Routine  radiologic studies do not, often enough, concentrate on the part of the anatomy and physiology of importance for the diagnosis. The close cooperation between the pediatrician, urologist and the radiologist will insure more useful uro-radiographic studies on which rational clinical decisions can be based. The child\u27s signs and symptoms, as well as the anatomic and physiologic information needed, dictate the type and order of the radiographic studies. It is beyond the scope of this paper to go into the indications for specific uro-radiographic studies. The radiographic techniques will be presented

Grossman, Herman

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Pediatric Ure-Radiology* HERMAN GROSSMAN, M.D. Professor of Radiology and Pediatrics, Duke University Medical Center, Durham, North Carolina "Routine" radiologic studies do not, often enough, concentrate on the part of the anatomy and physiology of importance for the diagnosis. The close cooperation between the pediatrician, urologist and the radiologist will insure more useful uro-radiographic studies on which rational clinical de-cisions can be based. The child's signs and symptoms, as well as the anatomic and physiologic information needed, dictate the type and order of the radio-graphic studies. It is beyond the scope of this paper to go into the indications for specific uro-radio-graphic studies. The radiographic techniques will be presented. Cystourethrography. There are several methods for studying the bladder, urethra and vesicoureteral reflux. The method used most often is filling the bladder via a urethral catheter in a retrograde man-ner, either by gravity or by injecting the contrast material. Radionuclide introduced into the bladder can be used as an adjunct to radiographic investiga-tion of reflux. Cystourethrography can be done at the end of the intravenous pyelogram. This method avoids a urethral catheter and would appear to be more physiologic. The child voids immediately before the intravenous injection of contrast material. The ad-ministration of as much as 5 ml per kg of 50% or 60% contrast material is recommended. There are, however, several limitations of this method- the patient must be cooperative and usually several years of age. Another disadvantage is that often parents or an aid must be kept in the Radiology Department with the patient for several hours, adding to generally crowded waiting areas. The bladder must become sufficiently distended to stimulate the urge to void. * Presented by Dr. Grossman at the 26th Annual Stoneburner Lecture Series, February 23, 1973, at the Medi-cal College of Virginia, Richmond. MCV QUARTERLY 9(3): 261-269. 1973 Contrast in the lower portion of the ureter during the voiding phase presents the problem of differen-tiating between urine flow from the kidney and reflux into a ureter that maintains its normal caliber. Cinecystourethrography came into wide use in the mid 1950's. The chief contribution of cine re-cording was its revelation of the importance of performing the procedure under fluoroscopic control. Fluoroscopy during the voiding phase of cystoure-throgram allows optimal timing of films for the permanent record. Dissatisfaction with the cine pro-cedure is that it has poor resolution, and that it delivers a large radiation dose to the patient's gonads. Fluoroscopy with video tape recording for the docu-mentation of motion, and spot filming with 70, 90 or 105 mm film is diagnostic with less radiation than cinefluoroscopy. Video tape recording delivers no additional radiation to the patient beyond that re-quired for image-intensification fluoroscopy. Retrograde filling of the bladder by gravity permits the observation of reflux at low or high water pressure. In the absence of infection, low pressure reflux is considered a more significant ob-servation when making a decision about reimplant-ing a ureter. Sufficient distention of the bladder can be obtained by gravity filling to stimulate voiding. The normal male urethra demonstrates many variations. Sequential spot x-rays avoid confusion of normal anatomical structures ( fig. 1). It is neces-sary to identify accurately the urethrovesical junc-tion and prevent the error of considering the trigo-nal canal as part of the urethra. Controversy exists among urologists about the existence or frequency of bladder neck obstruction and meatal stenosis in boys or girls . Posterior ure-thral valves, lesions probably existing only in males, appear to be the most common bladder outlet or urethral obstruction. From the Hospital for Sick Children in London, 165 children were recently 261 262 Trigonal canal __ _ Urelhrovesicol junclion-----t Verumontanum Urogenital diophrogm Fig. I-Sequential spot filming during voiding demonstrates a normal male urethra. The urethrovesical junction can be identified and not confused as existing along the trigonal canal. reported with lesions at or below the bladder neck which interfered with normal urine flow. From 1959 to 1970, of 130 boys and 35 girls, all were under the care of Mr. Ennis Williams. The most common lesions were posterior urethral valves and ectopic ureteroceles. Stenosis or atresia of the urethra and Fig. 2-A. One-day-old male that did not urinate. Abdomi-nal mass was palpated; on radiograph the mass extended from the pelvis to the eleventh ribs posteriorly. GROSSMAN: PEDIATRIC URO-RADIOLOGY Fig. 2-B. Voiding cystourethrogram demonstrates bilat-eral reflux and a dilated posterior urethra due to posterior urethral valves. bladder neck obstruction were uncommon. A pal-pable bladder was the most common physical finding in this group of patients. A one-day-old boy had not voided since birth and a large abdominal mass was felt ( fig. 2, A). Catheterization of the bladder revealed a large vol-ume of urine. The catheter was left in place and a cystourethrogram was done. During fluoroscopic ob-servation reflux occurred when the bladder was partially filled (low pressure), and during the act of voiding it was noted that massive reflux occurred in dilated ureters and calyces (fig. 2, B). The poster-ior urethra was dilated and distal to this point, the urinary stream was narrow. The association of pos-terior urethral valves and reflux is common. Posterior urethral valves may be present, however, with com-petent ureterovesical valves and normal ureters and kidneys. In boys, defects in the anterior urethra are less GROSSMAN: PEDIATRIC URO-RADIOLOGY 263 Fig. 3-A). (left) Four-month-old male with urinary tract infection. Voiding cystourethrogram demonstrates an anterior urethral diverticulum. No reflux occurred. Fig. 3-B). (right) Residual contrast in diverticulum persisted after the bladder emptied. After surgical removal of the diverticulum the infant remained free of infection. common than in the posterior urethra. Most often a single "pouch" in the anterior urethra is non-obstructive and represents Cowper's ducts or glands. Fig. 4-A. (left) Normal female urethra during voiding. Fig. 4-B. (right) With the stopping of micturition the "spinning top" deformity develops and is a normal variation. Other lesions in the anterior urethra appear to repre-sent congenital diverticulae or anterior urethral valves which may cause obstruction or be a cause of infection because of stasis in the diverticulum (figs. 3, A, B). Fig. 5-A. (left) Cystogram with water soluble contrast material demonstrates massive reflux into both ureters and kidneys. Fig. 5-B. (right) Cystogram with technetium 99 M pertechnetate, followed by scanning over the kidneys de-tects reflux into the kidneys. 264 Fig. 6-Intervesical ureterocele causing a lucent defect in the bladder. Ureterocele developed from the ureter draining the upper pole of a double right renal collecting system. Obstruction caused hydronephrosis and nonfunction of the upper pole with downward disp lacement of the lower pole collecting system. Double collection system is present in the left kidney. Fig. 8-A. Prolapsed ureterocele dilates the posterior urethra. Density of the contrast material around the ureterocele ob-scures the lucency normally seen. Reflux into dilated ureter also is noted. GROSSMAN, PEDIATRIC URO-RADIOLOGY Fig. 7-Nephrotomography demonstrated the rim of func-tioning renal tissue in the right upper pole suggesting a duplicate renal system. Ectopic ureter was obstructed in the posterior urethra. Fig. 8-B. Retrograde urethrogram demonstrates the lu-cency in the bladder caused by the ureterocele. GROSSMAN: PEDIATRIC URO-RADIOLOGY Fig. 9-Ectopic ureter from a solitary ureter insertion at the bladder neck demonstrating reflux during voiding. Fig. IO-Newborn with left flank mass. Large lucent areas in large left renal mass. Lucent defect in bladder due to ureterocele from a solitary ureter. 265 Fig. 11-Early during intravenous pyelogram, the well vas-cularized organs opacify and a lesion with poor blood supply produces a lucent defect as was noted in this new-born with a multicystic kidney. In the early 1960's, the "spinning top de-formity" of the female was considered a sign of urethritis or of meatal stenosis. It is now regarded as a normal variation in most instances. A single roentgenogram during voiding may be exposed when the patient is beginning or stopping micturition, and it is during this phase of voiding that the "spinning top" configuration is most common (figs. 4, A, B). Video tape recording and multiple spot x-rays usually show the normal anatomy and demonstrate physio-logic function. At any rate, bladder neck obstruction and meatal stenosis are not radiographic diagnoses. There is a high correlation of urinary tract infection in children with vesicoureteral reflux. In some patients, an obvious anatomic abnormality in the urinary tract is present; in many children, how-ever, no discernible defect is found . Vesicoureteral reflux while a child has a urinary tract infection 266 GROSSMAN: PEDIATRIC URO-RADIOLOGY Fig. 12-A. (left) Right ureteral reflux during voiding cystourethrogram. B. (right) Right kidney demonstrates caliectasis and de. creased amount of cortex. Fig. 13-A. (left) Poor delineation of the left kidney due to overlying gas and feces. Fig. 13-B. (right) Paddle with an inflated balloon dis-places the bowel contents and delineated the calyceal system. Fig. 14-Carbonated beverage or carbon dioxide capsules contrast the calyces and renal outlines. GROSSMAN: PEDIATRIC URO-RADIOLOGY 267 Fig. 15-Nephrotomography demonstrates the renal outline in a patient with normal calyces on urogram. Evaluation of the cortex was important in this patient. may be due to inflammation of the vesicoureteral orifice; therefore, it is preferable to do a cystoure-throgram when the patient has been free of infection for more than two weeks. The main use of cystourethrography is the de-tection of ureterovesical reflux. Instillation into the bladder of a short-lived pure gamma-e~itting radio-pharmaceutical, such as technetium 99m pertech-netate, followed by scanning over the kidneys (fig. 5), can be an ad jun ct to the radiographic investiga~ tion of reflux. This procedure does not give the detail of standard radiographic methods, nor does it detect transient ureteral reflux. The markedly lower gonadal dose of radiation may make this method useful as a means of following patients for gross reflux into the kidneys. Ectopic ureters, with or without a ureterocele, are most frequently present with renal duplication. The upper renal pole drains into a ureter whose ori-fice is medial and inferior to the normal orifice. Ap-proximately three-quarters of the patients with ectopic ureters in association with renal duplication are female. Bilateral renal duplication is present in approximately one-quarter of the patients with an ectopic ureter. The intervesical ectopic ureter balloons out as a cyst-like mass within the bladder lumen causing a lucent defect (fig. 6). The poorly functioning hydro-nephrotic upper pole is outlined by thinned renal pa-renchymal. Generally there is function in the lower pole of the involved kidney. The lower pole calyces may be displaced downward and laterally by the dilated medially positioned ureter. The distal end of the ectopic ureter may be stenotic and terminate in the bladder neck, ("pos-terior") urethra, or in the vagina, with dilation of the proximal portion of the ureter. Nephrotomog-raphy may be necessary to visualize the rim of func-tioning renal tissue ( fig. 7). Ureteroceles may prolapse into the urethra causing dilatation of the posterior urethra on a cystourethrogram, which mimics posterior urethra 268 Fig. 16-Nephrotomography in infant with poor renal function demonstrates a hypoplastic right kidney and small normal left kidney. Visualization was not successful on intravenous pyelography. valves (fig. 8, A). Slow filling of the bladder via retrograde urethrography demonstrates a large lucent defect due to a ureterocele ( fig. 8, B). An ectopic ureter from a solitary ureter occurs in 20-30% of all ectopic ureters. Its site of inser-tion is similar to ectopic ureters associated with renal duplication. Ureterovesical reflux may occur when the ectopic ureter inserts in the bladder or urethra (fig. 9). A newborn infant was noted to have a left flank mass. Nonfunction of the left kidney could have been due to hydronephrosis or a multicystic kidney (fig. 10). The lucency in the bladder suggested the cor-rect diagnosis. This latter observation was important so that the ureterocele could be surgically removed in order to prevent the opposite ureterovesical junc-tion from becoming obstructed. Various simple techniques may help make a GROSSMAN: PEDIATRIC URO-RADIOLOGY Fig. 17-A. (left) Incomplete filling of calyceal system on intravenous pyelogram. Fig. 17-B. (right) Compression band on lower abdomen and inflatable balloon causes partia l stenosis of ureter and filling out of normal ureter and pelvocalyceal system. Fig. 18- A. On intravenous pyelogram no visualization is seen in the left kidney. The right kidney demonstrates mod-erate ureteropelvic obstruction. Large left flank mass was palpated. GROSSMAN: PEDIATRIC URO-RADIOLOGY 269 L (!) ICtDHEY Fig. 18- B. Ultrasound shows a large echo free area in left flank indicating a cystic mass. At surgery, a hydronephrotic kidney was found. correct radiographic interpretation. The "bodygram" is the result of high dose ( 4 ml per kg) intravenous urography. Thirty seconds to one minute after the injection of urographic contrast material, there is opacification of well vascularized abdominal organs. Lesions with little or no blood supply produce lucent defects within the opacified structures, as was noted in a newborn that had a multicystic kidney (fig. 11). Because of decreased concentrating ability of the kidneys of newborns for many days after birth, poor visualization on intravenous pyelography will not be improved by an immediate repeat dose. If possible, wait five or more days before repeating the intravenous pyelogram. Satisfactory visualiza-tion is usually obtained on the delayed study. Prolonged nephrograms, lasting many hours-to-days, may be seen in newborns or infants who were dehydrated or oliguric prior to excretory urography. It is postulated that a mucoprotein (Tamm-Hors-fall), normally produced by renal tubular cells, forms a precipitate that blocks the lumen of the renal tubules . Since diagnostic visualization can be obtained without iatrogenic dehydration, no fluid restriction is necessary prior to excretory urography. U reterovesical reflux causes damage to the kidneys because of the frequently associated infection and to a lesser degree the effect of the "back pres-sure" on the kidneys. Therefore, it is essential to be able to evaluate the renal outline, cortex and caly-ceal system. Often this can be done on the pyelogram (fig. 12, A, B) . The radiologist has various devices to obtain maximal information from excretory urography, often obviating the necessity for retrograde pyelog-raphy. A paddle with an inflatable balloon can be used to displace confusing bowel gas from the renal areas ( fig. 13, A, B) . Carbon dioxide in the stomach may contrast the renal outline and delineate the calyceal structures (fig. 14). Usually, nephrotomog-raphy will outline the kidney contour (fig. 15), and has been useful when kidneys fail to visualize well because of poor renal function (fig. 16). If visualiza-tion of the pelvocalyceal system is not adequate, compression bands may be placed on the lower abdo-men, causing partial ureteral stasis with better filling of the structures in question ( fig. 17, A , B). The question of whether a flank mass that does not visualize on intravenous pyelography is cystic or solid can now be answered by ultrasonography. This procedure is noninvasive and emits no radia-tion. Low energy waves from a probe passed over the structure in question reflects echoes (sound re-flection occurs at tissue interfaces) which are re-corded as densities if the mass is solid in nature; if the mass is cystic, the recording will be echo "free" (fig. 18, A, B). 

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