Clinical Radiology xxx (2014) e1ee6
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
The appearance of dextranomerehyaluronic acid copolymer implants on ultrasound may predict resolution of vesicoureteral reflux after injection therapy K.J. Park a, b, T.Y. Jeon a, *, S.-Y. Yoo a, J.H. Kim a, H. Eo a, K.D. Song a a
Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea b Department of Radiology, Chung-Ang University Hospital, School of Medicine, Seoul, Republic of Korea
art icl e i nformat ion Article history: Received 5 August 2013 Received in revised form 20 March 2014 Accepted 15 April 2014
AIM: To investigate the correlation between implant appearance on ultrasound (US) and voiding cystourethrography (VCUG) results after dextranomerehyaluronic acid copolymer (DxHA) injection in children with vesicoureteral reflux (VUR). MATERIALS AND METHODS: Consecutive cases of primary VUR treated by endoscopic subureteral injection of DxHA were retrospectively reviewed. All children had postoperative bladder US and VCUG with a mean interval of 34 days and 47 days after injection, respectively. VUR resolution at postoperative VCUG was considered as treatment success. Implant appearance on US was graded according to the retained volume and its location by visual inspection; it was then correlated with VCUG results using the Spearman correlation coefficient. RESULTS: A total of 36 children (56 ureters) were identified in which 38 ureters (68%) had a clearly visualized implant on postoperative US and 40 ureters (71%) showed VUR resolution. The sensitivity of implant visualization on US for predicting reflux resolution was 73% (29/40), specificity 44% (7/16), positive predictive value 76% (29/38), and negative predictive value 39% (7/18). The grade 1, grade 2, and grade 3 implant appearances showed VUR resolution in 88% (22/25), 54% (7/13), and 61% (11/18), and showed persistent VUR in 8% (2/25), 15% (2/13), and 28% (5/18), respectively (p ¼ 0.032). CONCLUSION: The implant appearance on postoperative US showed good correlation with VCUG results in the early post-injection period. Large retained implants were associated with treatment success, while small or non-visualized implants were related to the persistent reflux. Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction * Guarantor and correspondent: T.Y. Jeon, Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea. Tel.: þ82 2 3410 1305; fax: þ82 2 3410 2559. E-mail address: [email protected] (T.Y. Jeon).
Vesicoureteral reflux (VUR) is the most common urological disease in children and it can lead to pyelonephritis, progressive renal damage, and hypertension.1e3 Endoscopic subureteral injection of dextranomerehyaluronic acid copolymer (DxHA) has become a widely accepted treatment
0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.04.015
Please cite this article in press as: Park KJ, et al., The appearance of dextranomerehyaluronic acid copolymer implants on ultrasound may predict resolution of vesicoureteral reflux after injection therapy, Clinical Radiology (2014), http://dx.doi.org/10.1016/j.crad.2014.04.015
e2
K.J. Park et al. / Clinical Radiology xxx (2014) e1ee6
option for VUR due to its minimal invasiveness and low morbidity, with reported success rates ranging from 60e92%.4e6 Many studies have tried to identify the factors that best predict outcome after injection therapy, and have focused on preoperative VUR grade, anatomical abnormality, surgeon’s experience, and presence of the subureteral mound formation.6e10 Voiding cystourethrography (VCUG) is still the reference standard for both diagnosis and follow-up of children having VUR; however, unfortunately, it remains a distressing and uncomfortable investigation for children and their parents.11,12 In addition, the concern for radiation hazard imposes limits on the use of this technique, particularly in children who should undergo subsequent follow-up examinations. Some groups have advocated that intraoperative or postoperative implant morphology could play a significant role in the follow-up prediction of success, thereby decreasing the necessity of postoperative VCUG.8,9,13,14 The purpose of the present study was to investigate the correlation between the implant appearance on ultrasound (US) and VCUG results after DxHA injection in children with VUR.
Materials and methods This retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. In total, 41 patients were included who had undergone endoscopic subureteral injection of DxHA for primary VUR between January 2008 and August 2009. All procedures were performed by a single surgeon. VUR was graded based on the classification by International Reflux Study in Children.15 Children with a history of neurogenic bladder (n ¼ 2) or associated with genitourinary anomalies (n ¼ 3) were excluded. Follow-up visits with routine US examination and VCUG were scheduled after injection therapy at our institution (Samsung Medical Center, Seoul, Korea) according to the American Urological Association guideline.16 Bladder US examination was obtained in all children after surgery. The mean interval between surgery and bladder US was 34 days (range 21e53 days). The US examinations were performed by one of two paediatric radiologists. The equipment used included two US systems (HDI 5000, Philips Medical Systems, Best, the Netherlands; Sequoia, Siemens Healthcare, Erlangen, German) with a high-resolution 5e12 MHz linear-array transducer and a 5e10 MHz curved-array transducer. Two radiologists, who were unaware of the VCUG results, retrospectively reviewed all images in consensus. The US findings were evaluated with emphasis on the implant appearance and it was categorized on a three-point scale (Fig 1): grade 1, protruding mound formation into the bladder lumen at the ureteral orifice; grade 2, visible substance at the distal ureter without mound formation; grade 3, non-visualization of the DxHA implant at both ureteral orifice and distal ureter. VCUG examinations were performed using a regular technique.17 VCUG was obtained in all children before and
after surgery. The mean interval between surgery and postoperative VCUG was 47 days (range 25e84 days). VCUG results were considered the reference standard. The resolution of VUR at postoperative VCUG was considered as treatment success. Downgrading of VUR indicated a minimum two-grade decrease. The results of VCUG were classified as resolution of VUR, downgrading of VUR, or persistent VUR. The correlation between the sonographic appearance of the DxHA implant and VCUG results were investigated using the Spearman correlation coefficient. A p-value of
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
The appearance of dextranomerehyaluronic acid copolymer implants on ultrasound may predict resolution of vesicoureteral reflux after injection therapy K.J. Park a, b, T.Y. Jeon a, *, S.-Y. Yoo a, J.H. Kim a, H. Eo a, K.D. Song a a
Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea b Department of Radiology, Chung-Ang University Hospital, School of Medicine, Seoul, Republic of Korea
art icl e i nformat ion Article history: Received 5 August 2013 Received in revised form 20 March 2014 Accepted 15 April 2014
AIM: To investigate the correlation between implant appearance on ultrasound (US) and voiding cystourethrography (VCUG) results after dextranomerehyaluronic acid copolymer (DxHA) injection in children with vesicoureteral reflux (VUR). MATERIALS AND METHODS: Consecutive cases of primary VUR treated by endoscopic subureteral injection of DxHA were retrospectively reviewed. All children had postoperative bladder US and VCUG with a mean interval of 34 days and 47 days after injection, respectively. VUR resolution at postoperative VCUG was considered as treatment success. Implant appearance on US was graded according to the retained volume and its location by visual inspection; it was then correlated with VCUG results using the Spearman correlation coefficient. RESULTS: A total of 36 children (56 ureters) were identified in which 38 ureters (68%) had a clearly visualized implant on postoperative US and 40 ureters (71%) showed VUR resolution. The sensitivity of implant visualization on US for predicting reflux resolution was 73% (29/40), specificity 44% (7/16), positive predictive value 76% (29/38), and negative predictive value 39% (7/18). The grade 1, grade 2, and grade 3 implant appearances showed VUR resolution in 88% (22/25), 54% (7/13), and 61% (11/18), and showed persistent VUR in 8% (2/25), 15% (2/13), and 28% (5/18), respectively (p ¼ 0.032). CONCLUSION: The implant appearance on postoperative US showed good correlation with VCUG results in the early post-injection period. Large retained implants were associated with treatment success, while small or non-visualized implants were related to the persistent reflux. Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction * Guarantor and correspondent: T.Y. Jeon, Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea. Tel.: þ82 2 3410 1305; fax: þ82 2 3410 2559. E-mail address: [email protected] (T.Y. Jeon).
Vesicoureteral reflux (VUR) is the most common urological disease in children and it can lead to pyelonephritis, progressive renal damage, and hypertension.1e3 Endoscopic subureteral injection of dextranomerehyaluronic acid copolymer (DxHA) has become a widely accepted treatment
0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.04.015
Please cite this article in press as: Park KJ, et al., The appearance of dextranomerehyaluronic acid copolymer implants on ultrasound may predict resolution of vesicoureteral reflux after injection therapy, Clinical Radiology (2014), http://dx.doi.org/10.1016/j.crad.2014.04.015
e2
K.J. Park et al. / Clinical Radiology xxx (2014) e1ee6
option for VUR due to its minimal invasiveness and low morbidity, with reported success rates ranging from 60e92%.4e6 Many studies have tried to identify the factors that best predict outcome after injection therapy, and have focused on preoperative VUR grade, anatomical abnormality, surgeon’s experience, and presence of the subureteral mound formation.6e10 Voiding cystourethrography (VCUG) is still the reference standard for both diagnosis and follow-up of children having VUR; however, unfortunately, it remains a distressing and uncomfortable investigation for children and their parents.11,12 In addition, the concern for radiation hazard imposes limits on the use of this technique, particularly in children who should undergo subsequent follow-up examinations. Some groups have advocated that intraoperative or postoperative implant morphology could play a significant role in the follow-up prediction of success, thereby decreasing the necessity of postoperative VCUG.8,9,13,14 The purpose of the present study was to investigate the correlation between the implant appearance on ultrasound (US) and VCUG results after DxHA injection in children with VUR.
Materials and methods This retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. In total, 41 patients were included who had undergone endoscopic subureteral injection of DxHA for primary VUR between January 2008 and August 2009. All procedures were performed by a single surgeon. VUR was graded based on the classification by International Reflux Study in Children.15 Children with a history of neurogenic bladder (n ¼ 2) or associated with genitourinary anomalies (n ¼ 3) were excluded. Follow-up visits with routine US examination and VCUG were scheduled after injection therapy at our institution (Samsung Medical Center, Seoul, Korea) according to the American Urological Association guideline.16 Bladder US examination was obtained in all children after surgery. The mean interval between surgery and bladder US was 34 days (range 21e53 days). The US examinations were performed by one of two paediatric radiologists. The equipment used included two US systems (HDI 5000, Philips Medical Systems, Best, the Netherlands; Sequoia, Siemens Healthcare, Erlangen, German) with a high-resolution 5e12 MHz linear-array transducer and a 5e10 MHz curved-array transducer. Two radiologists, who were unaware of the VCUG results, retrospectively reviewed all images in consensus. The US findings were evaluated with emphasis on the implant appearance and it was categorized on a three-point scale (Fig 1): grade 1, protruding mound formation into the bladder lumen at the ureteral orifice; grade 2, visible substance at the distal ureter without mound formation; grade 3, non-visualization of the DxHA implant at both ureteral orifice and distal ureter. VCUG examinations were performed using a regular technique.17 VCUG was obtained in all children before and
after surgery. The mean interval between surgery and postoperative VCUG was 47 days (range 25e84 days). VCUG results were considered the reference standard. The resolution of VUR at postoperative VCUG was considered as treatment success. Downgrading of VUR indicated a minimum two-grade decrease. The results of VCUG were classified as resolution of VUR, downgrading of VUR, or persistent VUR. The correlation between the sonographic appearance of the DxHA implant and VCUG results were investigated using the Spearman correlation coefficient. A p-value of
