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Andrew J. Kirsch - One of the best experts on this subject based on the ideXlab platform.
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Standardized protocol for Voiding Cystourethrogram: Are recommendations being followed?
Journal of pediatric urology, 2020Co-Authors: Karmon M. Janssen, Andrew J. Kirsch, Traci Leong, Theodore C. Crisostomo-wynne, Scott P. Cuda, Angela M. ArlenAbstract:Summary Background Voiding Cystourethrogram (VCUG) images the urethra and bladder during filling and emptying, as well as ureters and kidneys when vesicoureteral reflux (VUR) is present, providing detailed information about both anatomical and functional status of the urinary tract. Given the importance of information obtained, and the varying quality depending on VCUG technique and radiology reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016. Objective We compared VCUG reports from multiple institutions before and after publication of the protocol to determine adherence to recommendations. Study Design VCUG reports generated during two separate time periods were assessed – before and after publication – to evaluate impact of the protocol. Adherence to the reporting template was evaluated. Studies performed on patients >18 years of age and those obtained for trauma evaluation were excluded from study. Results A total of 3121 VCUG reports were analyzed, 989 (31.7%) were generated before and 2132 (68.3%) after protocol publication. Comparing cohorts, there was no difference in gender (62.6% female versus 61.4%; p = 0.53) though children in the post-cohort were slightly older (3.34 ± 3.82 versus 3.68 ± 4.19 years; p = 0.03). A significant increase in scout image reporting (91.5%) and cyclic studies (20.5%) were observed in the post-cohort, in comparison to 79.2% and 13.1%, respectively, in the pre-protocol cohort (p Discussion The 2016 VCUG protocol recommended inclusion of various data points, however the volume at which reflux occurs remained vastly underreported. Timing of reflux has been shown to predict likelihood of spontaneous resolution and risk of breakthrough urinary tract infection; thus, its omission may limit the information used to counsel families and provide individualized care. Conclusion Despite consensus on standard VCUG protocol to best perform and record data, reports remain inconsistent. While VUR grade is routinely reported, other important anatomic and functional findings which are known to impact resolution and breakthrough urinary tract infection rates, such as volume at which reflux occurs, are consistently underreported. Download : Download high-res image (190KB) Download : Download full-size image Summary Figure . A significant increase in reporting of cyclic studies (20.5%) was observed in the post-cohort, in comparison to 13.1 in the pre-protocol cohort (p
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Accuracy of subjective vesicoureteral reflux timing assessment: supporting new Voiding Cystourethrogram guidelines
Pediatric Radiology, 2020Co-Authors: Dabin Ji, Andrew J. Kirsch, Angela M. Arlen, Derrick E. Ridley, J. Damien Grattan-smith, Joseph P. Williams, Courtney M. Mccracken, Christopher S. Cooper, Wesley W. Durrence, Michelle A. LightfootAbstract:Background Bladder volume at the onset of vesicoureteral reflux (VUR) is an important prognostic indicator of spontaneous resolution and the risk of pyelonephritis. Objective We aim to determine whether pediatric urologists and pediatric radiologists can accurately estimate the timing of reflux by examining Voiding Cystourethrogram (VCUG) images without prior knowledge of the instilled contrast volume. Materials and methods Total bladder volume and the volume at the time of reflux were collected from VCUG reports to determine the volume at the onset of VUR. Thirty-nine patients were sorted into three groups: early-/mid-filling reflux, late-filling and Voiding only. Thirty-nine images were shown to three pediatric urologists and two pediatric radiologists in a blinded fashion and they were then asked to estimate VUR timing based on the above categories. A weighted kappa statistic was calculated to assess rater agreement with the gold standard volume-based report of VUR timing. Results The mean patient age at VCUG was 3.1±2.9 months, the median VUR was grade 3, and 20 patients were female. Overall agreement among all five raters was moderate (k=0.43, 95% confidence interval [CI] 0.36–0.50). Individual agreement between rater and gold standard was slight to moderate with kappa values ranging from 0.13 to 0.43. Conclusion Pediatric radiologists and urologists are unable to accurately and reliably characterize VUR timing on fluoroscopic VCUG. These findings support the recently published American Academy of Pediatrics protocol recommending the routine recording of bladder volume at the onset of VUR as a standard component of all VCUGs to assist in a more accurate assessment of the likelihood of resolution and risk of recurrent urinary tract infections.
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National Trends in the Management of Primary Vesicoureteral Reflux in Children
The Journal of urology, 2017Co-Authors: Michael L. Garcia-roig, Curtis Travers, Courtney Mccracken, Andrew J. KirschAbstract:Purpose: In September 2011 the AAP (American Academy of Pediatrics) released updated guidelines for the evaluation of children 2 to 24 months old with a febrile urinary tract infection. We documented the impact of the guideline on diagnosis and surgical management of vesicoureteral reflux at U.S. children’s hospitals. We hypothesized that Voiding Cystourethrogram studies and the vesicoureteral reflux treatment rate decreased concurrent with the national guideline release.Materials and Methods: The Pediatric Health Information System was queried for children (younger than 18 years) with primary vesicoureteral reflux and their antireflux surgical history from January 2004 to June 2015. Voiding Cystourethrogram orders were recorded. Interrupted time series analysis quantified trends surrounding several seminal vesicoureteral reflux publications (2007) and guideline publication (2011).Results: A total of 43,341 Voiding Cystourethrogram encounters (male 23,946 [55.3%]) were identified for patients at a median ...
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Delayed upper tract drainage on Voiding Cystourethrogram may not be associated with increased risk of urinary tract infection in children with vesicoureteral reflux.
Journal of pediatric urology, 2016Co-Authors: Michael L. Garcia-roig, Angela M. Arlen, Traci Leong, Eleonora Filimon, Jonathan Huang, Andrew J. KirschAbstract:Summary Introduction Urinary stasis in the setting of obstruction provides an opportunistic environment for bacterial multiplication and is a well-established risk factor for UTI. Vesicoureteral reflux (VUR) with delayed upper tract drainage (UTD) on VCUG has been reported to correlate with increased UTI risk. We sought to determine whether delayed UTD can be reliably classified, and whether it correlates with UTI incidence, VCUG, or endoscopic findings. Methods Children undergoing endoscopic surgery for primary VUR (2009–2012) were identified. VUR grade, timing, and laterality were abstracted. Demographics, hydrodistention (HD) grade, reported febrile and culture-proven UTI were assessed. UTD on VCUG was graded on post-void images as 1 = partial/complete UTD or 2 = no/increased UTD. Inter-observer agreement was calculated. Patients were excluded for incomplete imaging or inability to void during VCUG. Results The cohort included 128 patients (10M, 118F), mean age 4.1 ± 2.1 years. Mean age at diagnosis was 2.8 ± 2.8 years. Mean maximum VUR grade was 3 ± 0.9: 1 (7.8%), 2 (20.3%), 3 (43%), 4 (25.8%), 5 (3.1%). UTD occurred in 45 (35%), and no drainage in 83 (65%) patients. Agreement coefficient between graders was 0.596 (p Conclusion We sought to determine whether UTD was an accurate predictor of UTI risk to maximize available prognostic information from a single VCUG. Delayed UTD was not a predictor of infection in our patients, nor was it associated with previously described UTI risk factors, such as VUR timing or grade, and Voiding dysfunction. Limitations included the retrospective nature of the study in patients undergoing endoscopic VUR treatment, and possible inaccurate UTI reports from parents and pediatricians. UTD can be reliably scored using a binary system with high inter-observer correlation. Our data call into question the previous finding that children with poor UTD are at increased risk of recurrent UTI. Delayed UTD is also not associated with higher HD, or VUR grade compared with those with more prompt UTD. Table . Urinary tract infection rate/year by parent reported and positive culture UTI versus upper tract drainage on Voiding Cystourethrogram according to binary drainage scoring system. Urinary tract infection vs. upper tract drainage p-value N Mean (SD) Median (mad) UTI rate/year by parent reported UTI Complete upper tract contrast drainage or less than filling 45 0.66 (0.53) 0.47 (0.28) 0.71 Unchanged upper tract contrast or more than filling 83 0.7 (0.5) 0.62 (0.33) UTI rate/year by positive culture Complete upper tract contrast drainage or less than filling 24 0.746 (0.657) 0.47 0.1664 Unchanged upper tract contrast or more than filling 49 0.538 (0.410) 0.441
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Is routine Voiding Cystourethrogram necessary following double hit for primary vesicoureteral reflux
Journal of pediatric urology, 2015Co-Authors: Angela M. Arlen, Hal C. Scherz, Traci Leong, Eleonora Filimon, Andrew J. KirschAbstract:Summary Introduction and objective Current AUA guidelines recommend Voiding Cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG. Study design Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those Results Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were “routine” and 38 were “indicated” [ Figure ]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2–50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2–40). Nine children (4.1%) underwent additional procedures. Discussion We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an “indicated” VCUG (i.e. those less than 2 years of age, grade 4–5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an “indicated” VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence “spontaneous resolution” is unknown. Conclusion Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method. Download : Download high-res image (194KB) Download : Download full-size image Figure . Flowchart demonstrating the clinical and radiographic success of patients according to postoperative VCUG status. “Indicated” VCUGs include those for grade 4–5 VUR, those in children less than 2 years of age, and those obtained for a postoperative fUTI.
Martin A. Koyle - One of the best experts on this subject based on the ideXlab platform.
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Population-based trend analysis of Voiding Cystourethrogram ordering practices in a single-payer healthcare system before and after the release of evaluation guidelines.
Journal of pediatric urology, 2019Co-Authors: Jessica M. Ming, Martin A. Koyle, L.c. Lee, Michael E. Chua, J. Zhu, Luis H. Braga, Armando J LorenzoAbstract:Summary Introduction While Voiding Cystourethrogram (VCUG) is a widely-accepted test, it is invasive and associated with radiation exposure. Most cases of primary vesicoureteral reflux (VUR) are low-grade and unlikely to be associated with acquired renal scarring. To select patients at greatest risk, in 2011 the American Academy of Pediatrics (AAP) published guidelines for evaluation of children ages 2 - 24 months with urinary tract infections (UTIs). Similarly, in 2010 the Society for Fetal Urology (SFU) published guidelines for patients with hydronephrosis. Herein a prospectively-collected database was queried through the Institute of Clinical Evaluative Sciences (ICES), exploring trends in VCUG ordering within the Ontario Health Insurance Program (OHIP), which guarantees universal access to care. Material and methods A dedicated ICES analyst extracted data on all patients younger than 18 years in Ontario, Canada, with billing codes for VCUG and ICD-9 codes for VUR, from 2004-2014. The baseline characteristics included patient age, gender, geographic region, specialty of ordering provider and previous diagnoses of UTI and/or antenatal hydronephrosis to determine the indication for ordering the test. Of these, patients were subsequently incurred OHIP procedure codes for endoscopic injection or ureteral reimplantation. Patients who had a VCUG in the setting of urethral trauma, posterior urethral valves, and neurogenic bladder were excluded. Results and discussion Trend analysis demonstrated that the total number of VCUGs ordered in the province has decreased over a decade (Figure 1), with a concurrent decrease in VUR diagnosis. On multivariate regression analysis, the decrease in VCUG ordering could not be explained by changes in population demographics or other baseline patient variables. Most VCUGs obtained per year were ordered by pediatricians or family physicians (mean 2,022+523.8), compared with urologists and nephrologists (mean 616+358.3). Interestingly, while the rate of VCUG requests decreased, the annual number of surgeries performed for VUR (endoscopic or open) did not show a significant reduction over time. Conclusions We present a large population-based analysis in a universal access to care system, reporting a decreasing trend in the number of cystograms and differences by primary care versus specialist providers. While it is reassuring to see practice patterns favorably impacted by guidelines, it is also encouraging to note that the number of surgeries has remained stable. This suggests that patients at risk continue to be detected and offered surgical correction. These data confirm previous institution-based assessments and affirm changes in VCUG ordering independent of variables not relevant to the healthcare system, such as the insurance status.
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contemporary practice patterns of Voiding cystourethrography use at a large tertiary care center in a single payer health care system
The Journal of Urology, 2017Co-Authors: Armando J Lorenzo, Rakan I Odeh, Michelle Falkiner, Dawnann Lebarron, Jeffrey Traubici, Erika Mann, Paul R Bowlin, Martin A. KoyleAbstract:Purpose: Voiding Cystourethrogram involves radiation exposure and is invasive. Several guidelines, including the 2011 AAP (American Academy of Pediatrics) guidelines, no longer recommend routine Voiding Cystourethrogram after the initial urinary tract infection in children. The recent trend in Voiding Cystourethrogram use remains largely unknown. We examined practice patterns of Voiding Cystourethrogram use and explored the impact of these guidelines in a single payer system in the past 8 years.Materials and Methods: We identified all Voiding Cystourethrograms performed at a large pediatric referral center between January 2008 and December 2015. Patients 2 to 24 months old who underwent an initial Voiding Cystourethrogram for the diagnosis of a urinary tract infection in the first 6 months of 2009 and 2014 were identified. Medical records were retrospectively reviewed.Results: During the study period 8,422 Voiding Cystourethrograms were performed and the annual number declined over time. In the pre-AAP an...
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Contemporary Practice Patterns of Voiding Cystourethrography Use at a Large Tertiary Care Center in a Single Payer Health Care System.
The Journal of urology, 2016Co-Authors: Linda C Lee, Armando J Lorenzo, Michelle Falkiner, Dawnann Lebarron, Jeffrey Traubici, Erika Mann, Paul R Bowlin, Rakan Odeh, Martin A. KoyleAbstract:Voiding Cystourethrogram involves radiation exposure and is invasive. Several guidelines, including the 2011 AAP (American Academy of Pediatrics) guidelines, no longer recommend routine Voiding Cystourethrogram after the initial urinary tract infection in children. The recent trend in Voiding Cystourethrogram use remains largely unknown. We examined practice patterns of Voiding Cystourethrogram use and explored the impact of these guidelines in a single payer system in the past 8 years. We identified all Voiding Cystourethrograms performed at a large pediatric referral center between January 2008 and December 2015. Patients 2 to 24 months old who underwent an initial Voiding Cystourethrogram for the diagnosis of a urinary tract infection in the first 6 months of 2009 and 2014 were identified. Medical records were retrospectively reviewed. During the study period 8,422 Voiding Cystourethrograms were performed and the annual number declined over time. In the pre-AAP and post-AAP cohorts 233 and 95 initial Voiding Cystourethrograms were performed, respectively. While there was no statistically significant difference in the vesicoureteral reflux detection rate between 2009 and 2014 (37.3% vs 43.0%, p = 0.45), there was a threefold increase in high grade vesicoureteral reflux in 2014 (2.6% vs 8.4%, p = 0.03). A clear trend toward fewer Voiding Cystourethrograms was noted at our institution. This decrease started before 2011 and cannot be attributed to the AAP guidelines alone. While most detected vesicoureteral reflux remains low grade, there was a greater detection rate of high grade vesicoureteral reflux in 2014 compared to 2009. This may reflect a favorable impact of a more selective approach to obtaining Voiding Cystourethrograms. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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Can we Rely on the Presence of Dextranomer-Hyaluronic Acid Copolymer Mounds on Ultrasound to Predict Vesicoureteral Reflux Resolution After Injection Therapy?
The Journal of Urology, 2011Co-Authors: Ismael Zamilpa, Martin A. Koyle, Richard W. Grady, Byron D. Joyner, Margarett Shnorhavorian, Thomas S. LendvayAbstract:Purpose: We determined whether the presence or absence of dextranomer-hyaluronic acid copolymer mounds on bladder ultrasound coincides with Voiding Cystourethrogram results after injection therapy in children with primary vesicoureteral reflux.Materials and Methods: We retrospectively reviewed consecutive cases of dextranomer-hyaluronic acid copolymer injection for primary vesicoureteral reflux. The primary outcome investigated was the appearance of dextranomer-hyaluronic acid copolymer mounds on ultrasound and their association with Voiding Cystourethrogram results postoperatively. An intramural dextranomer-hyaluronic acid copolymer mound on ultrasound was considered a negative test result for vesicoureteral reflux.Results: A total of 187 cases were identified, of which 132 had imaging available for evaluation. Intramural mounds were seen on ultrasound in 86 cases postoperatively, of which 34 (40%) had a positive Voiding Cystourethrogram. Of 46 cases in which no mound was identified 21 (46%) had a positi...
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Can we rely on the presence of dextranomer-hyaluronic acid copolymer mounds on ultrasound to predict vesicoureteral reflux resolution after injection therapy?
The Journal of urology, 2011Co-Authors: Ismael Zamilpa, Martin A. Koyle, Richard W. Grady, Byron D. Joyner, Margarett Shnorhavorian, Thomas S. LendvayAbstract:We determined whether the presence or absence of dextranomer-hyaluronic acid copolymer mounds on bladder ultrasound coincides with Voiding Cystourethrogram results after injection therapy in children with primary vesicoureteral reflux. We retrospectively reviewed consecutive cases of dextranomer-hyaluronic acid copolymer injection for primary vesicoureteral reflux. The primary outcome investigated was the appearance of dextranomer-hyaluronic acid copolymer mounds on ultrasound and their association with Voiding Cystourethrogram results postoperatively. An intramural dextranomer-hyaluronic acid copolymer mound on ultrasound was considered a negative test result for vesicoureteral reflux. A total of 187 cases were identified, of which 132 had imaging available for evaluation. Intramural mounds were seen on ultrasound in 86 cases postoperatively, of which 34 (40%) had a positive Voiding Cystourethrogram. Of 46 cases in which no mound was identified 21 (46%) had a positive Voiding Cystourethrogram. The sensitivity of ultrasound to determine the presence or absence of vesicoureteral reflux was 38%, specificity was 67%, accuracy was 55%, the positive predictive value was 46% and the negative predictive value was 60%. Our results indicate poor correlation of dextranomer-hyaluronic acid copolymer mound appearance on ultrasound with Voiding Cystourethrogram results after injection. To adequately evaluate for the resolution of vesicoureteral reflux a Voiding cystogram or nuclear medicine cystogram needs to be performed after injection therapy. Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Hal C. Scherz - One of the best experts on this subject based on the ideXlab platform.
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Is routine Voiding Cystourethrogram necessary following double hit for primary vesicoureteral reflux
Journal of pediatric urology, 2015Co-Authors: Angela M. Arlen, Hal C. Scherz, Traci Leong, Eleonora Filimon, Andrew J. KirschAbstract:Summary Introduction and objective Current AUA guidelines recommend Voiding Cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG. Study design Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those Results Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were “routine” and 38 were “indicated” [ Figure ]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2–50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2–40). Nine children (4.1%) underwent additional procedures. Discussion We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an “indicated” VCUG (i.e. those less than 2 years of age, grade 4–5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an “indicated” VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence “spontaneous resolution” is unknown. Conclusion Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method. Download : Download high-res image (194KB) Download : Download full-size image Figure . Flowchart demonstrating the clinical and radiographic success of patients according to postoperative VCUG status. “Indicated” VCUGs include those for grade 4–5 VUR, those in children less than 2 years of age, and those obtained for a postoperative fUTI.
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Early effect of American Academy of Pediatrics Urinary Tract Infection Guidelines on radiographic imaging and diagnosis of vesicoureteral reflux in the emergency room setting.
The Journal of urology, 2014Co-Authors: Angela M. Arlen, Hal C. Scherz, Traci Leong, Laura S Merriman, Jared M Kirsch, Edwin A Smith, Bruce H Broecker, Andrew J. KirschAbstract:In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and children 2 to 24 months old. New imaging recommendations invigorated the ongoing debate regarding the diagnosis and management of vesicoureteral reflux. We compared evaluations in these patients with febrile urinary tract infection before and after guideline publication. During 2 separate 6-month periods 350 patients 2 to 24 months old were evaluated in the emergency room setting. Demographics, urine culture, renal-bladder ultrasound, Voiding Cystourethrogram and admission status were assessed. A total of 172 patients presented with initial febrile urinary tract infection in 2011, of whom 47 (27.3%) required hospitalization, while 42 of 178 (23.6%) were admitted in 2012. Admission by year did not significantly differ (p = 0.423). After guideline revision 41.2% fewer Voiding Cystourethrograms were done (72.1% of cases in 2011 vs 30.9% in 2012, p <0.001). A 17.2% decrease in renal-bladder ultrasound was noted (75.6% in 2011 vs 58.4% in 2012, p <0.001). Of 55 Voiding Cystourethrograms 21 (38.2%) were positive in 2012 compared to 36.3% in 2011 (p = 0.809). Mean ± SD maximum vesicoureteral reflux grade was unchanged in 2011 and 2012 (2.9 ± 1.2 and 2.5 ± 0.93, respectively, p = 0.109). There was no association between abnormal renal-bladder ultrasound and Voiding Cystourethrogram positivity (p = 0.116). AAP guidelines impacted the treatment of infants and young children with febrile urinary tract infection. We found no relationship between renal-bladder ultrasound and abnormal Voiding Cystourethrogram, consistent with previous findings that call ultrasound into question as the determinant for additional imaging. Whether forgoing routine Voiding Cystourethrogram results in increased morbidity is the subject of ongoing study. Copyright © 2015. Published by Elsevier Inc.
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Temporal pattern of vesicoureteral reflux on Voiding Cystourethrogram correlates with dynamic endoscopic hydrodistention grade of ureteral orifice.
The Journal of urology, 2014Co-Authors: Angela M. Arlen, Hal C. Scherz, Kristin M. Broderick, Kathy H. Huen, Traci Leong, Andrew J. KirschAbstract:Purpose: The double hydrodistention implantation technique uses ureteral hydrodistention to visualize injection site(s) and determine required bulking agent volume. Along with grade, early vesicoureteral reflux on Voiding Cystourethrogram provides prognostic information regarding spontaneous resolution of reflux. We hypothesized that reflux timing is predictive of endoscopic hydrodistention grade.Materials and Methods: We identified children undergoing the double hydrodistention implantation technique for primary vesicoureteral reflux between 2009 and 2012. Hydrodistention grade (0 to 3) was assigned prospectively, and compared to vesicoureteral reflux grade and timing on Voiding Cystourethrogram.Results: A total of 196 children with a mean ± SD age of 3.94 ± 2.58 years underwent injection of 332 ureters. Mean ± SD vesicoureteral reflux grade was 2.8 ± 0.9. Of the ureters 52.4% demonstrated early to mid filling, 39.2% late filling and 8.4% Voiding only reflux. Mean ± SD reflux grade was 3.1 ± 0.81 for ear...
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Long-term preservation of dextranomer/hyaluronic acid copolymer implants after endoscopic treatment of vesicoureteral reflux in children: a sonographic volumetric analysis.
Journal of Urology, 2007Co-Authors: Leah P. Mcmann, Hal C. Scherz, Andrew J. KirschAbstract:Purpose: We compared injected volume of dextranomer/hyaluronic acid with sonographic volumes obtained 2 weeks to 36 months postoperatively to evaluate the amount of volume retention with time and to correlate volume retention with Voiding Cystourethrogram results.Materials and Methods: We retrospectively reviewed sonographic volume measurements of dextranomer/hyaluronic acid implants in children at 2 weeks to 36 months postoperatively. Hydronephrosis and percentage of dextranomer/hyaluronic acid retained at each interval were recorded. Average change in volume at each interval was used to compare volume retention with time. The fraction of dextranomer/hyaluronic acid retained was compared to Voiding Cystourethrogram at 3 months.Results: No patient had new or worsened hydronephrosis. Volumetric data were available for 296, 150, 42, 23 and 20 ureters at 2, 3, 6 and 12 weeks, and 24 to 36 months postoperatively, respectively. Percentage of dextranomer/hyaluronic acid retained was 79% at 2, 74% at 3, 70% at 6...
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long term preservation of dextranomer hyaluronic acid copolymer implants after endoscopic treatment of vesicoureteral reflux in children a sonographic volumetric analysis
The Journal of Urology, 2007Co-Authors: Leah P. Mcmann, Hal C. Scherz, Andrew J. KirschAbstract:Purpose: We compared injected volume of dextranomer/hyaluronic acid with sonographic volumes obtained 2 weeks to 36 months postoperatively to evaluate the amount of volume retention with time and to correlate volume retention with Voiding Cystourethrogram results.Materials and Methods: We retrospectively reviewed sonographic volume measurements of dextranomer/hyaluronic acid implants in children at 2 weeks to 36 months postoperatively. Hydronephrosis and percentage of dextranomer/hyaluronic acid retained at each interval were recorded. Average change in volume at each interval was used to compare volume retention with time. The fraction of dextranomer/hyaluronic acid retained was compared to Voiding Cystourethrogram at 3 months.Results: No patient had new or worsened hydronephrosis. Volumetric data were available for 296, 150, 42, 23 and 20 ureters at 2, 3, 6 and 12 weeks, and 24 to 36 months postoperatively, respectively. Percentage of dextranomer/hyaluronic acid retained was 79% at 2, 74% at 3, 70% at 6...
Angela M. Arlen - One of the best experts on this subject based on the ideXlab platform.
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Standardized protocol for Voiding Cystourethrogram: Are recommendations being followed?
Journal of pediatric urology, 2020Co-Authors: Karmon M. Janssen, Andrew J. Kirsch, Traci Leong, Theodore C. Crisostomo-wynne, Scott P. Cuda, Angela M. ArlenAbstract:Summary Background Voiding Cystourethrogram (VCUG) images the urethra and bladder during filling and emptying, as well as ureters and kidneys when vesicoureteral reflux (VUR) is present, providing detailed information about both anatomical and functional status of the urinary tract. Given the importance of information obtained, and the varying quality depending on VCUG technique and radiology reporting, the American Academy of Pediatrics Sections on Urology and Radiology published a joint standardized VCUG protocol in 2016. Objective We compared VCUG reports from multiple institutions before and after publication of the protocol to determine adherence to recommendations. Study Design VCUG reports generated during two separate time periods were assessed – before and after publication – to evaluate impact of the protocol. Adherence to the reporting template was evaluated. Studies performed on patients >18 years of age and those obtained for trauma evaluation were excluded from study. Results A total of 3121 VCUG reports were analyzed, 989 (31.7%) were generated before and 2132 (68.3%) after protocol publication. Comparing cohorts, there was no difference in gender (62.6% female versus 61.4%; p = 0.53) though children in the post-cohort were slightly older (3.34 ± 3.82 versus 3.68 ± 4.19 years; p = 0.03). A significant increase in scout image reporting (91.5%) and cyclic studies (20.5%) were observed in the post-cohort, in comparison to 79.2% and 13.1%, respectively, in the pre-protocol cohort (p Discussion The 2016 VCUG protocol recommended inclusion of various data points, however the volume at which reflux occurs remained vastly underreported. Timing of reflux has been shown to predict likelihood of spontaneous resolution and risk of breakthrough urinary tract infection; thus, its omission may limit the information used to counsel families and provide individualized care. Conclusion Despite consensus on standard VCUG protocol to best perform and record data, reports remain inconsistent. While VUR grade is routinely reported, other important anatomic and functional findings which are known to impact resolution and breakthrough urinary tract infection rates, such as volume at which reflux occurs, are consistently underreported. Download : Download high-res image (190KB) Download : Download full-size image Summary Figure . A significant increase in reporting of cyclic studies (20.5%) was observed in the post-cohort, in comparison to 13.1 in the pre-protocol cohort (p
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Accuracy of subjective vesicoureteral reflux timing assessment: supporting new Voiding Cystourethrogram guidelines
Pediatric Radiology, 2020Co-Authors: Dabin Ji, Andrew J. Kirsch, Angela M. Arlen, Derrick E. Ridley, J. Damien Grattan-smith, Joseph P. Williams, Courtney M. Mccracken, Christopher S. Cooper, Wesley W. Durrence, Michelle A. LightfootAbstract:Background Bladder volume at the onset of vesicoureteral reflux (VUR) is an important prognostic indicator of spontaneous resolution and the risk of pyelonephritis. Objective We aim to determine whether pediatric urologists and pediatric radiologists can accurately estimate the timing of reflux by examining Voiding Cystourethrogram (VCUG) images without prior knowledge of the instilled contrast volume. Materials and methods Total bladder volume and the volume at the time of reflux were collected from VCUG reports to determine the volume at the onset of VUR. Thirty-nine patients were sorted into three groups: early-/mid-filling reflux, late-filling and Voiding only. Thirty-nine images were shown to three pediatric urologists and two pediatric radiologists in a blinded fashion and they were then asked to estimate VUR timing based on the above categories. A weighted kappa statistic was calculated to assess rater agreement with the gold standard volume-based report of VUR timing. Results The mean patient age at VCUG was 3.1±2.9 months, the median VUR was grade 3, and 20 patients were female. Overall agreement among all five raters was moderate (k=0.43, 95% confidence interval [CI] 0.36–0.50). Individual agreement between rater and gold standard was slight to moderate with kappa values ranging from 0.13 to 0.43. Conclusion Pediatric radiologists and urologists are unable to accurately and reliably characterize VUR timing on fluoroscopic VCUG. These findings support the recently published American Academy of Pediatrics protocol recommending the routine recording of bladder volume at the onset of VUR as a standard component of all VCUGs to assist in a more accurate assessment of the likelihood of resolution and risk of recurrent urinary tract infections.
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Hospital-acquired Urinary Tract Infections in Neonatal ICU Patients: Is Voiding Cystourethrogram Necessary?
Urology, 2017Co-Authors: Aeen M. Asghar, Christopher S. Cooper, Traci Leong, Angela M. ArlenAbstract:Objective To evaluate the radiographic findings of neonatal intensive care unit (NICU) patients diagnosed with hospital-acquired urinary tract infection (UTI). Materials and Methods Children with no preexisting genitourinary anomalies undergoing a Voiding Cystourethrogram (VCUG) for culture-documented UTI during NICU admission were identified. Demographics, microbiology results, and imaging findings were evaluated. Results A total of 147 NICU patients underwent VCUG during the study period. Of these, the indication for VCUG was UTI in 58 children. Neonates diagnosed with UTI were born at a mean gestational age of 28 3/7 ± 4 3/7 weeks, and underwent VCUG at a mean of age of 70.3 ± 42 days. Urine culture grew Enterococcus in 32 (55.2%), Enterobacter in 6 (10.3%), coagulase negative staphylococcus in 6 (10.3%), Escherichia coli in 5 (8.7%), and other in 9 infants (15.5%). All patients underwent a retroperitoneal ultrasound, which was read as normal in 31 patients (53.4%). Fourteen children (24.1%) diagnosed with UTI were found to have vesicoureteral reflux on VCUG. On univariate analysis, no patient characteristics were associated with VCUG positivity. On multivariate analysis, the effect of age at VCUG differed by renal-bladder ultrasound results. Patients with an abnormal ultrasound were 3.6 (95% confidence interval, 1.39-9.24) times more likely to have a positive VCUG for every 1 month increase in age. Conclusion Ultrasound anomalies are common in NICU patients diagnosed with UTI. The effect of age at VCUG differed by ultrasound result; the probability of vesicoureteral reflux in infants with sonographic abnormalities and UTI increases with age.
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Delayed upper tract drainage on Voiding Cystourethrogram may not be associated with increased risk of urinary tract infection in children with vesicoureteral reflux.
Journal of pediatric urology, 2016Co-Authors: Michael L. Garcia-roig, Angela M. Arlen, Traci Leong, Eleonora Filimon, Jonathan Huang, Andrew J. KirschAbstract:Summary Introduction Urinary stasis in the setting of obstruction provides an opportunistic environment for bacterial multiplication and is a well-established risk factor for UTI. Vesicoureteral reflux (VUR) with delayed upper tract drainage (UTD) on VCUG has been reported to correlate with increased UTI risk. We sought to determine whether delayed UTD can be reliably classified, and whether it correlates with UTI incidence, VCUG, or endoscopic findings. Methods Children undergoing endoscopic surgery for primary VUR (2009–2012) were identified. VUR grade, timing, and laterality were abstracted. Demographics, hydrodistention (HD) grade, reported febrile and culture-proven UTI were assessed. UTD on VCUG was graded on post-void images as 1 = partial/complete UTD or 2 = no/increased UTD. Inter-observer agreement was calculated. Patients were excluded for incomplete imaging or inability to void during VCUG. Results The cohort included 128 patients (10M, 118F), mean age 4.1 ± 2.1 years. Mean age at diagnosis was 2.8 ± 2.8 years. Mean maximum VUR grade was 3 ± 0.9: 1 (7.8%), 2 (20.3%), 3 (43%), 4 (25.8%), 5 (3.1%). UTD occurred in 45 (35%), and no drainage in 83 (65%) patients. Agreement coefficient between graders was 0.596 (p Conclusion We sought to determine whether UTD was an accurate predictor of UTI risk to maximize available prognostic information from a single VCUG. Delayed UTD was not a predictor of infection in our patients, nor was it associated with previously described UTI risk factors, such as VUR timing or grade, and Voiding dysfunction. Limitations included the retrospective nature of the study in patients undergoing endoscopic VUR treatment, and possible inaccurate UTI reports from parents and pediatricians. UTD can be reliably scored using a binary system with high inter-observer correlation. Our data call into question the previous finding that children with poor UTD are at increased risk of recurrent UTI. Delayed UTD is also not associated with higher HD, or VUR grade compared with those with more prompt UTD. Table . Urinary tract infection rate/year by parent reported and positive culture UTI versus upper tract drainage on Voiding Cystourethrogram according to binary drainage scoring system. Urinary tract infection vs. upper tract drainage p-value N Mean (SD) Median (mad) UTI rate/year by parent reported UTI Complete upper tract contrast drainage or less than filling 45 0.66 (0.53) 0.47 (0.28) 0.71 Unchanged upper tract contrast or more than filling 83 0.7 (0.5) 0.62 (0.33) UTI rate/year by positive culture Complete upper tract contrast drainage or less than filling 24 0.746 (0.657) 0.47 0.1664 Unchanged upper tract contrast or more than filling 49 0.538 (0.410) 0.441
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Is routine Voiding Cystourethrogram necessary following double hit for primary vesicoureteral reflux
Journal of pediatric urology, 2015Co-Authors: Angela M. Arlen, Hal C. Scherz, Traci Leong, Eleonora Filimon, Andrew J. KirschAbstract:Summary Introduction and objective Current AUA guidelines recommend Voiding Cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG. Study design Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those Results Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were “routine” and 38 were “indicated” [ Figure ]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2–50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2–40). Nine children (4.1%) underwent additional procedures. Discussion We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an “indicated” VCUG (i.e. those less than 2 years of age, grade 4–5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an “indicated” VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence “spontaneous resolution” is unknown. Conclusion Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method. Download : Download high-res image (194KB) Download : Download full-size image Figure . Flowchart demonstrating the clinical and radiographic success of patients according to postoperative VCUG status. “Indicated” VCUGs include those for grade 4–5 VUR, those in children less than 2 years of age, and those obtained for a postoperative fUTI.
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long term followup of dextranomer hyaluronic acid injection for vesicoureteral reflux late failure warrants continued followup
The Journal of Urology, 2009Co-Authors: Eugene K. Lee, Romano T. Demarco, John M. Gatti, Patrick J MurphyAbstract:Purpose: Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative Voiding Cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as “nondilating” reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative Voiding cystourethrography.Materials and Methods: We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative Voiding Cystourethrogram. We then evaluated long-term success by obtaining a Voiding Cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experie...
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Long-Term Followup of Dextranomer/Hyaluronic Acid Injection for Vesicoureteral Reflux: Late Failure Warrants Continued Followup
Journal of Urology, 2009Co-Authors: Eugene K. Lee, Romano T. Demarco, John M. Gatti, J. Patrick MurphyAbstract:Purpose: Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative Voiding Cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as “nondilating” reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative Voiding cystourethrography.Materials and Methods: We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative Voiding Cystourethrogram. We then evaluated long-term success by obtaining a Voiding Cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experie...
