
Collapse
Affiliation(s)
- Hansel J. Otero
- Department of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, DC, USA
| | - Juan J. Cerrolaza
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC, USA
| | - Judyta Loomis
- Department of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, DC, USA
| | - Amanda George
- Department of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, DC, USA
| | - Elijah Biggs
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC, USA
| | | | - Marius G. Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC, USA
| |
Collapse
|
17
|
Li X, Liu X, Li J, Song EL, Sun N, Liu W, Wang T, Yang J, Li Z. Semaphorin-3A and Netrin-1 predict the development of kidney injury in children with congenital hydronephrosis. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 78:55-61. [DOI: 10.1080/00365513.2017.1411972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Xiaobing Li
- School of Basic Medicine, Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Xianghua Liu
- Pathological Experiment Center, Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Ji Li
- Pediatric Urology Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
| | - ELi Song
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, PR China
| | - Ning Sun
- Pathological Experiment Center, Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Wen Liu
- School of Basic Medicine, Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Tian Wang
- School of Basic Medicine, Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Jinchang Yang
- School of Basic Medicine, Henan University of Traditional Chinese Medicine, Zhengzhou, PR China
| | - Zhenzhen Li
- Nephrology Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
| |
Collapse
|
18
|
Weitz M, Schmidt M, Laube G. Primary non-surgical management of unilateral ureteropelvic junction obstruction in children: a systematic review. Pediatr Nephrol 2017; 32:2203-2213. [PMID: 28012005 DOI: 10.1007/s00467-016-3566-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 12/21/2022]
Abstract
Ureteropelvic junction obstruction (UPJO) is the most common obstructive uropathy and its optimal management remains controversial. However, there is a current trend towards non-surgical management. We aimed to determine the effects of the non-surgical management in children with unilateral UPJO. For a systematic review, we searched MEDLINE, EMBASE, CENTRAL, clinical trials registries, and selected conference proceedings for eligible studies. Any type of study reporting the outcomes renal function, secondary surgical intervention, drainage pattern or hydronephrosis of non-surgical management in children with unilateral UPJO was included. Data from 20 studies were extracted and evaluated by two independent authors. The pooled prevalence was 21% for split renal function deterioration, 27.9% for secondary surgical intervention, 3.2% for progressive hydronephrosis, and 82.2% for improved drainage pattern. Not all patients with surgical intervention regained split renal function from enrolment. Renal imaging methods did not strongly correlate with each other. Many studies had to be excluded because of a lack of detection of an obstruction or mixed populations with bilateral UPJO or other uropathies. The variable definitions of UPJO, different criteria for surgical intervention, incongruity of management protocols, and the imprecise reporting of outcomes were limiting factors in the comparability of the results, leading to heterogeneity in meta-analyses. Although the available evidence cannot recommend or refute the current non-surgical management, the systematic review clarifies aspects of the ongoing controversy by providing realistic estimates for non-surgical management in children with unilateral UPJO. Additionally, it reveals unclear potential risks, particularly for long-term outcomes, which were rarely reported.
Collapse
Affiliation(s)
- Marcus Weitz
- Department of Nephrology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
| | - Maria Schmidt
- Department of Nephrology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Guido Laube
- Department of Nephrology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| |
Collapse
|
19
|
Imaging in children with unilateral ureteropelvic junction obstruction: time to reduce investigations? Eur J Pediatr 2017; 176:1173-1179. [PMID: 28711954 DOI: 10.1007/s00431-017-2966-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/05/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED The objective of the study was the development of an abridged risk-stratified imaging algorithm for the management of children with unilateral ureteropelvic junction obstruction (UPJO). Data on timing, frequency and duration of diagnostic imaging in children with unilateral UPJO was extracted retrospectively. Based on these findings, an abridged imaging algorithm was developed without changing the intended management by the clinicians and the outcome of the individual patient. The potential reduction of imaging studies was analysed and stratified by risk and management groups. The reduction in imaging studies, seen for ultrasound (US) and functional imaging (FI), was 45% each. On average, this is equivalent to 3 US and 1 FI studies less for every patient within the study period. The change was more pronounced in the low-risk groups. Progression of UPJO never occurred after 2 years of age and all secondary surgeries were carried out until the age of 3. CONCLUSIONS Although our findings need to be validated by further prospective research, the developed imaging algorithm represents a risk-stratified approach towards less imaging studies in children with unilateral UPJO, and a follow-up beyond 3 years of age should be considered only in selected cases at the discretion of the clinician. What is Known: • ultrasound and functional imaging represent an integral part of therapeutic decision-making in children with unilateral ureteropelvic junction obstruction • imaging studies cannot accurately assess which patients are in need of surgical intervention, therefore close, serial imaging is preferred What is New: • a new, risk-stratified imaging algorithm was developed for the first 3 years of life • applying this algorithm could lead to a considerable reduction of imaging studies, and also the associated risks and health-care costs.
Collapse
|
20
|
Sharma G, Sharma A. Usefulness of Ultrasonography and Cortical Transit Time to Differentiate Nonobstructive From Obstructive Dilatation in the Management of Prenatally Detected Pelvic Ureteric Junction Like Obstruction. Urology 2017; 110:208-212. [PMID: 28823637 DOI: 10.1016/j.urology.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 07/30/2017] [Accepted: 08/02/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To differentiate a nonobstructive dilatation from an obstructive dilatation in prenatally detected presumed pelvi-ureteric junction obstruction so that intervention can be planned before irreversible damage can occur to the renal unit. MATERIALS AND METHODS From January 2012 to December 2016, all patients with prenatally detected or asymptomatic incidentally detected presumed pelvi-ureteric junction obstruction were evaluated by ultrasonography and renogram. The anteroposterior diameter of the renal pelvis was measured in supine and prone position. Presence of calyceal dilatation in prone position was noted. They were categorized into obstructed, nonobstructed, and equivocal groups based on sonography findings. The differential renal function and the cortical transit time (CTT) was calculated and compared with the sonography groups. RESULTS Of the 98 patients, 72 were in the obstructed, 18 were in the nonobstructed, and 8 were in the equivocal category. All except 1 in the nonobstructed category had a function of >40% with CTT of <3 minutes. Seventy patients in the obstructed category had a CTT of >3 minutes, whereas 61 had function <40% on initial evaluation. Eleven patients in the obstructed category with an initial function of >40% had CTT of >3 minutes. All of them showed increasing hydronephrosis and deterioration of function during follow-up, necessitating pyeloplasty. All patients in the equivocal group had function >40% and CTT <3 minutes. CONCLUSION Ultrasonography along with CTT can help to differentiate nonobstructive from obstructive dilatation.
Collapse
Affiliation(s)
| | - Anshu Sharma
- Chitale Clinic Pvt. Ltd., Solapur, Maharashtra, India
| |
Collapse
|
21
|
Mendichovszky I, Solar BT, Smeulders N, Easty M, Biassoni L. Nuclear Medicine in Pediatric Nephro-Urology: An Overview. Semin Nucl Med 2017; 47:204-228. [PMID: 28417852 DOI: 10.1053/j.semnuclmed.2016.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the context of ante-natally diagnosed hydronephrosis, the vast majority of children with a dilated renal pelvis do not need any surgical treatment, as the dilatation resolves spontaneously with time. Slow drainage demonstrated at Tc-99m-mercaptoacetyltriglycine (MAG3) renography does not necessarily mean obstruction. Obstruction is defined as resistance to urinary outflow with urinary stasis at the level of the pelvic-ureteric junction (PUJ) which, if left untreated, will damage the kidney. Unfortunately this definition is retrospective and not clinically helpful. Therefore, the identification of the kidney at risk of losing function in an asymptomatic patient is a major research goal. In the context of renovascular hypertension a DMSA scan can be useful before and after revascularisation procedures (angioplasty or surgery) to assess for gain in kidney function. Renal calculi are increasingly frequent in children. Whilst the vast majority of patients with renal stones do not need functional imaging, DMSA scans with SPECT and a low dose limited CT can be very helpful in the case of complex renal calculi. Congenital renal anomalies such as duplex kidneys, horseshoe kidneys, crossed-fused kidneys and multi-cystic dysplastic kidneys greatly benefit from functional imaging to identify regional parenchymal function, thus directing further management. Positron emission tomography (PET) is being actively tested in genito-urinary malignancies. Encouraging initial reports suggest that F-18-fluorodeoxyglucose (FDG) PET is more sensitive than CT in the assessment of lymph nodal metastases in patients with genito-urinary sarcomas; an increased sensitivity in comparison to isotope bone scans for skeletal metastatic disease has also been reported. Further evaluation is necessary, especially with the promising advent of PET/MRI scanners. Nuclear Medicine in paediatric nephro-urology has stood the test of time and is opening up to new exciting developments.
Collapse
Affiliation(s)
- Iosif Mendichovszky
- Department of Radiology, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | | | - Naima Smeulders
- Department of Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marina Easty
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lorenzo Biassoni
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| |
Collapse
|
22
|
Abstract
The article presents common pitfalls encountered in pediatric radionuclide renography, illustrated with clinical cases. It is important to recognize normal variants. A good acquisition technique is essential. Correlation with other imaging techniques, with the clinical background and symptoms, is critical. A clear clinical question is essential: based on the question and knowing the strengths and weaknesses of each test, the test which can best answer the question can be selected. Awareness of the pitfalls of radionuclide renography helps avoid errors of interpretation and allows the selection of the most helpful test for clinical management.
Collapse
Affiliation(s)
- Lorenzo Biassoni
- Dept of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| |
Collapse
|
23
|
Ballouhey Q, Lescure V, Larradet M, El-Badaoui A, Grimaudo Benaïssa A, Guigonis V, Monteil J, Verbeke S, Fourcade L. [Pitfalls for renogram interpretation in pediatric urology]. Arch Pediatr 2015; 23:66-70. [PMID: 26481045 DOI: 10.1016/j.arcped.2015.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 05/11/2015] [Accepted: 09/20/2015] [Indexed: 11/25/2022]
Abstract
Renograms are currently used for functional assessment by pediatric urologists. The aim of the present work was to focus on the potential pitfalls concerning renography. Potential confounding factors are described in reference to concrete cases. The main types of pitfalls concern venous or urinary catheters and background area definition. Protocols and renogram interpretation are critiqued in a bibliographic review. We propose a technical update and original data on the potential pitfalls in renography interpretation. Multidisciplinary discussion between nuclear medicine, pediatrics and pediatric surgery departments is required before drawing conclusions.
Collapse
Affiliation(s)
- Q Ballouhey
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France.
| | - V Lescure
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| | - M Larradet
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - A El-Badaoui
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - A Grimaudo Benaïssa
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| | - V Guigonis
- Service de pédiatrie, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| | - J Monteil
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - S Verbeke
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - L Fourcade
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| |
Collapse
|
24
|
Ultrasound of the paediatric urogenital tract. Eur J Radiol 2014; 83:1538-48. [DOI: 10.1016/j.ejrad.2014.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/07/2014] [Indexed: 02/04/2023]
|
25
|
Validation of IAEA software package for the analysis of scintigraphic renal dynamic studies: parameters of renal transit in children with renal pelvic dilatation. Clin Nucl Med 2014; 39:598-604. [PMID: 24873786 DOI: 10.1097/rlu.0000000000000470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The objectives of the study were to use the International Atomic Energy Agency (IAEA) software package for the analysis of scintigraphic renal dynamic studies to obtain values of curve parameters and excretory parameters in children with hydronephrosis and to validate the reliability of these numerical outputs by comparing with values established by consensus reports. PATIENTS AND METHODS Fifty children with hydronephrosis (median age, 16 months; 30 boys, 20 girls; 99 kidneys) underwent Tc-MAG3 diuresis renography. Studies were analyzed by 2 observers, and according to the assessment of images, renograms, and differential function, kidneys were classified as normal (42, kidneys contralateral to hydronephrotic kidney), hypotonic unobstructed (49), and obstructed (8). The IAEA software was applied to each renogram. The parameters analyzed were as follows: normalized residual activity at 20 minutes (NORA 20) and on postmicturition (PM) acquisition, output efficiency at 20 minute (OE 20), PM to maximum renal count ratio (PM/max), and mean transit time (MTT). RESULTS Mean values for normal, hypotonic unobstructed, and obstructed kidneys were as follows: NORA 20: 0.25, 0.57, and 2.16; OE 20 (%): 94.5, 87, and 57; normalized residual activity on PM acquisition: 0.02, 0.03, and 0.27; PM/max: 0.01, 0.02, and 0.13; and MTT (minutes): 1.9, 3.5, and 8.9, respectively. Difference between obstruction/dilatation and normal/dilatation was significant (P < 0.0001), as well as the correlation between NORA 20/OE 20 (R = -0.982). Cutoff values to predict obstruction were as follows: NORA 20, 1.6; OE 20, 73%; NORA PM, 0.11; PM/max, 0.06; and MTT, 8.23 minutes. CONCLUSIONS The IAEA software package gives reliable values of numerical parameters of renal excretion. The use of the software improves diagnostic accuracy of diuresis renography in children.
Collapse
|
26
|
Sanavi C, Dacher JN, Caudron J, Dolores M, Liard A, Vivier PH. Supranormal differential renal function in unilateral hydronephrotic kidney: Insights from functional MR urography. J Magn Reson Imaging 2013; 40:577-82. [DOI: 10.1002/jmri.24440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 08/23/2013] [Indexed: 12/26/2022] Open
Affiliation(s)
- Claire Sanavi
- CHU C. Nicolle; Service d'imagerie pédiatrique et fœtale; Rouen Cedex France
| | - Jean-Nicolas Dacher
- CHU C. Nicolle; Service d'imagerie pédiatrique et fœtale; Rouen Cedex France
- Université de Rouen; INSERM U1096; Rouen Cedex France
| | - Jérome Caudron
- CHU C. Nicolle; Service d'imagerie pédiatrique et fœtale; Rouen Cedex France
- Université de Rouen; INSERM U1096; Rouen Cedex France
| | - Michael Dolores
- CHU C. Nicolle; Service d'imagerie pédiatrique et fœtale; Rouen Cedex France
| | - Agnès Liard
- CHU C. Nicolle; Service de chirurgie pédiatrique; Rouen Cedex France
| | - Pierre-Hugues Vivier
- CHU C. Nicolle; Service d'imagerie pédiatrique et fœtale; Rouen Cedex France
- QuantIF - LITIS [UPRES EA 4108]; Université de Rouen; France
| |
Collapse
|
27
|
|
28
|
Sinha A, Bagga A, Krishna A, Bajpai M, Srinivas M, Uppal R, Agarwal I. Revised guidelines on management of antenatal hydronephrosis. Indian J Nephrol 2013; 23:83-97. [PMID: 23716913 PMCID: PMC3658301 DOI: 10.4103/0971-4065.109403] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Widespread antenatal screening has resulted in increased detection of anomalies of the kidneys and urinary tract. The present guidelines update the recommendations published in 2000. Antenatal hydronephrosis (ANH) is transient and resolves by the third trimester in almost one-half cases. The presence of oligohydramnios and additional renal or extrarenal anomalies suggests significant pathology. All patients with ANH should undergo postnatal ultrasonography; the intensity of subsequent evaluation depends on anteroposterior diameter (APD) of the renal pelvis and/or Society for Fetal Urology (SFU) grading. Patients with postnatal APD exceeding 10 mm and/or SFU grade 3-4 should be screened for upper or lower urinary tract obstruction and vesicoureteric reflux (VUR). Infants with VUR should receive antibiotic prophylaxis through the first year of life, and their parents counseled regarding the risk of urinary tract infections. The management of patients with pelviureteric junction or vesicoureteric junction obstruction depends on clinical features and results of sequential ultrasonography and radionuclide renography. Surgery is considered in patients with increasing renal pelvic APD and/or an obstructed renogram with differential renal function <35-40% or its subsequent decline. Further studies are necessary to clarify the role of prenatal intervention, frequency of follow-up investigations and indications for surgery in these patients.
Collapse
Affiliation(s)
- A. Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, India
| | - A. Bagga
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, India
| | - A Krishna
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Ansari Nagar, India
| | - M. Bajpai
- Max Institute of Pediatrics and Pediatric Surgery, Vellore, Tamil Nadu, India
| | - M. Srinivas
- Max Institute of Pediatrics and Pediatric Surgery, Vellore, Tamil Nadu, India
| | - R. Uppal
- Uppal Radiology Center, Christian Medical College, Vellore, Tamil Nadu, India
| | - I. Agarwal
- Pediatrics, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
29
|
[(99m)Tc-MAG3 diuretic renography in assessment of obstructive uropathy. The new test F+10SP: a step ahead in the differential diagnosis]. Urologia 2011; 78:221-6. [PMID: 21948140 DOI: 10.5301/ru.2011.8633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND Dilation of the renal pelvis is a problem Urologists have often to deal with. One of the key aspects is to clear if the dilation is the consequence of an obstruction to the outflow or a simple anatomic variant. Aim of this study was to compare two diuretic renographic procedures, F-15 vs the new procedure F+10SP (Seated Position) in a group of hydronephrotic patients, in order to increase the accuracy in the differential diagnosis between non-obstructive and obstructive dilation. MATERIALS AND METHODS 34 Patients (14 male, 20 female, 18-71 yrs range), 27 pts having an unilateral hydronephrosis and 7 pts a bilateral hydronephrosis diagnosed by ultrasound, were enclosed in the study. They were subjected to two 99mTc-MAG3 diuretic renography with furosemide consecutively, with different modalities: 1) 40 mg of furosemide were administered IV to patient in supine position 15 minutes before tracer injection (Test F-15, by English); 2) the new procedure: 20 mg of furosemide were administered IV to patient in Seated Position (SP), 10 minutes after tracer injection during dynamic acquisition (Test F+10 SP). The average interval between the two tests was 7 days. Two different physicians analyzed all the tests. The results were classified as: non-obstruction (only F+10SP can distinguish between normal and dilated without obstruction), obstruction, equivocal and not applicable. RESULTS Among the 68 renal units (RU) included in the analysis, the F+10SP test showed normal findings in 21 RU (30,8%), dilation without obstruction in 21 RU (30,8%), obstruction in 25 RU (36.8%) and equivocal result in 1 RU. The F-15 renography showed non-obstructive results in 35 RU (51.5%), obstruction in 20 RU (29.4%) and equivocal findings in 11 RU (16.1%); the test was not applicable in 2 RU (2.9%) due to insufficient renal function. Side effects reported for the F-15 renogram were hypotension in 1 patient, renal colic in 3 patients, bladder filling in 13 patients, disruption because of voiding in 4 patients. No complications were observed during or after the F+10SP renography. The 20 RU diagnosed with obstruction at the F-15 test were considered obstructed also at the F+10SP test. CONCLUSIONS The "equivocal" test rate lowered from 16% for the F-15 test to less than 1.5% for the new F+10 SP test. The F+10SP procedure is easy, well tolerated, time saving and seems to be a more reliable tool in assessment of obstructive uropathy in adults.
Collapse
|
30
|
Freeman LM, Blaufox MD. Letter from the editors: radionuclides in nephrourology. Semin Nucl Med 2010; 41:1-2. [PMID: 21111854 DOI: 10.1053/j.semnuclmed.2010.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|