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Clinical Applications of Nuclear Cystography
0022-534 7/82/1283-0550$02.00/0 Vol. 128, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
CLINICAL APPLICATIONS OF NUCLEAR CYSTOGRAPHY PHILLIP F. NASRALLAH, SREERAMULU NARA
AND
JOSEPH CRAWFORD
From the Divisions of Urology and Department of Radiology, Children's Hospital Medical Center and Akron City Hospital, Akron, Ohio
ABSTRACT
Nuclear cystography is a sensitive test for detection of vesicoureteral reflux. The value of this sensitivity has not always been appreciated fully. A significant degree of reflux that warrants surgical repair seems readily demonstrable by conventional x-ray methods. Our experience with x-ray and nuclear cystography illustrates the frequent inadequacies of the conventional x-ray study. In 15 of 86 patients reflux of significant clinical degree was demonstrated by the nuclear study alone. This information has proved valuable in the eventual management of these patients. Since introduction of the method by Winter in 1959 1 several investigators have defined the advantages of radionuclide cystography over its conventional x-ray counterpart. 2 • 3 Increased sensitivity, decreased radiation exposure and quantitative data are 3 clear advantages of the nuclear study. 4 One major criticism is that increased sensitivity offers no real clinical advantage over conventional x-ray cystography in the vast majority of ca.ses, that is mild grades of reflux often defined by the nuclear study do not really pose a threat of pyelonephritis to the patient. Reflux of sufficient magnitude to cause renal scarring and to warrant surgical correction is thought to be defined readily by either study. Our experience with nuclear cystography shows several specific clinical situations in which the increased sensitivity of the radionuclide study has proved invaluable. METHODS AND MATERIALS
Since 1978 we have examined 86 patients with conventional and radionuclide cystography. Only those patients who underwent both studies within 3 months of each other are included for purposes of discussion. The technique of radionuclide cystography has been described in detail elsewhere. 5 The x-ray cystogram is done by obtaining 5 films, including oblique views, during bladder filling as well as several during and after voiding. There were 11 male and 75 female patients, ranging from 2 to 19 years old. Most nuclear studies were done as followup examinations for reflux that had been defined previously on x-ray cystography. Some patients underwent the nuclear study after negative xray cystograms in an effort to disclose the cause of ureteral dilatation, calicectasis, renal scarring or severe renal atrophy with nonfunction. RESULTS
In 67 patients the results of both studies were in agreement. There were 45 negative and 22 positive studies. In 11 patients reflux was defined with the nuclear study when the conventional x-ray was normal. In 4 additional patients the nuclear study showed bilateral reflux when the x-ray cystogram demonstrated unilateral reflux. In 4 patients the x-ray cystogram was positive when nuclear studies were negative. There was no case in which bilateral reflux was demonstrated on an x-ray when the nuclear study showed unilateral reflux. DISCUSSION
Nuclear cystography offers clear advantages over the conventional x-ray study. However, the true value of the increased Accepted for publication December 4, 1981.
Our
sensitivity of the radionuclide study has been debatable. study supports the work of other investigators, 2- 4 confirming the superior sensitivity of the nuclear study. More importantly, our series demonstrates several clinical settings in which nuclear cystography was invaluable in eventual patient management and gave information not realized from the x-ray study. An excretory urogram (IVP) and cystogram of a girl (case 1) who has had several episodes of pyelonephritis (fever, flank pain and culture-proved urinary tract infection) are shown in figure 1, A and B. Aside from mild calicectasis on the left side the study, along with another done 1 year later, was unremarkable. However, the nuclear study showed significant left reflux (fig. 1, C). Cystoscopy revealed a slightly lateral orifice along with a paraureteral diverticulum of 1.5 cm. Antireflux surgery was performed and the patient was well 10 months postoperatively. An IVP from a 3-year-old girl (case 2) with recurrent urinary infection and anemia is shown in figure 2, A and B. She had grade 2b left reflux but the ureterectasis on the right side was unexplained. Cystoscopy showed the right orifice in the B position with a 5 mm. tunnel and a right retrograde pyelogram ruled out obstruction. The nuclear cystogram demonstrated bilateral reflux to the renal pelvis (fig. 2, C). Presently, the patient is being managed conservatively. Conventional x-ray cystography is attended by a small percentage of false negatives and in some cases the reflux may be of a clinically significant degree. In children with recurrent pyelonephritis, or unexplained ureteral dilatation or calicectasis the nuclear cystogram may aid in the diagnosis of reflux without unwarranted x-ray exposure to the child. The cystograms from a 3-year-old boy (case 3) who presented with urinary infection are shown in figure 3, A and B. Cystoscopy showed the right orifice in the C position and the left orifice in the D position at the inferior margin of a diverticulum. Neither orifice had any submucosal tunnel. Followup films 6 months later showed that the reflux on the right side had stopped but the reflux on the left side remained the same. Nuclear cystography was done immediately after the x-ray study to be sure that bilateral reimplantation would not be necessary. The nuclear study revealed that both sides did, indeed, have reflux and, therefore, bilateral reimplantation was done (fig. 3, C). Currently, it is our practice to obtain nuclear cystography before reimplantation to define better the procedure(s) needed. It is apparent that in cases in which reflux appears on the contralateral side after reimplantation reflux may have, indeed, been present and missed preoperatively. Figure 4, A and B shows a nonfunctioning, atrophic left kidney in a 17-year-old woman (case 4) with recurrent severe urinary infections. This renal unit is part of a horseshoe kidney. A conventional x-ray failed to show reflux but the nuclear study 550
P...PFLICATIO~TS O}~ 1\TUCLEltH. CYSTGGR.
FIG. 2. Case 2.1'°1, IVP. B, voiding cystourethrogn,m. C, nuclear cystogTam
FIG. 3. Case 3. A, IVP. B, voiding cystourethrogram. C, nucleaT cystogrnm
did demonstrate reflux to the left renal pelvis (fig. 4, The patient was managed by right pyeloplasty plus left nephroureterectomy. A diagnosis of reflux in the atrophic left unit aided in the decision to remove the entire ureteL Postoperatively, she has remained free of infection. The cystograms from a 9-month-old girl (case 5) are shown in figure 5, A and H Bilateral reflux was thought to have resolved after just 6 months of conservative therapy. However, after antimicrobial suppression was discontinued the patient presented with a severe episode of pyelonephritis. Nuclear
cystography demonstrated that the reflux was, indeed, continuing and was of significant grade (fig. 5, C). This case and several similaT ones have influenced us to consider reflux as still present in those patients being followed with conservative therapy until the nuclear study is negative. Cystograms that show reflux that was missed on nuclear cystography are shown in figure 6. The grade of reflux was mild and in each case the followup x-rays have shown the reflux to have spontaneously dissipated. We have not missed clinically significant reflux with the nuclear study.
552
NASRALLAH, NARA AND CRAWFORD
Fm. 4. Case 4. A, IVP. B, voiding cystourethrogram. C, nuclear cystogram shows reflux (arrow)
C
• Fm. 5. Case 5. A, original voiding cystourethrogram. B, followup voiding cystourethrogram 4 months later. No reflux was seen. C, simultaneous nuclear cystogram shows severe left reflux.
Fm. 6. Voiding cystourethrograms of 3 patients in whom nuclear cystogram was negative. All reflux spontaneously resolved as determined on conventional and nuclear cystography.
REFERENCES 1. Winter, C. C.: A new test for vesicoureteral reflux: an external
technique using radioisotopes. J. Urol., 81: 105, 1959. 2. Conway, J. J., King, L. R., Belman, A. B. and Thorson, T., Jr.: Detection of vesicoureteral reflux with radionuclide cystography. A comparison study with roentgenographic cystography. Amer. J. Roentgen., 115: 720, 1972. 3. Rothwell, D. L., Constable, A. and Albrecht, M.: Radionuclide cystography in the investigation of vesicoureteric reflux in children. Lancet, 1: 1072, 1977. 4. Nasrallah, P. F., Conway, J. J., King, L. R., Belman, A. B. and
Weiss, S.: Quantitative nuclear cystogram. Aid in determining spontaneous resolution ofvesicoureteral reflux. Urology, 12: 654, 1978. 5. Weiss, S. and Conway, J. J.: The technique of direct radionuclide cystography. Appl. Rad., 4: 133, 1975. EDITORIAL COMMENT The isotope cystogram has become an accepted tool in pediatric urology and, as noted by the authors, may be more sensitive than the standard cystogram in determining if reflux is present. A significant advantage, not mentioned by the authors, is that of constant monitoring
553 during the p:rocedure ,;vithout additional radiation exposure to the patient. Constant monitoring nJ.ay account for the increased sensitivity of the study. One can consider evaluating all girls with urinary tract infection with an isotope cystogra,"Il as the initial study, since radiographic evaluation of the ureth:ra has no real diagnostic role in that group. Those of us who are participating in the International Reflux Study have to grade reflux accurately to determine when a child has grade IV /V (DwoskinPerlmutter grade III) vesicoureteral reflux and, thus, becomes a candidate for inclusion. The only drawback of the isotope cystogram is the
inability tc define accurately the configuration of the collectir_;_g system. Our policy is to use the isotope cvst,J21·arn as a means of follov.;ing those p·atients with reflux who are nonoperatively and are on continuous antibacterial prophylaxis (referred to as conservative therapy in this paper). Annual isotope cystograms are used as a means of determining when medication can be discontinued. A. Barry Belman Department of Urology Children's Hospital National Medical Center Washington, D. C.
THE JOURNAL OF UROLOGY
Copyright© 1982 by The Williams & Wilkins Co.
CLINICAL APPLICATIONS OF NUCLEAR CYSTOGRAPHY PHILLIP F. NASRALLAH, SREERAMULU NARA
AND
JOSEPH CRAWFORD
From the Divisions of Urology and Department of Radiology, Children's Hospital Medical Center and Akron City Hospital, Akron, Ohio
ABSTRACT
Nuclear cystography is a sensitive test for detection of vesicoureteral reflux. The value of this sensitivity has not always been appreciated fully. A significant degree of reflux that warrants surgical repair seems readily demonstrable by conventional x-ray methods. Our experience with x-ray and nuclear cystography illustrates the frequent inadequacies of the conventional x-ray study. In 15 of 86 patients reflux of significant clinical degree was demonstrated by the nuclear study alone. This information has proved valuable in the eventual management of these patients. Since introduction of the method by Winter in 1959 1 several investigators have defined the advantages of radionuclide cystography over its conventional x-ray counterpart. 2 • 3 Increased sensitivity, decreased radiation exposure and quantitative data are 3 clear advantages of the nuclear study. 4 One major criticism is that increased sensitivity offers no real clinical advantage over conventional x-ray cystography in the vast majority of ca.ses, that is mild grades of reflux often defined by the nuclear study do not really pose a threat of pyelonephritis to the patient. Reflux of sufficient magnitude to cause renal scarring and to warrant surgical correction is thought to be defined readily by either study. Our experience with nuclear cystography shows several specific clinical situations in which the increased sensitivity of the radionuclide study has proved invaluable. METHODS AND MATERIALS
Since 1978 we have examined 86 patients with conventional and radionuclide cystography. Only those patients who underwent both studies within 3 months of each other are included for purposes of discussion. The technique of radionuclide cystography has been described in detail elsewhere. 5 The x-ray cystogram is done by obtaining 5 films, including oblique views, during bladder filling as well as several during and after voiding. There were 11 male and 75 female patients, ranging from 2 to 19 years old. Most nuclear studies were done as followup examinations for reflux that had been defined previously on x-ray cystography. Some patients underwent the nuclear study after negative xray cystograms in an effort to disclose the cause of ureteral dilatation, calicectasis, renal scarring or severe renal atrophy with nonfunction. RESULTS
In 67 patients the results of both studies were in agreement. There were 45 negative and 22 positive studies. In 11 patients reflux was defined with the nuclear study when the conventional x-ray was normal. In 4 additional patients the nuclear study showed bilateral reflux when the x-ray cystogram demonstrated unilateral reflux. In 4 patients the x-ray cystogram was positive when nuclear studies were negative. There was no case in which bilateral reflux was demonstrated on an x-ray when the nuclear study showed unilateral reflux. DISCUSSION
Nuclear cystography offers clear advantages over the conventional x-ray study. However, the true value of the increased Accepted for publication December 4, 1981.
Our
sensitivity of the radionuclide study has been debatable. study supports the work of other investigators, 2- 4 confirming the superior sensitivity of the nuclear study. More importantly, our series demonstrates several clinical settings in which nuclear cystography was invaluable in eventual patient management and gave information not realized from the x-ray study. An excretory urogram (IVP) and cystogram of a girl (case 1) who has had several episodes of pyelonephritis (fever, flank pain and culture-proved urinary tract infection) are shown in figure 1, A and B. Aside from mild calicectasis on the left side the study, along with another done 1 year later, was unremarkable. However, the nuclear study showed significant left reflux (fig. 1, C). Cystoscopy revealed a slightly lateral orifice along with a paraureteral diverticulum of 1.5 cm. Antireflux surgery was performed and the patient was well 10 months postoperatively. An IVP from a 3-year-old girl (case 2) with recurrent urinary infection and anemia is shown in figure 2, A and B. She had grade 2b left reflux but the ureterectasis on the right side was unexplained. Cystoscopy showed the right orifice in the B position with a 5 mm. tunnel and a right retrograde pyelogram ruled out obstruction. The nuclear cystogram demonstrated bilateral reflux to the renal pelvis (fig. 2, C). Presently, the patient is being managed conservatively. Conventional x-ray cystography is attended by a small percentage of false negatives and in some cases the reflux may be of a clinically significant degree. In children with recurrent pyelonephritis, or unexplained ureteral dilatation or calicectasis the nuclear cystogram may aid in the diagnosis of reflux without unwarranted x-ray exposure to the child. The cystograms from a 3-year-old boy (case 3) who presented with urinary infection are shown in figure 3, A and B. Cystoscopy showed the right orifice in the C position and the left orifice in the D position at the inferior margin of a diverticulum. Neither orifice had any submucosal tunnel. Followup films 6 months later showed that the reflux on the right side had stopped but the reflux on the left side remained the same. Nuclear cystography was done immediately after the x-ray study to be sure that bilateral reimplantation would not be necessary. The nuclear study revealed that both sides did, indeed, have reflux and, therefore, bilateral reimplantation was done (fig. 3, C). Currently, it is our practice to obtain nuclear cystography before reimplantation to define better the procedure(s) needed. It is apparent that in cases in which reflux appears on the contralateral side after reimplantation reflux may have, indeed, been present and missed preoperatively. Figure 4, A and B shows a nonfunctioning, atrophic left kidney in a 17-year-old woman (case 4) with recurrent severe urinary infections. This renal unit is part of a horseshoe kidney. A conventional x-ray failed to show reflux but the nuclear study 550
P...PFLICATIO~TS O}~ 1\TUCLEltH. CYSTGGR.
FIG. 2. Case 2.1'°1, IVP. B, voiding cystourethrogn,m. C, nuclear cystogTam
FIG. 3. Case 3. A, IVP. B, voiding cystourethrogram. C, nucleaT cystogrnm
did demonstrate reflux to the left renal pelvis (fig. 4, The patient was managed by right pyeloplasty plus left nephroureterectomy. A diagnosis of reflux in the atrophic left unit aided in the decision to remove the entire ureteL Postoperatively, she has remained free of infection. The cystograms from a 9-month-old girl (case 5) are shown in figure 5, A and H Bilateral reflux was thought to have resolved after just 6 months of conservative therapy. However, after antimicrobial suppression was discontinued the patient presented with a severe episode of pyelonephritis. Nuclear
cystography demonstrated that the reflux was, indeed, continuing and was of significant grade (fig. 5, C). This case and several similaT ones have influenced us to consider reflux as still present in those patients being followed with conservative therapy until the nuclear study is negative. Cystograms that show reflux that was missed on nuclear cystography are shown in figure 6. The grade of reflux was mild and in each case the followup x-rays have shown the reflux to have spontaneously dissipated. We have not missed clinically significant reflux with the nuclear study.
552
NASRALLAH, NARA AND CRAWFORD
Fm. 4. Case 4. A, IVP. B, voiding cystourethrogram. C, nuclear cystogram shows reflux (arrow)
C
• Fm. 5. Case 5. A, original voiding cystourethrogram. B, followup voiding cystourethrogram 4 months later. No reflux was seen. C, simultaneous nuclear cystogram shows severe left reflux.
Fm. 6. Voiding cystourethrograms of 3 patients in whom nuclear cystogram was negative. All reflux spontaneously resolved as determined on conventional and nuclear cystography.
REFERENCES 1. Winter, C. C.: A new test for vesicoureteral reflux: an external
technique using radioisotopes. J. Urol., 81: 105, 1959. 2. Conway, J. J., King, L. R., Belman, A. B. and Thorson, T., Jr.: Detection of vesicoureteral reflux with radionuclide cystography. A comparison study with roentgenographic cystography. Amer. J. Roentgen., 115: 720, 1972. 3. Rothwell, D. L., Constable, A. and Albrecht, M.: Radionuclide cystography in the investigation of vesicoureteric reflux in children. Lancet, 1: 1072, 1977. 4. Nasrallah, P. F., Conway, J. J., King, L. R., Belman, A. B. and
Weiss, S.: Quantitative nuclear cystogram. Aid in determining spontaneous resolution ofvesicoureteral reflux. Urology, 12: 654, 1978. 5. Weiss, S. and Conway, J. J.: The technique of direct radionuclide cystography. Appl. Rad., 4: 133, 1975. EDITORIAL COMMENT The isotope cystogram has become an accepted tool in pediatric urology and, as noted by the authors, may be more sensitive than the standard cystogram in determining if reflux is present. A significant advantage, not mentioned by the authors, is that of constant monitoring
553 during the p:rocedure ,;vithout additional radiation exposure to the patient. Constant monitoring nJ.ay account for the increased sensitivity of the study. One can consider evaluating all girls with urinary tract infection with an isotope cystogra,"Il as the initial study, since radiographic evaluation of the ureth:ra has no real diagnostic role in that group. Those of us who are participating in the International Reflux Study have to grade reflux accurately to determine when a child has grade IV /V (DwoskinPerlmutter grade III) vesicoureteral reflux and, thus, becomes a candidate for inclusion. The only drawback of the isotope cystogram is the
inability tc define accurately the configuration of the collectir_;_g system. Our policy is to use the isotope cvst,J21·arn as a means of follov.;ing those p·atients with reflux who are nonoperatively and are on continuous antibacterial prophylaxis (referred to as conservative therapy in this paper). Annual isotope cystograms are used as a means of determining when medication can be discontinued. A. Barry Belman Department of Urology Children's Hospital National Medical Center Washington, D. C.