Veziko üreteral reflü hastalığında ultrasonun rolünü nasıl belirleyebiliriz?

Öz

Amaç: Ultrasonografinin (US), veziko-üreteral reflü tanısındaki rolünü, endikasyonlarını açıklamak ve özellikli hasta grubunda, tanıda gold standart olan voiding sistoüretrografi’yle (VCUG) kıyaslamayı amaçladık. Gereç ve Yöntemler: Nisan 2010 - Mart 2019 tarihleri arasında tek bir radyolog tarafından uygulanmış 532 VCUG ve eş zamanlı US tetkiki retrospektif olarak değerlendirildi. Demografik özellikler, US’de; pelvik staz, pelvikaliksiyel dilatasyon, hidroüreteronefroz ile VCUG’de reflü varlığı kaydedildi. İki testi kıyaslamak için ROC analizi yapıldı. Bulgular: Yaşları 5 ay- 18 yaş arasında değişen hastaların 342’ si (% 64,3) kadın, 190 ‘ı (% 35,7) erkek idi. Hastalar 6 yaş altı (n=286) ve 6 yaş üstü (n=246) olmak üzere iki gruba ayrıldı. 6 yaş altında US ve VCUG bulgularında korelasyon saptanırken (p<0.005, OR=6,977), 6 yaş üstünde saptanmadı (p=0,539). ROC analizinde US’nin VUR saptamadaki, sensitivite, spesifite, pozitif prediktif değer (PPV), ve negatif prediktif değeri (NPV) 6 yaş altında; % 89,76 , % 47,86 %, % 65,1 ve % 81,2 (AUC= 0,688, p= 0,0001), 6 yaş üstünde % 50,49, % 53,55, % 38,0 ve % 65,8 (AUC=0,520, p= 0,5720) olarak hesaplandı. Tartışma: US, hastalığın tanısında kolay, tekrarlanabilen, güvenli ve etkin bir yöntemdir. Yüksek sensitivite (% 89,7) ve NPV ( % 81,2) oranları ile 6 yaş altında tarama testi olarak kullanılabilir. VCUG tüm yaş gruplarında kesin tanı için gold standart incelemedir.

Anahtar Kelimeler

• Vezikoüreteral reflü,Voiding sistoüreterografi,, Ultrasonografi,,Pediatri,,Tanı,, Görüntüleme

How can we specify the role of ultrasonography in the vesico – ureteral reflux disease?

Öz

Objectives: We aimed to explore the role and indication for the use of ultrasonography (US) in the vesico-ureteral reflux (VUR) disease and demonstrate the non – inferiority against the gold standard voiding cystourethrography (VCUG) for the screening in a certain group of patients. Material and Methods: This is a retrospective analysis of 532 simultaneous VCUG and US examinations between April 2010 and March 2019, by a single radiologist in our hospital. Demographic characteristics, pelvic stasis, pelvi – calyxeal dilatation and hydro – uretero – nephrosis in the US, and reflux in the VCUG were recorded. ROC analysis was done for comparing the two tests. Results: Among the cases between 5 months to 18 years of age, 342 (64.3 %) were female, and 190 (35.7 %) were male. The cases were divided into two groups below and after 6 years of age (N = 246 (46.2 %), and 286 (43.8%) respectively. There was a correlation between US and VCUG findings below the age of 6 (p<0.005, OR=6,977), but not in the cases over (p=0,539). In the ROC analysis of US in detection of VUR, compared to VCUG, sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) below 6 years age is 89,76 %, 47,86 %, 65,1 %, and 81,2 % (AUC= 0,688, p= 0,0001) respectively, and those above 6 years of age are 50,49 %, 53,55 %, 38,0 %, and 65,8 % (AUC=0,520, p= 0,5720). Conclusion: US is easy, reproducible, safe and effective for diagnosis, and staging of the disease. Its high sensitivity (89.7 %), and negative predictive value (81.2 %), can make it an initial screening test in the patients below 6 years of age. VCUG as a gold standard modality can be reserved for definitive diagnosis in the suspected cases below the age of 6 and all of the cases after the age of 6.

Anahtar Kelimeler

• Vesicoureteral reflux,, Voiding cysto-urethrography,Ultrasonography,Pediatrics,Diagnosis,Screening

Kaynakça

1. 1. Adibi A, Gheysari A, Azhir A, Merikhi A, Khami S, Tayari N. Value of Sonography in the Diagnosis of Mild, Moderate and Severe Vesicoureteral Reflux in Children. Saudi J Kidney Dis Transpl 2013; 24: 297-302.
2. 2. Lim R. Vesicoureteral reflux and urinary tract infection: Evolving practices and current controversies in pediatric imaging. Am J Roentgenol 2009; 192: 1197-208.
3. 3. Nafisi-Moghadam R, Malek M, Najafi F, Shishehsaz B. The Value of Ultrasound in Diagnosing Vesicoureteral Reflux in Young Children with Urinary Tract Infection. Acta Med Iran 2011; 49: 588-591.
4. 4. Lebowitz RL, Olbing H, Parkkuleinen KV, Smellie JM, Tamminen-Möbius TE. International system of radiographic grading of vesicoureteric reflux. Pediatr Radiol 1985; 15: 105–109.
5. 5. Fallah MM, Falahati M, Mohammadi A, Alizadeh M, Mladkova-Suchy N, Ghasemi-Rad M. Comparative study of color doppler voiding urosonography without contrast enhancement and direct radionuclide voiding cystography for diagnosis of vesicoureteric reflux in children. J Ultrasound Med 2012; 31: 55–61.
6. 6. Shaikh N, Spingarn RB, Hum SW. Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections. Cochrane Database Syst Rev. 2016 Jul 5;7:CD010657. doi: 10.1002/14651858. CD010657.
7. 7. Kenney IJ, Negus AS, Miller FN. Is sonographically demonstrated mild distal ureteric dilatation predictive of vesicoureteric reflux as seen on micturating cystoureterography. Pediatr Radiol 2002; 32:175-8.
8. 8. Muensterer OJ. Comprehensive ultrasound versus voiding cysturethrographyin the diagnosis of vesicoureteral reflux. Eur J Pediatr 2002; 161: 435–437.

9. 9. Otukesh H, Hoseini R, Behzadi AH, Mehran M, Tabbaroki A, Khamesan B, et al. Accuracy of cystosonography in the diagnosis of vesicourethral reflux in children. Saudi J Kidney Dis Transpl 2011; 22: 488-491.
10. 10. Thompson M, Simon SD, Sharma V, Alon US. Timing of Follow-up Voiding Cystourethrogram in Children With Primary Vesicoureteral Reflux: Development and Application of a Clinical Algorithm. Pediatrics 2005; 115:426-34.
11. 11. Darge K. Diagnosis of vesicoureteral reflux with ultrasonography. Pediatr Nephrol 2002; 17:52–60.
12. 12. Ji LN, Cao L, Chen DK,Cui YC, Zhang YL, Ye H, et al. Evaluation of the clinical and imaging examination in high-risk children with vesicoureteral reflux. Zhonghua Er Ke Za Zhi 2011; 49: 282-6.
13. 13. Haberlik A. Detection of low-grade vesicoureteral reflux in children by color Doppler imaging mode. PediatrSurg Int 1997; 12:38-43.
14. 14. Darge K, Riedmiller H. Current status of vesicoureteral reflux diagnosis. World J Urol 2004; 22: 88–95.
15. 15. Lee LC, Lorenzo AJ, Koyle MA. The role of voiding cystourethrography in the investigation of children with urinary tract infections. Can Urol Assoc J. 2016; 10: 210-214.
16. 16. Schaeffer AJ, Greenfield SP, Ivanova A, Cui G, Zerin JM, Chow JS, et al. Reliability of grading of vesicoureteral reflux and other findings on voiding cystourethrography. J Pediatr Urol. 2017; 13: 192-198.