1 1/2 MONTH OLD MALE WITH PELVICALIECTASIS ON ULTRASOUND; NORMAL VCUG

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1 1/2 MONTH OLD MALE WITH PELVICALIECTASIS ON ULTRASOUND; NORMAL VCUG

Contributed by: grace kalish.

Patient: 1 month 16 day old male

History: 1.5 month old male with pelvicaliectasis on renal ultrasound of 7/5/06 which showed moderate pelvicaliectasis bilaterally and moderate distal ureteral dilatation on the right. VCUG was negative for vesicoureteral reflux.

Images:

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Fig. 1: There is an increase in activity at 16 minutes, correlating to reflux


Fig. 2: Differential function is asymmetric in this 1.5 month old


Fig. 3: In this 8 year old boy, VCUG demonstrated Grade I left reflux


Fig. 4: The same 8 year old boy got a lasix renogram to evaluate obstruction. There is no obstruction but there is at least grade 2 reflux on the left.


Fig. 5: This 8 year old boy's kidnyes have asymmetric uptake, indicating decreased function on the left.


Fig. 6: Note that there are symmetrical bumps at 8 minutes, indicating motion

Findings: There is an increase in radiotracer activity at 16 minutes in the right kidney, which is consistent with reflux. There is also asymmetric renal function, with right kidney uptake of 39% and 61% on the left.

Diagnosis: Right vesicoureteral reflux.

Discussion:

Ureteral Abnormalities in Children:

Incidence or urogenital abnormalities: 3.2% of infants; VUR is the most common abnormality, occuring in about 1% of infants.

Cause of VUR:
- abnormal maturation of the vesicoureteral junction
- short submucosal tunnel in the bladder.

Complications of VUR:
- increases risk of pyelonephritis
- leads to renal scar formation (also called "chronic pyelonephritis") and eventually renal failure
- the younger the child, the more likely he/she will develop scars from reflux

Presentation:
- hydronephrosis, hydroureter or dilatation on prenatal ultrasound
- UTI

Diagnosis:
- VCUG
     - determine grade
     - occurs during micturition or bladder filling
- Grading
     I:   reflux to ureter
     II: reflux to ureter, pelvis, and calices. no dilatation.
     III: mild/moderate dilatation; mild bluting of fornices
     IV: complete obliteration of fornices but papillary impressions maintained
     V:   papillary impressions not visible

- nuclear cystography
     - Tc99m DTPA
     - lower radiation dose to bladder (0.3mGy) vs. 3 mGy for VCUG
     - anatomic detail is lost, however
     - good for follow-up or screening females, whose urethra do not need to be imaged

- echo-ehnanced cystosonography
     - cannot image the urethra well
     - also great for females or follow-up exams

- lasix renograms are usually obtained to evaluate for obstruction or differntial function.
     - Tc 99m MAG3 is used (tubular agent)
     - cortical uptake is evaluated during the first 2 minutes
     - during washout phase, the presence of obstruction is evaluated.
     - washout that is longer than 20 minutes is considered abnormal

Treatment:
- goal is to avoid scar formation.
- Antibiotic treatment(Bactrim) once believed to be feasible in preventing pyeloneprhiritis during UVJ maturation, is now more controversial. A recent (albeit, inadequately-powered) study showed that treatment with Bactrim does not change clinical outcome.
- open versus endoscopic surgical correction of UVJ.
- The endoscopic technique is an ambulatory procedure (STING -- Subureteric Transurethral Injection) in which urologists inject a copolymer substance into the mucosa, changing the angle of the UVJ. Success rates (in treating reflux) depend on Grade: Grade I --79% and Grade 5 -- 51%.
- Even surgical correction of reflux does not significantly prevent renal scar formation, when compared to medical treatment.

Additional Points:
- can be associated with other congenital anomalies, such as posterior urethral valves or complete duplication of the urinary tract.

Comments:

No comments posted.

Additional Details:

Case Number: 5459620Last Updated: 08-02-2006
Anatomy: Genitourinary (GU) Pathology: Congenital
Modality: Nuc MedExam Date: Access Level: Readable by all users

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