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Intravenous Urography in Infants and Children1. Observations in 304 Cases
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDREN 1 OBSERVATIONS IN 304 CASES MEREDITH F. CAMPBELL From the Babies' Hospital and the Departments of Urology and Children's Medicine, Bellevue Hospital
Increased diagnostic accuracy in congenital or acquired uropathy in infants and children was one of the anticipated advantages of intravenous urography when first introduced. Subsequent experience has demonstrated that the method (a) is often inadequate even in normal cases and (b) is not always a reliable last resort in urologic diagnosis in those cases in which complete instrumental investigation is undesirable, or is pro·· hibited by lack of parental consent or inability of the investigator. During the past two years several reports of intravenous urography in small series of juveniles have appeared. Among the reports most favorable to the method is that of Schwentker who found that in 56 young patients thus examined at the Johns Hopkins Hospital satisfactory diagnostic help was obtained in 65 per cent of the 42 children over two years of age and in 35 per cent of the remaining fourteen under two years . The present report is based on our observations in 381 intravenous urographic series in 304 infants and children; in this study almost 1900 films were analyzed. There were 2 patients three weeks old and 2 weeks old (table 1). There were 182 females and 122 males. Although the data acquired in this comparative study warrant only general conclusions, they suggest that even under favorable conditions intravenous urography in children will be unsatisfactory in about a third of the cases and under unfavorable conditions is practically valueless. In the investigation of these patients a wide variety of roentgenographic assistance has been received. In general, the patience of the roentgenographer and the accuracy of his technic are the most Important factors termining the success of excretory urography and for comparative study our cases have been grouped on this basis (table 2). 1. The Lysholm plate grid has been used recently in several cases with considerable improvement in clarity of detail.
55 THE JOURNAL OF UROLOGY 1 VOL. XXXIT 1 NO,
1
56
MEREDITH F. CAMPBELL INDICATIONS
Intravenous urography is indicatJd in almost every case in which visualization of the urinary tract is desired. We have employed the method in children for diagnostic assistance in chronic pyuria, in hematuria not due to nephritis, in tumor or pain in or along the upper urinary TABLE 1 NUMBER OF CASES
26
Under 6 months* ................................................. . 7 to 12 months ................................................... . 1 to 3 years ...................................................... . 4 to 6 years ...................................................... . 7 to 10 years ..................................................... . 11 to 12 years .................................................... .
95 36
Total. ................................. ·····.················
304
14
57 76
* Youngest three weeks, oldest twelve years.
TABLE 2 DIAG-
URETER
NOSIS
STRICTURE
., C
I i:1 :,,
t.z
"'
~
!:l A B C
85 134 85
z
"'c3
...
6 1
+-
....@!
:,,
;1
0
21 6 19
28 30 27 101 37 28
4 79 19
24 88 47
~
z
0
.,"'~ § j ~ . . ~ ~ 8 - - - - - -
"'., 9 ti "'ci
~lo<
Ir
ti
0
~ 5
~
0
CJ
~z
~ CJ Plp
0
~
0
36 20 24
4 31 2
-
18 32 27
~
I.,"
0
;s.,
::;0
@!
:,,
.Isi .I . ~
i -. -. -. -z - -~ CJ
17 8 11
1 2 2
>, .0
>, .0
-;.
.,l
"""
-~/; i
l
~
"' 0
:5" j - - -< - - lo<
III
35 9 39
.3"
l
el
~
-~"
4 1 1
6 1
~
"'
~
·;;
~
10 7 4
-g ~
21 20 23
8 4 3
2
5 8
-
6 7 21 64 15 2 13 Total. ....... 304 7 46 92 159 102 159 80 37 77 83 36 5 1. 9 15.1 30.5 52.2 33.5 52. 2 26.3 12.1 25.3 27 .3 11.8 1.6 1. 9 1. 9 7 .0 21.5 4.9 0.6 4.2 Per cent .....
• All details sharply defined; the kind a manufacturer of intravenous media would display in advertising. t Clear enough to permit an accurate diagnosis. t The probable diagnosis can be made by compositing the entire series. § Less satisfactory than (3) or unreadable. ,r Doubtless in many of these cases overlying gas and fecal shadows clouded the shadows of the excreted drug.
tract and, in some instances, in disturbances of urination not falling under the above groupings. In two instances each it was employed to differentiate from kidney, enlargement of the spleen or liver and in one case each dermoid, mesenteric cyst, pyloric obstruction, and perirenal teratoma. In 243 cases (80 per cent) of this series, the indication was
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDREN
chronic pyuria and although we now employ precystoscopic excretory urography routinely in these cases, in some of the earlier ones 1 intravenous urography was not attempted until retrograde pyelographic studies had been made. Parenthetically, in practically every case in children showing an abnormal excretion urogram or in which the ureteral. catheter findings suggest upper tract disease, a retrograde pyelogram should be made. Using the intravenous urographic media for catheter injection, I have not hesitated to perform bilateral retrograde pyelography. Retrograde urography was employed in all but 36 of the 304 cases and serves as a check on the intravenous method. Intravenous urography is particularly indicated in those cases in which ureteral catheterization (or cystoscopy) is impossible or is refused, or in which the condition of the patient does not warrant instrumentation. Yet with modern miniature cystoscopic instruments and due care, many conditions which have been considered indications for excretory urography alone, should be accessible to more direct examination. I have performed simultaneous bilateral ureteral catheterization in several girls under three months of age and using a No. 7 F. (Wolff) cystoscope have without difficulty performed observation cystoscopy in a boy of ten days. Using a No. 13 F. double catheterizing cystoscope made for me this past year, I have performed simultaneous bilateral catheterization in a boy of nine months. Therefore, and contrary to popular conception among physicians, intravenous urography need not be looked upon as the only source of definitive uro·· logic information in the very young. CONTRAINDICATIONS
Intravenous urography is said to be contraindicated by: (1) severe renal or (2) hepatic deficiency, (3) iodine idiosyncrasy, (4) thyrotoxicosis, (5) active pulmonary tuberculosis (6) exudative diathesis in children. Yet I have used it (neo-skiodan) without demonstrable untoward effect in several children whose phenolsulphonphthalein output was less than 5 per cent in two hours (in 2 cases the output was zero) and in 3 children with advanced nephrosis. Failure to obtain urographic shadows was accounted for by the severe renal impairment. Age is no contraindication; fairly satisfactory excretory urograms were once obtained in a child three weeks of age and in 2 cases at four weeks of age (table 1). LIMITATIONS
Unsatisfactory results are favored by faulty roentgen technique 1 poor renal function, polyuria and confusing gas or fecal shadows. With poor
58
MEREDITH F . CAMPBELL
renal function in the presence of obstruction, diagnostic films may not be obtained until late; in one of my patients, shadows did not appear until four hours after injection and in another only after twenty-four hours. In polyuria the low concentration of the medium in the urine causes failure; in infants I have several times found practically the entire excretion of the medium in the bladder ten minutes after injection. Preliminary dehydration combats this. Freedom from gas shadows is largely a matter of chance. Excretory shadows too indefinite to permit an accurate diagnosis are often seen in renal infection, both tuberculous and non-tuberculous, in tumors and polycystic disease and, unless there is low obstruction, the ureter shadow will probably be partial or indefinite. In connection with the latter point: the normally small pelvis and ureter in the very young will contain only a relatively thin thread of excreted medium for radiographic exposure. Unless confirmatory retrograde pyelograms are made, hazy, fuzzy or absent shadows due to incomplete pelvic filling are likely to be erroneously interpreted. Although radiographic evidence of the quantitative and qualitative excretion of the medium is a moderately reliable comparative test of the function of the two kidneys, it should not replace the phenolsulphonphthalein or indigocarmine excretion estimations. TECHNIQUE
Media. Iopax (19 times), neo-iopax (8 times), skiodan (7 times) and neo-skiodan (347 times) have been employed in this series. Iopax and skiodan are disadvantageous to inject because of the relatively large fluid bulk required; in highly nervous or unruly children this is a real disadvantage. Because of its freedom from irritating effect as manifested by absence of pain in the arm on injection, its minimal toxicity, rapid excretion and satisfactory concentration, I prefer neo-skiodan and particularly in children. Dose. This is relatively much greater than in adults; the average doses I employ in children are as follows :. Per cent of adult dose
Under 6 months ... . . .. . . ... . .... . . ... . . . . . . . .. . ... . ... . . .. . .... . .. 7 to 12 months . .. ..... ..... ... . .... .. . .. . . .. . ..... . . . . .... .. . . . .. . 1 to 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 to 6 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 7 to 8 years ..... . . .. . . .. . .... .. . ..... ... .. .. . ... ..... . . .. . . ... . ...
25-30 30-35 35-50 50-80 80-100
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDR\EN
59
Yet I have given a full adult dose of neo-skiodan to children of :five years without untoward effect. Preparation of patient. The child should be spared purging, enemas "until the return is clear," and starvation. Yet in constipated children a small dose of castor oil and low enema to clear out the rectum are sometimes advantageous. No meal should be omitted; the longer the interval from the last meal, the greater will be the gaseous distension of the bowel. Greatly reducing the fluid intake for from twelve to eighteen hours before the examination considerably increases the concentration in the urine of the excreted medium and thereby favors better urographic definition. I have experimented with practically every recommended method to eliminate intestinal gas, including the administration of charcoal to adsorb the gas, but the best results have been obtained when there has been no preparation other than dehydration. Injection. In older children the injection is usually given in one of the cubital veins; in infants with fat arms and delicate vessels one may be forced to employ superficial veins elsewhere (wrist, back of hand, feet or scalp), the external jugular vein or, as I did but once, the fontanelle. The injection should take at least two minutes; employment of a fine needle will control any tendency to too rapid injection. To submit the child to a general anesthetic in order to give the intravenous injection is unjustifiable. Yet I am aware that it has been done. If general anesthesia is to be given, perform cystoscopy and, if indications exist, ureteral catheterization and retrograde pyelography. Maneuvers to favor satisfactory urograms. Some children were kept in exaggerated Trendelenburg position from the beginning of the injection until completion of the radiographic exposures. In some the bladder was kept full of urine or other fluid in the hope of producing upper tract stasis to retard uretero-pelvic emptying. Both methods were soon abandoned. The compression bag over the lower abdomen sometimes promotes good pelvic and upper ureter :filling in older children but has been unsuccessful in younger patients. Adequate dehydration as described above is the best solution that I have found to this problem in children. Roentgenography. The conventional Bucky diaphragm can be used only in older cooperative children. In all others shorter exposures (i16 to ¼second) must be employed. 1 With the latter group the roentgenographer must exert unusual patience and cooperation to make the
60
MEREDITH F. CAMPBELL
exposure in the fraction of a second when the child is still; this is usually at one of the extremes of respiration and preferably at full expiration. Interval between exposures. As a rule this is considerably less in children than in adults. The following schedule will be found satisfactory in most children: (1) flat plate before intravenous injection; (2) inject the radiopaque medium; (3) take films five, ten and fifteen minutes from completion of the injection. The immediate development of the early films will indicate whether longer or shorter intervals between exposures will be advantageous-in some instances subsequent films at intervals of an hour or more may be indicated. Reaction. In this series of 381 administrations of radiopaque media, erythema occurred twice. In an eight-year-old girl given 40 cc. of skiodan the neck and face were involved with marked swelling of the lips, tongue and about the eyes. The reaction appeared about ten minutes after the injection and did not disappear entirely until three hours later. A girl of six years was given 12 cc. of neo-skiodan; a generalized erythema but without edema appeared within ten minutes and disappeared within the hour. Transient nausea and flushing are occasionally observed but are no cause for alarm; the former may be usually overcome by a few deep respirations. RESULTS
The results in this series of 304 cases have been grouped according to the source of the films (table 2). The cases in series A are from a hospital whose roentgen technician is unusually tolerant with children and meticulous in radiographic detail. He is gifted with patience to wait until the fractional-second exposure can properly be made. In two-thirds of these cases (64.7 per cent) the urograms were of diagnostic aid. Series B is from a large municipal hospital employing for the greater part mediocre, impatient and often careless roentgen technicians. In this series, a fourth (24.6 per cent) of the urograms were of aid. To one unusually well qualified technician at this institution is accredited nearly all of the satisfactory films. The poor results obtained when proper roentgenographic technic and intelligence are not displayed bespeak the enormous economic loss in the wasted use of equipment and supplies, and the unfairness to the patient as well as the fruitlessness of the physician's time and efforts. I have examined the patients in series C in other hospitals in the New York Metropolitan area and in my office. It is believed they represent average results under reasonably favorable con-
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDREN
61
ditions. Two-thirds (67 per cent) of these urograms were of diagnostic assistance. It is unimportant to detail the urographic findings in~- this series. Eighty-three or 57.2 per cent of the 145 cases in which a diagnosis could be hazarded (table 2) were classified as normal. Among the more teresting congenital anomalies, the diagnosis of which was otherwise confirmed, were uretero-pelvic reduplication, 19 cases, (unilateral in bilateral in 2, partial in 5, complete in 14 and with one ectopic urethra orifice in 3); congenital solitary kidney, 3 cases; fused pelvic kidney, horseshoe kidney, each one case. Among the interesting acquired lesions in which the diagnosis was made or assisted by intravenous urography were renal tuberculosis, 5 cases; renal stone and renal trauma, 2 cases; renal tumor, 6 cases; hydronephrosis, 36 cases; and extraurinary tract conditions stimulating renal disease (chiefly tumor) 7 caseso 2 In 4 cases of ureterosigmoidostomy for bladder extrophy, postoperative excretion urograms were excellent in one, moderately satisfactory in two and poor in one. The question of operation on excretory urographic findings arises . Although it may be done on the roentgen evidence in stone and hydronephrosis when these data are definite, in children at least, a more complete examination is advised. In the only patient upon whom I operated on the evidence of intravenous urography alone, a boy of five years with a large, soft right loin mass and a urogram showing advanced hydronephrosis and a ureter the size of the colon down to the ureterovesical junction, the collapsed removed kidney showed a wholly unsuspected amount of redeemable parenchyma. Elimination of the ureterovesical junction stricture alone might have preserved the organ. This is as an error in judgment and not as a fallacy of the method. Since this experience, no matter how striking the excretory evidence, I have in-eluded ureteral catheterization in the examination. In renal. tuberculosis, the function of the good kidney and its freedom from tuberculous infection can scarcely be determined except by the ureteral catheter and even then confusion may arise. SUMMARY
Despite the commonly encountered technical handicaps to successful intravenous urography, the method will frequently offer invaluable 2 In the above indicated congenital and acquired lesions there are 37 instances of reduplication, notably hydronephrosis as a secondary condition.
62
MEREDITH F. CAMPBELL
aid in urologic diagnosis in infants and children. Yet too much should not be expected of it. N ephrectomy in juveniles is seldom justified on excretory urographic findings alone. In final analysis, unsatisfactory intravenous urographic studies in infants and children are far more often due to improper roentgen technic than to abnormal renal function or other uropathy. 140 East 54th Street, New York, N . Y . REFERENCE SCHWENTKER,
F. F .: Bull. Johns Hopkins Hosp., November, 1932, Ii, 318.
Increased diagnostic accuracy in congenital or acquired uropathy in infants and children was one of the anticipated advantages of intravenous urography when first introduced. Subsequent experience has demonstrated that the method (a) is often inadequate even in normal cases and (b) is not always a reliable last resort in urologic diagnosis in those cases in which complete instrumental investigation is undesirable, or is pro·· hibited by lack of parental consent or inability of the investigator. During the past two years several reports of intravenous urography in small series of juveniles have appeared. Among the reports most favorable to the method is that of Schwentker who found that in 56 young patients thus examined at the Johns Hopkins Hospital satisfactory diagnostic help was obtained in 65 per cent of the 42 children over two years of age and in 35 per cent of the remaining fourteen under two years . The present report is based on our observations in 381 intravenous urographic series in 304 infants and children; in this study almost 1900 films were analyzed. There were 2 patients three weeks old and 2 weeks old (table 1). There were 182 females and 122 males. Although the data acquired in this comparative study warrant only general conclusions, they suggest that even under favorable conditions intravenous urography in children will be unsatisfactory in about a third of the cases and under unfavorable conditions is practically valueless. In the investigation of these patients a wide variety of roentgenographic assistance has been received. In general, the patience of the roentgenographer and the accuracy of his technic are the most Important factors termining the success of excretory urography and for comparative study our cases have been grouped on this basis (table 2). 1. The Lysholm plate grid has been used recently in several cases with considerable improvement in clarity of detail.
55 THE JOURNAL OF UROLOGY 1 VOL. XXXIT 1 NO,
1
56
MEREDITH F. CAMPBELL INDICATIONS
Intravenous urography is indicatJd in almost every case in which visualization of the urinary tract is desired. We have employed the method in children for diagnostic assistance in chronic pyuria, in hematuria not due to nephritis, in tumor or pain in or along the upper urinary TABLE 1 NUMBER OF CASES
26
Under 6 months* ................................................. . 7 to 12 months ................................................... . 1 to 3 years ...................................................... . 4 to 6 years ...................................................... . 7 to 10 years ..................................................... . 11 to 12 years .................................................... .
95 36
Total. ................................. ·····.················
304
14
57 76
* Youngest three weeks, oldest twelve years.
TABLE 2 DIAG-
URETER
NOSIS
STRICTURE
., C
I i:1 :,,
t.z
"'
~
!:l A B C
85 134 85
z
"'c3
...
6 1
+-
....@!
:,,
;1
0
21 6 19
28 30 27 101 37 28
4 79 19
24 88 47
~
z
0
.,"'~ § j ~ . . ~ ~ 8 - - - - - -
"'., 9 ti "'ci
~lo<
Ir
ti
0
~ 5
~
0
CJ
~z
~ CJ Plp
0
~
0
36 20 24
4 31 2
-
18 32 27
~
I.,"
0
;s.,
::;0
@!
:,,
.Isi .I . ~
i -. -. -. -z - -~ CJ
17 8 11
1 2 2
>, .0
>, .0
-;.
.,l
"""
-~/; i
l
~
"' 0
:5" j - - -< - - lo<
III
35 9 39
.3"
l
el
~
-~"
4 1 1
6 1
~
"'
~
·;;
~
10 7 4
-g ~
21 20 23
8 4 3
2
5 8
-
6 7 21 64 15 2 13 Total. ....... 304 7 46 92 159 102 159 80 37 77 83 36 5 1. 9 15.1 30.5 52.2 33.5 52. 2 26.3 12.1 25.3 27 .3 11.8 1.6 1. 9 1. 9 7 .0 21.5 4.9 0.6 4.2 Per cent .....
• All details sharply defined; the kind a manufacturer of intravenous media would display in advertising. t Clear enough to permit an accurate diagnosis. t The probable diagnosis can be made by compositing the entire series. § Less satisfactory than (3) or unreadable. ,r Doubtless in many of these cases overlying gas and fecal shadows clouded the shadows of the excreted drug.
tract and, in some instances, in disturbances of urination not falling under the above groupings. In two instances each it was employed to differentiate from kidney, enlargement of the spleen or liver and in one case each dermoid, mesenteric cyst, pyloric obstruction, and perirenal teratoma. In 243 cases (80 per cent) of this series, the indication was
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDREN
chronic pyuria and although we now employ precystoscopic excretory urography routinely in these cases, in some of the earlier ones 1 intravenous urography was not attempted until retrograde pyelographic studies had been made. Parenthetically, in practically every case in children showing an abnormal excretion urogram or in which the ureteral. catheter findings suggest upper tract disease, a retrograde pyelogram should be made. Using the intravenous urographic media for catheter injection, I have not hesitated to perform bilateral retrograde pyelography. Retrograde urography was employed in all but 36 of the 304 cases and serves as a check on the intravenous method. Intravenous urography is particularly indicated in those cases in which ureteral catheterization (or cystoscopy) is impossible or is refused, or in which the condition of the patient does not warrant instrumentation. Yet with modern miniature cystoscopic instruments and due care, many conditions which have been considered indications for excretory urography alone, should be accessible to more direct examination. I have performed simultaneous bilateral ureteral catheterization in several girls under three months of age and using a No. 7 F. (Wolff) cystoscope have without difficulty performed observation cystoscopy in a boy of ten days. Using a No. 13 F. double catheterizing cystoscope made for me this past year, I have performed simultaneous bilateral catheterization in a boy of nine months. Therefore, and contrary to popular conception among physicians, intravenous urography need not be looked upon as the only source of definitive uro·· logic information in the very young. CONTRAINDICATIONS
Intravenous urography is said to be contraindicated by: (1) severe renal or (2) hepatic deficiency, (3) iodine idiosyncrasy, (4) thyrotoxicosis, (5) active pulmonary tuberculosis (6) exudative diathesis in children. Yet I have used it (neo-skiodan) without demonstrable untoward effect in several children whose phenolsulphonphthalein output was less than 5 per cent in two hours (in 2 cases the output was zero) and in 3 children with advanced nephrosis. Failure to obtain urographic shadows was accounted for by the severe renal impairment. Age is no contraindication; fairly satisfactory excretory urograms were once obtained in a child three weeks of age and in 2 cases at four weeks of age (table 1). LIMITATIONS
Unsatisfactory results are favored by faulty roentgen technique 1 poor renal function, polyuria and confusing gas or fecal shadows. With poor
58
MEREDITH F . CAMPBELL
renal function in the presence of obstruction, diagnostic films may not be obtained until late; in one of my patients, shadows did not appear until four hours after injection and in another only after twenty-four hours. In polyuria the low concentration of the medium in the urine causes failure; in infants I have several times found practically the entire excretion of the medium in the bladder ten minutes after injection. Preliminary dehydration combats this. Freedom from gas shadows is largely a matter of chance. Excretory shadows too indefinite to permit an accurate diagnosis are often seen in renal infection, both tuberculous and non-tuberculous, in tumors and polycystic disease and, unless there is low obstruction, the ureter shadow will probably be partial or indefinite. In connection with the latter point: the normally small pelvis and ureter in the very young will contain only a relatively thin thread of excreted medium for radiographic exposure. Unless confirmatory retrograde pyelograms are made, hazy, fuzzy or absent shadows due to incomplete pelvic filling are likely to be erroneously interpreted. Although radiographic evidence of the quantitative and qualitative excretion of the medium is a moderately reliable comparative test of the function of the two kidneys, it should not replace the phenolsulphonphthalein or indigocarmine excretion estimations. TECHNIQUE
Media. Iopax (19 times), neo-iopax (8 times), skiodan (7 times) and neo-skiodan (347 times) have been employed in this series. Iopax and skiodan are disadvantageous to inject because of the relatively large fluid bulk required; in highly nervous or unruly children this is a real disadvantage. Because of its freedom from irritating effect as manifested by absence of pain in the arm on injection, its minimal toxicity, rapid excretion and satisfactory concentration, I prefer neo-skiodan and particularly in children. Dose. This is relatively much greater than in adults; the average doses I employ in children are as follows :. Per cent of adult dose
Under 6 months ... . . .. . . ... . .... . . ... . . . . . . . .. . ... . ... . . .. . .... . .. 7 to 12 months . .. ..... ..... ... . .... .. . .. . . .. . ..... . . . . .... .. . . . .. . 1 to 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 to 6 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . 7 to 8 years ..... . . .. . . .. . .... .. . ..... ... .. .. . ... ..... . . .. . . ... . ...
25-30 30-35 35-50 50-80 80-100
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDR\EN
59
Yet I have given a full adult dose of neo-skiodan to children of :five years without untoward effect. Preparation of patient. The child should be spared purging, enemas "until the return is clear," and starvation. Yet in constipated children a small dose of castor oil and low enema to clear out the rectum are sometimes advantageous. No meal should be omitted; the longer the interval from the last meal, the greater will be the gaseous distension of the bowel. Greatly reducing the fluid intake for from twelve to eighteen hours before the examination considerably increases the concentration in the urine of the excreted medium and thereby favors better urographic definition. I have experimented with practically every recommended method to eliminate intestinal gas, including the administration of charcoal to adsorb the gas, but the best results have been obtained when there has been no preparation other than dehydration. Injection. In older children the injection is usually given in one of the cubital veins; in infants with fat arms and delicate vessels one may be forced to employ superficial veins elsewhere (wrist, back of hand, feet or scalp), the external jugular vein or, as I did but once, the fontanelle. The injection should take at least two minutes; employment of a fine needle will control any tendency to too rapid injection. To submit the child to a general anesthetic in order to give the intravenous injection is unjustifiable. Yet I am aware that it has been done. If general anesthesia is to be given, perform cystoscopy and, if indications exist, ureteral catheterization and retrograde pyelography. Maneuvers to favor satisfactory urograms. Some children were kept in exaggerated Trendelenburg position from the beginning of the injection until completion of the radiographic exposures. In some the bladder was kept full of urine or other fluid in the hope of producing upper tract stasis to retard uretero-pelvic emptying. Both methods were soon abandoned. The compression bag over the lower abdomen sometimes promotes good pelvic and upper ureter :filling in older children but has been unsuccessful in younger patients. Adequate dehydration as described above is the best solution that I have found to this problem in children. Roentgenography. The conventional Bucky diaphragm can be used only in older cooperative children. In all others shorter exposures (i16 to ¼second) must be employed. 1 With the latter group the roentgenographer must exert unusual patience and cooperation to make the
60
MEREDITH F. CAMPBELL
exposure in the fraction of a second when the child is still; this is usually at one of the extremes of respiration and preferably at full expiration. Interval between exposures. As a rule this is considerably less in children than in adults. The following schedule will be found satisfactory in most children: (1) flat plate before intravenous injection; (2) inject the radiopaque medium; (3) take films five, ten and fifteen minutes from completion of the injection. The immediate development of the early films will indicate whether longer or shorter intervals between exposures will be advantageous-in some instances subsequent films at intervals of an hour or more may be indicated. Reaction. In this series of 381 administrations of radiopaque media, erythema occurred twice. In an eight-year-old girl given 40 cc. of skiodan the neck and face were involved with marked swelling of the lips, tongue and about the eyes. The reaction appeared about ten minutes after the injection and did not disappear entirely until three hours later. A girl of six years was given 12 cc. of neo-skiodan; a generalized erythema but without edema appeared within ten minutes and disappeared within the hour. Transient nausea and flushing are occasionally observed but are no cause for alarm; the former may be usually overcome by a few deep respirations. RESULTS
The results in this series of 304 cases have been grouped according to the source of the films (table 2). The cases in series A are from a hospital whose roentgen technician is unusually tolerant with children and meticulous in radiographic detail. He is gifted with patience to wait until the fractional-second exposure can properly be made. In two-thirds of these cases (64.7 per cent) the urograms were of diagnostic aid. Series B is from a large municipal hospital employing for the greater part mediocre, impatient and often careless roentgen technicians. In this series, a fourth (24.6 per cent) of the urograms were of aid. To one unusually well qualified technician at this institution is accredited nearly all of the satisfactory films. The poor results obtained when proper roentgenographic technic and intelligence are not displayed bespeak the enormous economic loss in the wasted use of equipment and supplies, and the unfairness to the patient as well as the fruitlessness of the physician's time and efforts. I have examined the patients in series C in other hospitals in the New York Metropolitan area and in my office. It is believed they represent average results under reasonably favorable con-
INTRAVENOUS UROGRAPHY IN INFANTS AND CHILDREN
61
ditions. Two-thirds (67 per cent) of these urograms were of diagnostic assistance. It is unimportant to detail the urographic findings in~- this series. Eighty-three or 57.2 per cent of the 145 cases in which a diagnosis could be hazarded (table 2) were classified as normal. Among the more teresting congenital anomalies, the diagnosis of which was otherwise confirmed, were uretero-pelvic reduplication, 19 cases, (unilateral in bilateral in 2, partial in 5, complete in 14 and with one ectopic urethra orifice in 3); congenital solitary kidney, 3 cases; fused pelvic kidney, horseshoe kidney, each one case. Among the interesting acquired lesions in which the diagnosis was made or assisted by intravenous urography were renal tuberculosis, 5 cases; renal stone and renal trauma, 2 cases; renal tumor, 6 cases; hydronephrosis, 36 cases; and extraurinary tract conditions stimulating renal disease (chiefly tumor) 7 caseso 2 In 4 cases of ureterosigmoidostomy for bladder extrophy, postoperative excretion urograms were excellent in one, moderately satisfactory in two and poor in one. The question of operation on excretory urographic findings arises . Although it may be done on the roentgen evidence in stone and hydronephrosis when these data are definite, in children at least, a more complete examination is advised. In the only patient upon whom I operated on the evidence of intravenous urography alone, a boy of five years with a large, soft right loin mass and a urogram showing advanced hydronephrosis and a ureter the size of the colon down to the ureterovesical junction, the collapsed removed kidney showed a wholly unsuspected amount of redeemable parenchyma. Elimination of the ureterovesical junction stricture alone might have preserved the organ. This is as an error in judgment and not as a fallacy of the method. Since this experience, no matter how striking the excretory evidence, I have in-eluded ureteral catheterization in the examination. In renal. tuberculosis, the function of the good kidney and its freedom from tuberculous infection can scarcely be determined except by the ureteral catheter and even then confusion may arise. SUMMARY
Despite the commonly encountered technical handicaps to successful intravenous urography, the method will frequently offer invaluable 2 In the above indicated congenital and acquired lesions there are 37 instances of reduplication, notably hydronephrosis as a secondary condition.
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MEREDITH F. CAMPBELL
aid in urologic diagnosis in infants and children. Yet too much should not be expected of it. N ephrectomy in juveniles is seldom justified on excretory urographic findings alone. In final analysis, unsatisfactory intravenous urographic studies in infants and children are far more often due to improper roentgen technic than to abnormal renal function or other uropathy. 140 East 54th Street, New York, N . Y . REFERENCE SCHWENTKER,
F. F .: Bull. Johns Hopkins Hosp., November, 1932, Ii, 318.