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Comparison of Voiding Cystourethrography and Expression Cystourethrography
Vol. 106, September Printed in U.S.A.
THE JOLRNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilbns Co.
COJ\fPARISON OF VOIDING CYSTOURETHROGRAPHY AND EXPRESSION CYSTOURETHROGRAPHY EMMANUEL VLAHAKIS, GLEN W. HARTMAN
AND
PANAYOTIS P. KELALIS
From the Departments of Diagnostic Radiology and Urologic Surgery, ivlayo Clinic and Mayo Founclation, Mayo Graduate School of Medicine, Rochester, Minnesota
Detection of vesicoureteral reflux is becoming more important in pediatric urology. However, because of its elusive nature, its demonstration may be difficult despite clinical and urographic findings which strongly suggest its presence. :N" onradiologic techniques have been described 1 • 2 but the 2 methods now in vogue for demonstrating retrograde flow of urine from the bladder to the kidneys are voiding cystourethrography and expression cystourethrography. 3 • 4 Despite reports as to the relative effectiveness of both methods in dernon~trating vesicoureteral reflux, 5 it has been our clinical impression that the 2 techniques are not comparable or even complementary to each other. In this study 66 consecutive cases are compared to determine if it is worth using both methods or if one is more productive than the other. Various findings such as degree of ureterectasis and extent and timing of reflux are evaluated to determine if they have an effect on the accuracy of either examination. METHODS
Voiding cystourethrography. This procedure is performed with the patient awake. The bladder is catheterized with a small-caliber catheter and filled with opaque medium by drip infusion via plastic tubing. Fluid is introduced to the point of a sensation of fullness. The catheter is then removed and the patient voids. The urinary tract is examined fluoro;;copically during filling and Accepted for publication December 1970. 1 Amar, A. D.: Cyst.oscopic demonstration of vesicoureteral reflux: evaluation in 250 patient,;. J. Urol., 95: 776, 1966. 2 Winter, C. C.: Pediatric urological tests using radioisotopes. J. Urcl., 95: 584, 1\J66. 3 Gross, K. K and Sanderson, S. S.: Cincurethrography and voiding cinecystography, with special attention to vesico-ureteral reflux. Radiology, 77: 573, 1961. 4 Stewart, C. JVL: Delayed cystography and voiding cystoureterography. J. Urol., 74: 749, 1\)55. 5 Smith, A. M.: Comparison of standard and cine cystography for detecting vesicoureteral reflux. J. Urol., 96: 49, 196G. 414
voiding, with the findings recorded on a video tape and appropriate 90 mm. spot films. Expression cystourethrography. Cystoscopy is done first. Because of this and the ages of our patients, light general anesthesia is used. The same opaque medium is used for both techniques and is allowed to flow into the bladder by gravity until flow ceases. Spontaneous voiding sometimes occurs but, if not, suprapubic bladder pressure produces a good uninterrupted stream. Two films are taken, one in the anteroposterior view and one in the oblique view. Patients. Both types of cystourethrography were done in 66 patients (42 female and 24 male) who ranged in age from l to 30 years; 91 per cent were less than 10 yearn old. In 17 patients (26 per cent) no reflux was demonstrated by either technique. In the remaining 49 patients reflux was demonstrated by either one or both methods. The latter 49 patients are the basis of this study. The records and roentgenograms of the 49 patients were reviewed and the following were noted for all refluxing ureteric units: 1) degree of ureterectasis- normal, mild, moderate and severe; 2) timing of reflux-reflux that occurred during filling or that which occurred during voiding and 3) extent-complete (to the renal pelvis) or incomplete. RESULTS
In the 49 patients with vesicoureteral reflux, 72 ureteral units were involved; 71 (99 per cent) were demonstrated by voiding cystourethrography and 27 (38 per cent) by the expression technique. Voiding cystourethrogra phy demonstrated reflux equally well during filling or voiding (see table). However, expression cystography was positive more frequently when the reflux occurred during filling. The voiding technique was positive regardless of the state of the ureter while the expression technique tended to be more accurate when advanced ureteral dilatation was present. The voiding technique also was positive
VOIDING CYSTOURETHROGHAPHY AND EXPRESSION CYSTOURETHROGRAPHY
regardless of the extent of reflux. The expression technique was more frequently with complete reflux than with incomplete reflux (19percent).
Method
treatment. Ureteral peristaltic can be assessed. Patients of all ages can be without anesthesia or premedication. case was reflux shown thrography but not raphy. Expression cystourethrography is not com ]llernentary to voiding cystourethrography. On the contrary, it is much less accurate, provides additional information and is an unnecessary duplication of effort. The use of 2 radiographic ]Jrocedures results in unwarranted radiation exposure for the child and the n , 1,u,c,." exposure of the hand of the examiner expression cystography is not without risk. Therefore, it is certainly not worth doing both studic:-; in the hope that one may show reflux mis:.;ed the other.
No.(%)
No.(%)
SUMMARY
56 16
55 (98) 16 (100)
23 (41) 4 (25)
28 20 16 8
28 (100) Jg !95) 16 (100)
3G 36
36 (100) 35 (97)
DISCUSSION
Voiding c:rntourethrography i~ the procedure of choice for detecting n,sicoureternl reflux. It effectively demonstrates advanced case:.; but, of more importance, minor degree:.; of reflux are accurate!.,· detected, al.lowing earl>· and effective Comparison of voiding and expression techniques of cystonrethrography Reflux Demonstrated by
Total Ureteral Units
Timing: Filling Voiding Degree of uretereciasis: None Mild Moderate Severe Extent: Incomplete Complete
4liJ
\~oiding ~icthod
8 (100)
Expres~ S10Il
8 6 7 6
(29) (30)
(44) (75)
7 (19) 20 (56)
In 49 of 66 comecutive cases in \Yhich thrography was done by both the voiding and the expression technique, the voiding revealed 71 of the 72 ureteral units with Ye,,1coureteral reflux compared to 27 of the 72 the expression technique. The comparisons in this study show that the voiding technique done under fluoroscopic control is the method of choice.
THE JOLRNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilbns Co.
COJ\fPARISON OF VOIDING CYSTOURETHROGRAPHY AND EXPRESSION CYSTOURETHROGRAPHY EMMANUEL VLAHAKIS, GLEN W. HARTMAN
AND
PANAYOTIS P. KELALIS
From the Departments of Diagnostic Radiology and Urologic Surgery, ivlayo Clinic and Mayo Founclation, Mayo Graduate School of Medicine, Rochester, Minnesota
Detection of vesicoureteral reflux is becoming more important in pediatric urology. However, because of its elusive nature, its demonstration may be difficult despite clinical and urographic findings which strongly suggest its presence. :N" onradiologic techniques have been described 1 • 2 but the 2 methods now in vogue for demonstrating retrograde flow of urine from the bladder to the kidneys are voiding cystourethrography and expression cystourethrography. 3 • 4 Despite reports as to the relative effectiveness of both methods in dernon~trating vesicoureteral reflux, 5 it has been our clinical impression that the 2 techniques are not comparable or even complementary to each other. In this study 66 consecutive cases are compared to determine if it is worth using both methods or if one is more productive than the other. Various findings such as degree of ureterectasis and extent and timing of reflux are evaluated to determine if they have an effect on the accuracy of either examination. METHODS
Voiding cystourethrography. This procedure is performed with the patient awake. The bladder is catheterized with a small-caliber catheter and filled with opaque medium by drip infusion via plastic tubing. Fluid is introduced to the point of a sensation of fullness. The catheter is then removed and the patient voids. The urinary tract is examined fluoro;;copically during filling and Accepted for publication December 1970. 1 Amar, A. D.: Cyst.oscopic demonstration of vesicoureteral reflux: evaluation in 250 patient,;. J. Urol., 95: 776, 1966. 2 Winter, C. C.: Pediatric urological tests using radioisotopes. J. Urcl., 95: 584, 1\J66. 3 Gross, K. K and Sanderson, S. S.: Cincurethrography and voiding cinecystography, with special attention to vesico-ureteral reflux. Radiology, 77: 573, 1961. 4 Stewart, C. JVL: Delayed cystography and voiding cystoureterography. J. Urol., 74: 749, 1\)55. 5 Smith, A. M.: Comparison of standard and cine cystography for detecting vesicoureteral reflux. J. Urol., 96: 49, 196G. 414
voiding, with the findings recorded on a video tape and appropriate 90 mm. spot films. Expression cystourethrography. Cystoscopy is done first. Because of this and the ages of our patients, light general anesthesia is used. The same opaque medium is used for both techniques and is allowed to flow into the bladder by gravity until flow ceases. Spontaneous voiding sometimes occurs but, if not, suprapubic bladder pressure produces a good uninterrupted stream. Two films are taken, one in the anteroposterior view and one in the oblique view. Patients. Both types of cystourethrography were done in 66 patients (42 female and 24 male) who ranged in age from l to 30 years; 91 per cent were less than 10 yearn old. In 17 patients (26 per cent) no reflux was demonstrated by either technique. In the remaining 49 patients reflux was demonstrated by either one or both methods. The latter 49 patients are the basis of this study. The records and roentgenograms of the 49 patients were reviewed and the following were noted for all refluxing ureteric units: 1) degree of ureterectasis- normal, mild, moderate and severe; 2) timing of reflux-reflux that occurred during filling or that which occurred during voiding and 3) extent-complete (to the renal pelvis) or incomplete. RESULTS
In the 49 patients with vesicoureteral reflux, 72 ureteral units were involved; 71 (99 per cent) were demonstrated by voiding cystourethrography and 27 (38 per cent) by the expression technique. Voiding cystourethrogra phy demonstrated reflux equally well during filling or voiding (see table). However, expression cystography was positive more frequently when the reflux occurred during filling. The voiding technique was positive regardless of the state of the ureter while the expression technique tended to be more accurate when advanced ureteral dilatation was present. The voiding technique also was positive
VOIDING CYSTOURETHROGHAPHY AND EXPRESSION CYSTOURETHROGRAPHY
regardless of the extent of reflux. The expression technique was more frequently with complete reflux than with incomplete reflux (19percent).
Method
treatment. Ureteral peristaltic can be assessed. Patients of all ages can be without anesthesia or premedication. case was reflux shown thrography but not raphy. Expression cystourethrography is not com ]llernentary to voiding cystourethrography. On the contrary, it is much less accurate, provides additional information and is an unnecessary duplication of effort. The use of 2 radiographic ]Jrocedures results in unwarranted radiation exposure for the child and the n , 1,u,c,." exposure of the hand of the examiner expression cystography is not without risk. Therefore, it is certainly not worth doing both studic:-; in the hope that one may show reflux mis:.;ed the other.
No.(%)
No.(%)
SUMMARY
56 16
55 (98) 16 (100)
23 (41) 4 (25)
28 20 16 8
28 (100) Jg !95) 16 (100)
3G 36
36 (100) 35 (97)
DISCUSSION
Voiding c:rntourethrography i~ the procedure of choice for detecting n,sicoureternl reflux. It effectively demonstrates advanced case:.; but, of more importance, minor degree:.; of reflux are accurate!.,· detected, al.lowing earl>· and effective Comparison of voiding and expression techniques of cystonrethrography Reflux Demonstrated by
Total Ureteral Units
Timing: Filling Voiding Degree of uretereciasis: None Mild Moderate Severe Extent: Incomplete Complete
4liJ
\~oiding ~icthod
8 (100)
Expres~ S10Il
8 6 7 6
(29) (30)
(44) (75)
7 (19) 20 (56)
In 49 of 66 comecutive cases in \Yhich thrography was done by both the voiding and the expression technique, the voiding revealed 71 of the 72 ureteral units with Ye,,1coureteral reflux compared to 27 of the 72 the expression technique. The comparisons in this study show that the voiding technique done under fluoroscopic control is the method of choice.