Clinical Spectrum of Congenital Anomalies of Kidney and Urinary Tract in Children

OBJECTIVES

To evaluate the clinical spectrum and patterns of clinical presentation in congenital anomalies of kidney and urinary tract.

METHODS

We enrolled 307 consecutively presenting children with congenital anomalies of kidney and urinary tract at the pediatric nephrology clinic. Patients were evaluated clinically, with serum biochemistry, appropriate imaging and radionuclide scans.

RESULTS

The most common anomaly was primary vesicoureteric reflux (VUR) (87, 27.3%), followed by pelviureteral junction obstruction (PUJO) (62,20.1%), multicystic dysplastic kidney (51 16.6%), non-obstructive hydronephrosis (32, 10.4%) and posterior urethral valves (PUV) (23, 7.4%). 247 (80.4%) anomalies had been identified during the antenatal period. Another 33 (10.7%) were diagnosed during evaluation of urinary tract infection, and 21 (6.8%) during evaluation for hypertension at presentation. Obstructive anomalies presented earlier than non-obstructive (7 (3, 22.5) vs 10 (4, 24) mo: (P=0.01)). The median (IQR) ages of presentation for children with PUV (n=23), VUR (n=87) and PUJO (n=62) were 4 (2, 14) mo, 10 (5, 27) mo, and 7 (3, 22.5) mo, respectively. Nine (2.9%) children had extrarenal manifestations.

CONCLUSIONS

The median age at clinical presentation for various subgroups of anomalies indicates delayed referral. We emphasize the need for prompt referral in order to initiate appropriate therapeutic strategies in children with congenital anomalies of kidney and urinary tract.

Evaluation of the patient with asymptomatic microscopic hematuria

Asymptomatic microscopic hematuria (AMH) is relatively common in clinical practice but the etiology remains unclear in the majority of patients; it is rarely related to genitourinary malignancies. The 2012 guidelines of the American Urological Association recommend an evaluation after a single positive urinalysis with mandatory upper tract evaluation in all patients, preferably with CT urography (CTU). The likelihood of detecting significant upper track abnormalities, particularly malignancies is low with CTU, while incidental extraurinary abnormalities are often found, the majority of which are not clinically significant. The workup for these incidental findings has significant financial and clinical implications. Primary care physicians, who are most apt to encounter patients with AMH, have a low rate of adherence to the AUA guidelines, possibly as a result of the broadening of criteria for AMH evaluation by the AUA, with resultant uncertainty amongst primary care physicians about the appropriate candidates for such evaluation. Selection of subgroups of patients with risk factors for GU malignancies who may benefit from a complete evaluation is essential, as opposed to evaluation of all patients classified as having AMH.

Paediatric urological investigations--dose comparison between urology-related and CT irradiation

BACKGROUND

Urological investigation in children frequently involves high radiation doses; however, the issue of radiation for these investigations receives little attention compared with CT.

OBJECTIVE

To compare the radiation dose from paediatric urological investigations with CT, which is commonly regarded as the more major source of radiation exposure.

MATERIALS AND METHODS

We conducted a retrospective audit in a tertiary paediatric centre of the number and radiation dose of CT scans, micturating cystourethrography exams and urological nuclear medicine scans from 2006 to 2011. This was compared with radiation doses in the literature and an audit of the frequency of these studies in Australia.

RESULTS

The tertiary centre audit demonstrated that the ratio of the frequency of urological to CT examinations was 0.8:1 in children younger than 17 years. The ratio of the radiation dose of urological to CT examinations was 0.7:1. The ratio in children younger than 5 years was 1.9:1. In Australia the frequency of urological procedures compared with CT was 0.4:1 in children younger than 17 years and 3.1:1 in those younger than 5 years. The ratio of radiation-related publications was 1:9 favouring CT.

CONCLUSION

The incidence and radiation dose of paediatric urological studies is comparable to those of CT. Nevertheless the radiation dose of urological procedures receives considerably less attention in the literature.

Procalcitonin to reduce the number of unnecessary cystographies in children with a urinary tract infection: a European validation study

OBJECTIVE

To validate high serum procalcitonin (PCT) as a predictor of vesicoureteral reflux (VUR) in children with a first febrile urinary tract infection (UTI).

STUDY DESIGN

This secondary analysis of prospective hospital-based cohort studies included children ages 1 month to 4 years with a first febrile UTI.

RESULTS

Of the 398 patients included in 8 centers in 7 European countries, 25% had VUR. The median PCT concentration was significantly higher in children with VUR than in those without: 1.6 versus 0.7 ng/mL (P = 10(-4)). High PCT (> or =0.5 ng/mL) was associated with VUR (OR: 2.3; 95% CI, 1.3 to 3.9; P = 10(-3)). After adjustment for all cofactors, the association remained significant (OR: 2.5; 95% CI, 1.4 to 4.4; P = 10(-3)). The strength of the relation increased with the grade of reflux (P = 10(-5)). The sensitivity of procalcitonin was 75% (95% CI, 66 to 83) for all-grade VUR and 100% (95% CI, 81 to 100) for grade > or =4 VUR, both with 43% specificity (95% CI, 37 to 48).

CONCLUSIONS

High PCT is a strong, independent and now validated predictor of VUR that can be used to identify low-risk patients and thus avoid one third of the unnecessary cystourethrographies in children with a first febrile UTI.

Investigation of acute flank pain: how do practices of U.K.and Irish urologists compare with those of transatlantic and continental European colleagues?

BACKGROUND AND PURPOSE

Noncontrast-enhanced spiral CT (NESCT) is more accurate and reliable than intravenous urography (IVU) in diagnosing the cause of acute flank pain. This study aimed to determine the impact of current literature on the choice of imaging modality used to investigate acute flank pain within the UK and the Republic of Ireland.

MATERIALS AND METHODS

A questionnaire regarding the preferred investigation for acute flank pain was sent to all consultant urologists registered as British Association of Urological Surgeons members.

RESULTS

Of the 548 consultants from 210 institutions surveyed, 293 (54%) from 171 (81.4%) institutions returned their questionnaires. Intravenous urography is used in the majority of institutions (146; 85.4%) for investigating acute flank pain. Only 18 (10.5%) use NESCT, while 4.1% use ultrasonography. Among those using IVU as the investigation of choice, the main reason given was limited CT services (82.4%). Others included familiarity with IVU features (51.2%), limited availability of radiologists for out-of-hours reporting of CT (26%), more rapid procedure (20.8%), lower cost (20%), and lower radiation exposure (19.6%). Only 52.4% of consultants using IVU would prefer NESCT if both were equally available.

CONCLUSIONS

Urography remains the commonest modality for the investigation of acute flank pain in the UK and Ireland primarily because of limited CT services and greater familiarity with the images. Given the opportunity, only half of consultant urologists would select NESCT in preference to IVU, suggesting that improving the availability of CT services alone may not lead to practice paralleling that of our transatlantic and continental European colleagues.

Outcome of intravenous urography in the year 2000

BACKGROUND

We studied the referrals for intravenous urography and their outcome during the year 2000 in a university department before the switch to unenhanced computed tomography (CT) and CT urography.

METHODS

From the Radiology Information System, we obtained information about age, sex, referring physician, indication, and diagnosis.

RESULTS

A total of 1229 intravenous urographies was performed in 1164 patients. In patients younger than 40 years, females were examined more frequently than males, and vice versa. Forty-five percent of all patients were referred with renal colic, and 41% were referred with hematuria. Renal colic was a more frequent indication than hematuria in patients younger than 61 years, whereas the opposite was the case in patients older than 60 years. Of the 559 urographies performed due to renal colic, a calculus in the upper urinary tract was found in 27% and a change indicating a tumor in 4%; the incidence of calculus increased with age up to 80 years. Of the 487 urographies performed due to hematuria, a calculus in the upper urinary tract was found in 6% and a change indicating a tumor in 15%. In the 277 patients younger than 40 years, an abnormality was diagnosed in 25% and a potential tumor was diagnosed in only 1.4%. The latter could not be confirmed at other examinations. Of the 887 patients older than 40 years, an abnormality was found in 45% and a potential tumor in 11%.

CONCLUSION

A switch from urography to unenhanced CT and CT urography should not be done without an audit of the referrals and their outcomes. Patients with hematuria and younger than 40 years seem more appropriate for ultrasound than for CT because the incidence of tumors and calculus disease is low. No transitional cellular cancer was found in these patients.

Wandel der perioperativen Therapie bei elektiven kolorektalen Resektionen in Deutschland 1991 und 2001/2002

BACKGROUND

To assess changes in perioperative treatment of patients undergoing elective colorectal resections, surveys were sent to all German surgical departments in 1991 and 2001/2002.

METHODS

1,207 chairmen of departments for general or visceral surgery were asked to answer a survey concerning the principles of perioperative treatment of patients undergoing elective colorectal resection. The results of this questionnaire were compared to a survey that had been performed in 1991.

RESULTS

616 chairmen (51.0%) responded to the survey (1991: 76.4%). In 2001/2002 preoperative parenteral alimentation was utilized routinely in only 10.3% (1991: 40.0%) of all hospitals. Preoperative i.v.-pyelography was used only in 24.7% of the hospitals (1991: 79.7%). Intraoperative testing of colorectal anastomoses was more common in 2001/2002 (63.7%) than in 1991 (40.1%). At the same time the incidence of "single-shot"-antibiotic prophylaxis increased from 24.0% to 70.4 %. Orthograde bowel lavage, perioperative antibiotic prophylaxis and postoperative parenteral alimentation were use as often in 2001/2002 as in 1991. Intraperitoneal drains were routinely inserted in most of the surgical departments after left-sided colonic resections (2001/2002: 86.2%; 1991: 88.2%) or rectal resections (2001/2002: 90.5%; 1991: 94.4%).

CONCLUSION

During the last decade, perioperative therapy for patients undergoing elective colorectal resection has changed substantially. Most of these changes occurred in the perioperative medical treatment. However, surgical traditions like intraperitoneal drainage are still very frequently utilized.

A new diagnostic algorithm for the evaluation of microscopic hematuria

OBJECTIVES

To evaluate a new diagnostic algorithm for microscopic hematuria in which intravenous urography (IVU) is performed as a secondary radiographic study when microhematuria has persisted for 3 months after the initial workup with renal ultrasound (US) and cystoscopy was negative.

METHODS

We evaluated 372 consecutive patients who presented with microhematuria and negative urine cultures and cytologic findings at our institution. All patients underwent renal US scanning and cystoscopy as their initial evaluation. All patients underwent re-evaluation 3 months after the initial workup. Patients with persistent microhematuria with no apparent etiology were then evaluated with IVU.

RESULTS

The initial evaluation was negative in 212 of 372 patients. Eighty-one of these patients had persistence of their microhematuria at the 3-month follow-up without a definitive diagnosis. Seventy-five of these patients underwent IVU. Abnormalities were found in 11 of the 75 patients. Six patients had renal stones, two had ureteral stones, two had ureteral tumors, and one had a tumor of the renal pelvis. Forty of the 131 patients with resolution of their microhematuria underwent IVU at their request. All those studies were normal.

CONCLUSIONS

The combination of cystoscopy and renal US along with urinalysis, urine culture, and cytology is a good initial evaluation in patients with microhematuria. Those patients with persistent microhematuria after 3 months without definite etiology of the bleeding may still benefit from IVU.

Need for intravenous urography in patients with primary transitional carcinoma of the bladder?

OBJECTIVE

To assess the need for and the efficacy of intravenous urography in the detection of a synchronous upper tract urothelial tumor (UTUT) in patients with primary bladder tumor.

MATERIALS

Between 1986 and 1996, 793 patients were diagnosed as having primary tumor of the bladder with pathological confirmation of transitional cell carcinoma. All patients underwent intravenous urography prior to transurethral resection. The mean age of the patients was 66.4 years, and 87.7% of them were male. Of these patients, 72% had superficial tumors, while the remaining 28% had infiltrative tumors. Histological classification of the tumors was: grade I, 10%; grade II, 45%, and grade III, 45%. A chi(2) test was used for statistical analysis.

RESULTS

The incidence of upper tract urothelial tumors was 1.1% (9 patients), although intravenous urography only diagnosed 6 cases (0.7%). No differences were seen between patients with or without UTUT with regard to histological grade (p = 0.7), multiple bladder tumors (p = 0.7) and tumor infiltration (p = 0.9). In 5.8% of the patients an unsuspected associated pathology was detected which required treatment in 1.4% of the cases.

CONCLUSIONS

Due to the low incidence of UTUT (1.1%) in our series and to the fact that intravenous urography was effective in diagnosing synchronous UTUT in only 66.6% of cases, we do not consider that this procedure should be routinely performed in the diagnostic workup of patients with primary transitional cell tumor of the bladder.

Intravenous urography in the emergency department: when do we need it?

Intravenous urography (IVU) is a useful radiographic study in the detection of renal and ureteral calculi. However, it is time consuming, expensive, and exposes the patient to i.v. contrast and radiation. To determine the impact of utilizing IVU less for the detection of renal calculi, criteria for ordering IVU in the emergency department (ED) were evaluated, and patients with high probability of positive IVU were identified. Variables included presence of acute flank pain with haematuria, prior history of renal calculus, degree of haematuria, and uncontrolled pain. We reviewed patients presenting with acute flank and abdominal pain with haematuria from May 1995 to May 1996 at a large urban university hospital. Charts were abstracted for prior history, reason for ordering IVU, time in the ED, laboratory results, IVU result, final diagnosis, and disposition. Data was analysed with Student's t-test, Wilcoxon rank-sum and receiver operating characteristic (ROC) analysis. A total of 302 patients were identified, and 185 underwent IVU during the study period. For patients with prior history of renal calculi 82% had positive IVU (sensitivity 51%, specificity 87%). For patients with both acute flank pain and haematuria, 92% had a positive IVU (sensitivity 93%, specificity 43%), and 19% of patients with abdominal pain of unclear aetiology with haematuria had a positive IVU. All patients with uncontrolled pain had evidence of high-grade obstruction on IVU. Degree of haematuria was not predictive of a positive IVU from ROC curve derivation. IVU is a useful study in the ED but may be overutilized, leading to lengthy patient stays. The combined objective findings of acute flank pain and haematuria are sensitive, and prior history is specific in identifying patients with renal calculi. Degree of haematuria was not useful in predicting renal calculi. By utilizing the criteria of acute flank pain and haematuria as a decision aid, 66% of all IVUs ordered could have been avoided.

[The adverse effects of the water-soluble iodinated contrast media used in excretory urography in the canine species]

In five dogs with normal renal function, doses of 200, 400, 600 and 800 mg of iodine/kg bodyweight of iohexol (350 mg of iodine/ml) were assessed in comparison to a dose of 880 mg of iodine/kg bodyweight of meglumine-sodium amidotrizoate (370 mg of iodine/ml) to determine the hematologic and biochemical parameters, urinalysis and urinary osmolality, pulse and respiratory rates, and adverse effects were determined. The such clinical secondary effects as tachycardia, muscular contractions and tremors took place in the animals with the contrast Iohexol, these were transitory and without vital repercussion. There was no significant difference between groups and times in any of the biochemical and hematological parameters analyzed. A decrease in urine creatinine was observed on Amidotrizoate group 24 hours after administration of the contrast agent while an increased was observed on Iohexol 600 mg of iodine/kg in that time.

Gadolinium-enhanced excretory MR urography after low-dose diuretic injection: comparison with conventional excretory urography

PURPOSE

To evaluate the clinical utility and morphologic accuracy of gadolinium-enhanced excretory magnetic resonance (MR) urography after low-dose diuretic injection and to correlate the results with those of conventional urography.

MATERIALS AND METHODS

In 71 patients with urologic symptoms, excretory MR urography was performed after intravenous injection of 5-10 mg furosemide and, 30-60 seconds later, 0.1 mmol of gadopentetate dimeglumine per kilogram of body weight. The MR urograms were interpreted by three radiologists, who were blinded to the clinical outcome, and subsequently compared with conventional urograms.

RESULTS

Injection of furosemide before contrast material led to rapid, uniform gadolinium distribution inside a sufficiently distended collecting system such that there was no excessive concentration of gadolinium in the urine. In patients with normal or moderately reduced excretory function, this effect allowed complete visualization of the urinary tract within 5-20 minutes of contrast material injection while minimizing gadolinium-related endoluminal T2* effects. The clinical course helped verify almost all MR urographic results. The MR urographic technique was significantly superior to conventional urography in the assessment of the ureters and bladder (P < .0001). Delineation of small caliceal abnormalities is still problematic. The best depiction of the pelvicaliceal system was obtained with fat-suppressed MR imaging, although it was still slightly inferior to conventional urography (P < .05).

CONCLUSION

Gadolinium-enhanced excretory MR urography performed after low-dose diuretic injection is a promising and accurate alternative to conventional excretory urography for imaging the morphology of the urinary tract.

Routine preoperative "one-shot" intravenous pyelography is not indicated in all patients with penetrating abdominal trauma

BACKGROUND

To determine which patients need a "one-shot" intravenous pyelogram (IVP) before laparotomy for penetrating abdominal trauma.

STUDY DESIGN

Over a 15-month period, 240 laparotomies were performed for penetrating trauma at our urban level I trauma center. Prospectively collected data included clinical suspicion of genitourinary injury, results of preoperative IVP, intraoperative findings, and operative decisions influenced by the IVP.

RESULTS

Preoperative IVP was performed in 175 patients (73%). Of these, 71 (41%) had suspicion of a renal injury based on the presence of a flank wound or gross hematuria. The IVP was believed to influence operative decisions in six patients, all in this group. Each of these six patients had either a shattered kidney or a renovascular injury and had a nephrectomy performed with the knowledge that a normal functioning kidney was present on the contralateral side. No patient without a flank wound or gross hematuria had an IVP that was judged to be helpful intraoperatively. Preoperative IVP was helpful only in patients with flank wounds or gross hematuria. Nephrectomy was performed in two additional patients who did not undergo IVP, both of whom presented in shock.

CONCLUSIONS

Routine preoperative IVP is not necessary in all patients undergoing laparotomy for penetrating trauma. The number of IVPs can be safely reduced by 60% if the indications are narrowed to include only those stable patients with a flank wound or gross hematuria.

Is intravenous urography still used in patients with prostatism?

The value of intravenous urography in patients with prostatism was retrospectively evaluated. One thousand four hundred ninety five intravenous urograms of male patients referred by the department of urology were reviewed. Based on the clinical information, only patients with complaints of prostatism as a single symptom were selected. Patients with associated symptoms (i.e. hematuria, urinary infection) were excluded. Forty seven patients could be included based on these criteria. In 29 of 47 cases (61.7%) no abnormalities were found. Abnormalities found in 18 cases included dilatation of the excretory system, urinary calculi, congenital anomaly, acquired small kidney, renal cysts and retroperitoneal fibrosis. In 5 cases (10.1%) the intravenous urography necessitated further treatment and/or follow up. In 3.1% prostatism was the indication for the examination. The number of relevant abnormalities at intravenous urography performed for prostatism is low and this is in accordance with results reported in literature. These results provide further evidence for the continuously changing indications for intravenous urography.

[The serum immunoglobulin indices in side effects to Triombrast administration]

The aim of the study was further investigation of immune mechanism underlying side effects of radiocontrast examinations. Various immunoglobulins were measured in the serum of 54 patients exposed to excretory urography. 13 of them had side effects. They exhibited elevated levels of serum IgM and IgE. The findings are discussed in terms of suggested allergic origin of negative triombrast effects.

Intravenous urography revisited in the age of ultrasound and computerized tomography: diagnostic yield in cases of renal colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis

The aim of our study was to assess the diagnostic yield of intravenous urography (IVU) compared to ultrasound (US) and computerized tomography (CT) in cases of renal colic, suspected pelvic and abdominal malignancies, suspected renal mass, and acute pyelonephritis. We retrospectively analyzed the case charts of 216 consecutive patients. The patients had been referred to the Department of Radiology by different hospital departments and local general practitioners. All had undergone clinical examination, US and IVU, in that order. When deemed necessary, conventional tomography was performed. Patients with renal masses also underwent CT. In cases without renal colic and normal US examination, the subsequent IVU failed to detect any further important pathology. Hydronephrosis was equally well detected using US and IVU, however, the level of obstruction was better determined using delayed X-ray films. In 24% of cases of renal colics the initial US was normal, however, the IVU revealed ureteric obstruction. Repeat US 8-12 h later always showed hydronephrosis. In 6 of 34 solid renal masses, IVU and conventional tomography failed to make the correct diagnosis, but never could the patient be spared a subsequent CT. IVU is only indicated if US shows hydronephrosis. In cases of renal colic, repeat US is necessary to diagnose the possibly developing hydronephrosis. Clinical history, US and a plain abdominal image will suffice to make the diagnosis. Renal masses always require CT. In these cases, IVU is not necessary. There is no indication left for conventional renal tomographies.

Adequacy of follow-up in children diagnosed with urinary tract infections in a pediatric emergency department

A retrospective chart review was undertaken to determine primary care provider (PCP) notification of patient visits and appropriateness of follow-up in children discharged from an inner city, university-affiliated children's emergency department with the diagnosis of urinary tract infection (UTI). Seventy-five charts met criteria for review, and phone calls were made to the PCP/families to obtain follow-up information. Statistical analysis was performed using the chi2 analysis and Fisher's exact test. The PCP was notified of the patient's diagnosis at the time of the ED visit in 24 cases (32%) and was aware of the ED visit/diagnosis of UTI in a total of 53 (71%). Children were more likely to have a repeat urine culture in follow-up if the PCP was aware of the diagnosis (60%) than if the PCP was not aware (9%) chi2 = 14.496 P < 0.001. Forty-seven children met criteria commonly accepted for radiographic evaluation. Nineteen children, whose PCPs were aware of their diagnosis, met criteria and had studies performed. Children were more likely to receive appropriate radiographic evaluation if their PCPs were aware of their diagnoses of UTI 19/35 (54%) than if their PCPs were unaware of their diagnoses 0/12 (0%). Fisher's exact two-tailed t test P < 0.001. We conclude that failure of PCP notification can impact negatively on appropriate patient follow-up and that, in many cases, PCPs are not following current recommendations in the management of children with UTIs.

Voiding cystourethrography in children with urinary tract infection: the frequency of vesicoureteric reflux is independent of the specialty of the physician requesting the study

OBJECTIVE

The purpose of this study was to determine if the frequency of vesicoureteric reflux on voiding cystourethrography in children with a history of urinary tract infection varies according to the specialty of the physician requesting the examination.

MATERIALS AND METHODS

The study included 309 children (192 girls, 117 boys) with a history of urinary tract infection who had their first voiding cystourethrogram. The median age at first voiding cystourethrogram in boys was 12 months; in girls, it was 48 months. The reports of these examinations were retrospectively reviewed, and the presence of vesicoureteric reflux was recorded. The age and sex distribution of children referred for voiding cystourethrography by pediatric urologists and nephrologists (subspecialists) was compared with the age and sex distribution of children referred by pediatricians, family practitioners, and adult urologists (other clinicians). The rate of detection of vesicoureteric reflux was calculated according to age and sex. Ages studied were younger than 1 year, younger than 2 years, 2-4 years, and 5 years or older. The frequency of vesicoureteric reflux in children referred by subspecialists was compared with the frequency in children referred by other clinicians, allowing for the age and sex of the children.

RESULTS

The sex distribution of children referred for voiding cystourethrography was similar for subspecialists and other clinicians. More children younger than 2 years old were referred by other clinicians than by subspecialists. Vesicoureteric reflux was found in 30% of boys and 29% of girls. The frequency of reflux in boys did not change with age. The frequency of reflux in girls 5 years or older (15%) was less than in younger girls. We found no significant difference between the rates of reflux in boys and girls within the age groups examined. The overall rate of detection of reflux in patients referred by subspecialists (30%) was almost the same as that in patients referred by other clinicians (29%). We also found no difference in the frequency of reflux in children referred by subspecialists compared with children referred by other clinicians after allowing for the age and sex of the children.

CONCLUSION

In children with a history of urinary tract infection, the rate of detection of vesicoureteric reflux on voiding cystourethrography is independent of the specialty of the physician requesting the examination.

Patterns of integration and clinical value of voiding cystourethrography in the work-up of urinary tract infection in children

OBJECTIVE

To evaluate the patterns of integration and the clinical value of voiding cystourethrography (VCUG) in the imaging work-up of children with urinary tract infection (UTI).

METHODS

We reviewed the medical records of a consecutive sample of 80 children that underwent VCUG as part of routine investigation for UTI. We assessed the following: the appropriateness of integration of VCUG in the patient work-up as determined by the presence or absence of a valid indication for VCUG in the specific clinical situation encountered, the correct timing of the examination and interpretation of its result; the change in clinical management initiated by the result of the test, and the reassurance conferred to the clinician.

RESULTS

Sixty-nine percent of the VCUG examinations were judged appropriately integrated, 14% of the examinations inappropriately integrated, while for the rest of the patients (17%) the appropriateness of integration of the test was rated as unclear. The change in patient management attributable to the VCUG result could be categorized as: no change (15%); decision to end the imaging investigation of the patient (39%); decision to end all investigations, and prophylactic or therapeutic interventions (17%); decision to discontinue chemoprophylaxis (1%); decision to end the imaging investigation and introduce chemoprophylaxis and follow-up for bacteriuria (5%); decision to continue the imaging investigation and introduce chemoprophylaxis and follow-up for bacteriuria (15%), and decision to operate or help in planning the surgical treatment required (8%).

CONCLUSION

The findings show the need for an increased effort to minimize overuse of VCUG in pediatric UTI. Future interventions should focus on issues of clinical efficacy of the method that may have not been emphasized sufficiently.

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.

[Routine intravenous urography before colorectal resections?]

The value of preoperative intravenous urography (IVU) to prevent iatrogenic damage to the urogenital tract was investigated in a series of 236 females and 188 males (mean age 54 [5-87] years) who underwent an operation on the colon or rectum between April 1988 and March 1992. The operations were: 101 right and 49 left hemicolectomies, 125 sigmoid resections, 74 anterior rectum resections, 58 abdomino-perineal rectum amputations and 17 total colectomies. Preoperative IVU was performed in 279 patients (65.8%), while in 145 (34.2%) urgency of the operation or intolerance to contrast medium prevented the procedure being done. The results were abnormal in 75 of the 279 IVUs (26.9%). Of the latter, only 19 (6.8%) of the abnormalities were related to the colorectal disease (renal obstruction due to tumour: 9, malignant invasion of the bladder: 5, ureter displacement: 5). Other diagnostic procedures had given abnormal results in six patients, although the preoperative IVU had been unremarkable. Iatrogenic damage to a ureter occurred in only one patient: the IVU had been normal. No ureteral damage occurred in any of the patients who had not had an IVU. These data indicate that the decisive factor in preventing intraoperative damage to a ureter is not a preoperative IVU but careful intraoperative dissection and visualization of the ureter. There is, therefore, no need for routine preoperative IVU in these cases.

Ultrasonography in medical imaging. Influence on diagnostic routines

It has been assumed that the introduction of ultrasonography in diagnostic imaging has led to dramatic changes in imaging routines by replacing other modalities like angiography, intravenous urography, and computerized tomography in several diagnostic procedures. The present retrospective study from five Norwegian hospitals during the period from 1978 to 1991 confirm this assumption, showing how ultrasonographic examinations have influenced diagnostic routines.

Intravenous urography pre prostatectomy: an evaluation of its use

The pre-operative intravenous urograms of 120 consecutive patients who had prostatectomy for benign prostatic hypertrophy (BPH) were studied. Of these, seventy eight patients (65%) had normal intravenous urograms (IVU) while 42 patients had abnormal IVU. In this study serum creatinine above 2.0mg/dl and blood urea above 35mg/dl proved valuable indices for possible selection of patients with BPH likely to show significant obstructive disease on IVU. This is not only cost saving, but also reduces unnecessary radiation to the patient.

[The evaluation of a digital system for the automatic analysis of the density of abdominal radiograms]

This paper reports the results of the evaluation of an automatic system developed to analyze radiographic densities. This system, called RADEN, has been implemented at the Institute for Information Processing of the Italian National Research Council in Pisa. Forty-three pairs of abdominal X-ray films were obtained before and after the administration of ionic iodate contrast medium (i.i.c.m.) during urographic examinations. The 86 X-ray films were acquired and digitized using a computer-controlled optoelectronic device with a sampling step ranging 125 microns to 250 microns. The resulting images were arrays of 512 x 512 pixels, each one quantified on a byte (256 gray levels). The computing system included a high-performance personal computer equipped with a video RAM board having built-in facilities for image processing and with an optical disk to archive the images. Automatic and semi-automatic procedures were developed to segment, recognize and classify the images and to characterize three homogeneous regions--i.e., bone, water and air. The output data were compared with the area values of the air densities computed directly on the X-ray films by a radiologist. Furthermore, both data sets were compared with the scores given in a blind study by four observers. The subsequent statistic analysis showed the increase in air density areas after i.i.c.m. administration and the applicability of the implemented system to the automatic examination of abdominal radiographic densities. The results encourage to believe that the proposed approach could be employed as a first step for the development of quite a more complex system oriented to X-ray image understanding and to assisted diagnosis.

Intravenous urography pre-prostatectomy: an evaluation of its use

The pre-operative intravenous urograms of 120 consecutive patients who had prostatectomy for benign prostatic hypertrophy (BPH) were studied. Of these, seventy-eight patients (65%) had normal intravenous urograms (IVU) while 42 patients had abnormal IVU. In this study serum creatinine above 2.0mg% and Blood urea above 35mg% proved valuable indices for possible selection of patients with BPH likely to show significant obstructive disease on IVU. This is not only cost saving, but also reduces unnecessary radiation to the patients.

Enuresis and the voiding cystourethrogram: a re-evaluation

Eighty-three children with a chief complaint of nocturnal enuresis and no history of urinary tract infection (UTI) were prospectively evaluated with a contrast voiding cystourethrogram (VCUG). The following four historical details of presentation were noted: primary vs. secondary enuresis, daytime wetting, urgency, and frequency. Each of these four symptoms were treated as a dichotomous variable, and the prognostic value with respect to vesicoureteral (VUR) reflux was assessed using a linear logistic regression model. Nineteen ureters in 13 patients (16%) demonstrated VUR: grade I, 7 ureters; grade II, 5 ureters; grade III, 3 ureters; grade IV, 4 ureters; and grade V, 0 ureters. Three patients demonstrated renal scarring (16%) and 2 patients underwent surgery. The linear regression analysis revealed that no one symptom, group of symptoms, or absence of all four symptoms segregated those patients likely to have reflux with statistical validity. One of 6 children, therefore, who present with nocturnal enuresis and sterile urine will have reflux. Screening these children with a VCUG should be considered.

Frequency and costs of diagnostic imaging in office practice--a comparison of self-referring and radiologist-referring physicians

BACKGROUND

To assess possible differences in physicians' practices with respect to diagnostic imaging, we compared the frequency and costs of imaging examinations as performed by primary physicians who used imaging equipment in their offices (self-referring) and as ordered by physicians who always referred patients to radiologists (radiologist-referring).

METHODS

Using a large, private insurance-claims data base, we analyzed 65,517 episodes of outpatient care by 6419 physicians for acute upper respiratory symptoms, pregnancy, low back pain, or (in men) difficulty urinating. The respective imaging procedures studied were chest radiography, obstetrical ultrasonography, radiography of the lumbar spine, and excretory urography, cystography, or ultrasonography.

RESULTS

For all four clinical presentations, the self-referring physicians obtained imaging examinations 4.0 to 4.5 times more often than the radiologist-referring physicians (P less than 0.0001 for all four). For chest radiography, obstetrical ultrasonography, and lumbar spine radiography, the self-referring physicians charged significantly more than the radiologists for imaging examinations of similar complexity (P less than 0.0001 for all three). The combination of more frequent imaging and higher charges resulted in mean imaging charges per episode of care that were 4.4 to 7.5 times higher for the self-referring physicians (P less than 0.0001). These results were confirmed in a separate analysis that controlled for the specialty of the physician.

CONCLUSIONS

Physicians who do not refer their patients to radiologists for medical imaging use imaging examinations more frequently than do physicians who refer their patients to radiologists, and the charges are usually higher when the imaging is done by the self-referring physician. From our results it is not possible to determine which group of physicians uses imaging more appropriately.

Intravenous pyelography: the case against its routine use

PURPOSE

To critically appraise four common uses of intravenous pyelography in adults.

DATA IDENTIFICATION

We reviewed the literature on the use of intravenous pyelography for four clinical indications.

STUDY SELECTION

We analyzed the literature to determine the proportion of intravenous pyelograms producing clinically useful information (yield) in four clinical situations. The best estimate of its accuracy (sensitivity and specificity) for associated pathologic findings was determined. The implications of using the test on the outcomes of patients and costs were evaluated.

RESULTS OF DATA SYNTHESIS

The yield of significant abnormalities in patients having prostatectomy is small; intravenous pyelography does not specifically indicate ureteral obstruction, and is not sensitive or specific enough for screening for urinary tract malignancies. Many false-positive results, little benefit, and significant costs can be expected. When used before hysterectomy, intravenous pyelography does not reduce injury to the ureters, and the yield of unexpected abnormalities is small. The use of the test to screen for unexpected anatomic abnormalities in adult women after urinary tract infections has not led to improved outcomes or prevention of impaired renal function. Acquired causes of obstruction will be suggested by the history or physical examination. In hypertensive adults, intravenous pyelography is not accurate enough in detecting renal artery stenosis or in predicting favorable outcomes of renal artery surgery. Also, large costs are generated by high false-positive rates, and candidates for successful surgery are not reliably identified.

CONCLUSIONS

Selective use of intravenous pyelography is recommended for patients before prostatectomy or hysterectomy, in women after urinary tract infections, and in adults whose hypertension may have a renovascular cause. Use should be reserved for patients whose history and physical examination raise specific questions for which this test could provide an answer that would affect treatment.

Intravenous urography and voiding cystoureterography in northern Norway: a retrospective study

Intravenous urography (IU) was performed in 489 patients aged 0-9 years during 1980-1983. A total of 35 (7.2%), 19 (13.1%) boys and 16 (4.7%) girls had pathological changes at IU. Of these, 11 boys and 5 girls had findings with therapeutic consequences. We have analysed the results of IU and voiding cystoureterography (VC) in 62 patients and show that a normal IU does not exclude vesicoureteral reflux into the renal pelvis. By performing only VC hydronephrosis, pyelonephritic scarring and anomalies may be missed.

Should the emergency IVP be used more selectively in blunt renal trauma?

A retrospective study was performed to determine if the emergency intravenous pyelogram (IVP) is being overused in the evaluation of blunt renal trauma. Medical records of 105 blunt renal trauma patients undergoing IVPs for suspected blunt renal trauma were analyzed. Eighty-eight patients (83.8%) had normal IVPs, and 17 patients (16.2%) had abnormal IVPs. Three of the 105 patients (2.9%) required urologic surgical intervention. The medical records of these patients were examined in detail because it was believed that this patient population needed to be identified by emergency IVP. All three patients requiring urologic surgery had gross hematuria. All three patients had one or more associated injuries. Two of the three patients had flank tenderness and/or flank mass. The third patient was obtunded. From this study and information from the literature an algorithm has been constructed as a guideline for a prospective study. Following this guideline no patients in the study requiring urologic surgical intervention would have been missed. Of patients requiring an emergency IVP, 7.3% would have required urologic surgery. This would have resulted in a savings of $10,432 at our institution.

Excretory urography in current practice: evidence against overutilization

Excretory urography could be performed less frequently if some combinations of genitourinary signs and symptoms were found to be predictive of either a specific disease or normality. To explore this possibility, the authors conducted a prospective study involving more than 3,000 patients at three institutions (a teaching hospital, a community hospital, and a health maintenance organization). Predictive algorithms were obtained by application of a polychotomous logistic regression model but did poorly at differentiating normal from abnormal patients or arriving at a specific diagnosis. Selection of patients on the basis of the logistic model would have required testing 90% of all patients in order to detect 95% of those with abnormal urograms. These results suggest that current clinical selection criteria for excretory urography are effective, and that present frequency of utilization is appropriate.

Too many cystograms in the investigation of urinary tract infection in children?

We report on 62 children referred for a first micturating cystourethrogram (MCU) and intravenous urogram (IVU) because of suspected or proven urinary tract infection (UTI). The study represents 1 year's experience of a district hospital, but excludes children below the age of 6 months and those with a diagnosis of urinary drainage anomaly. The IVU proved a good predictor of gross vesicoureteric reflux, which affected 11 children, all with suspect IVUs. Lesser grades of reflux can occur in the presence of a normal IVU but are unlikely to damage the kidney. They can be managed by treating symptoms of infection rather than by the need to protect nephrons. In our study a suspect IVU implied a 79% chance of gross reflux, and a normal IVU excluded such reflux. It is suggested that children over 6 months of age with a clinically important infection should be spared an MCU unless the IVU is abnormal, or troublesome infections recur.

Evaluation of a sequence of diagnostic tests using the workup of ureteral stone as a model

Additional tests are not always beneficial and can increase costs significantly while increasing the group of patients with an equivocal diagnosis. In general, diagnostic testing should cease for a group of patients when the tests that have been performed result in a sufficiently high level of diagnostic certainty and also result in the largest group of true positive or true negative diagnoses. Evaluation of diagnostic tests must include consideration of the results of sequences of tests, equivocal results of tests, and the effect of added costs on both advantageous sequences of tests and total expenditures. Evaluation of the diagnostic tests performed for ureteral stone in the emergency ward demonstrates that a significant group of patients, on whom an intravenous urogram could be avoided can be selected. As an alternative to the IVU in this selected group, hydration and diuresis could be considered. The IVU could be reserved for those patients who did not experience classic relief of pain and passage of stone.

Role of preoperative urography in benign prostatic hyperplasia

The excretory urograms of 184 consecutive patients admitted to hospital with a diagnosis of benign prostatic hyperplasia who subsequently underwent prostatectomy were reviewed to determine the usefulness of preoperative urography. Of 184 urograms reviewed, 10 were normal, 136 showed changes consistent with benign prostatic hyperplasia, and 38 revealed other abnormalities. Twenty-seven of 184 urograms (14.7 per cent) revealed significant pathologic conditions requiring further consideration, investigation, or treatment, of which 23 would not have been suspected without this radiologic examination.

The selection of patients for excretory urography

Symptoms, signs, and laboratory findings that indicated excretory urography in 1,622 patients, were compared with the radiographs. The chance that an indication would be associated with demonstrable disease was calculated. No "low-likelihood" indications could be identified. Elimination of the urograms obtained for any of the indications would not have been possible without simultaneously precluding detection of many diseased patients. The monetary cost of case-finding was low, and the efficacy of patient referral high.