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Study of Post Procedural Complications Associated with Voiding Cystourethrography
Abstract
Voiding cystourethrography(VCUG) is a commonly performed diagnostic procedure in children with urinary tract infections. Recently, with the widespread use of prenatal ultrasonography, VCUG is performed as part of the postnatal radiological evaluation of asymptomatic infants with prenatally detected hydronephrosis. The procedure is relatively simple but it involves discomfort and some complications. We studied post procedural symptoms and complications in children who underwent VCUG.
... MCUG is a commonly performed procedure for the evaluation of children with antenatally diagnosed hydroureteronephrosis, UTIs, suspected bladder outlet obstruction, etc. Commonly reported complications of MCUG include UTI, allergic reactions to the contrast, dysuria, hematuria, knotting of urethral catheter, etc. [2][3][4][5][6][7][8] Bladder rupture during MCUG is a rare complication and commonly seen in children with chronically unused bladders, previous surgeries, or underlying disease. [9] This may sometimes lead to life-threatening complications. ...
... The bladder dome is the weakest part of the bladder and can easily rupture when the excess volume is injected rapidly or forcefully. [8] The management of bladder rupture following MCUG is individualized. Keihani and Kajbafzadeh reviewed the reported cases of bladder rupture following MCUG in children without chronic underlying diseases. ...
Micturating cystourethrography (MCUG) is a very commonly performed diagnostic procedure in pediatric urology. Although considered to be simple, safe, and cost-effective, it can incur some complications. Bladder rupture during MCUG is a very rare complication and only a handful of cases have been reported in world literature. We report the case of a 2.5-month-old boy who had intraperitoneal bladder rupture during an MCUG needing surgical repair. At operation, the child had a bladder tear at the dome of the bladder which was repaired successfully. The postoperative recovery was uneventful and the child is doing well in follow-up. Although individual management of bladder rupture may differ, a majority of infants need surgery for the same. Thorough vigil and attention to the technique are a must to prevent such incidents in children.
... Iatrogenic complications associated with VCUG are rare events, but some complications include UTI, allergic reaction after procedure, contact dermatitis, knotting of the urethral catheter, and bladder rupture [5][6][7][8][9][10] . In Korea, one study reported that 32.7% of patients with VCUG showed complications such as bladder rupture, dysuria, irritability, and hematuria 11) . Bladder rupture associated with VCUG is more common in instances of chronically unused bladders such as chronic renal failure, and six cases of bladder rupture were reported in chronic renal failure 12) . ...
... [mo]); age>1 year, bladder volume (mL)=(age [yr]+1)×30 14,15) . However, the bladder volume is different among individuals, and the bladder dome which is the weakest part of bladder can easily be ruptured when excess volume is injected rapidly 11) . ...
Voiding cystourethrography (VCUG) is a commonly performed diagnostic procedure for the evaluation of vesicoureteral reflux with urinary tract infection or congenital renal diseases in children. The procedure is relatively simple and cost-effective, and complications are very rare. The iatrogenic complication of VCUG range from discomfort, urinary tract infection to bacteremia, as well as bladder rupture. Bladder rupture is a rare complication of VCUG, and only a few cases were reported. Bladder rupture among healthy children during VCUG is an especially uncommon event. Bladder rupture associated with VCUG is usually more common in chronically unused bladders like chronic renal failure. Presented is a case of bladder rupture that occurred during a VCUG in a healthy 9-month-old infant, due to instilled action of dye by high pressure. This injury completely healed after 7 days of operation, and it was confirmed with a postoperative cystography. The patient's bladder volume, underlying disease, velocity of the contrast media instilled, catheter size, and styles of instillation are important factors to prevent bladder rupture during VCUG. Management of bladder rupture should be individualized, but the majority of infants are treated with the operation. In conclusion, bladder rupture is a rare complication, however, delicate attention is needed in order to prevent more dire situations.
... Although VCUG offers significant diagnostic benefits, it is not without risk. In addition to the general health risks associated with ionizing radiation exposure and iodinated contrast administration, catheterization also poses the specific risk of introducing infection (Kim, Lee, Kim, Chang, & Lee, 2007). For this reason, catheterization is performed under sterile conditions by a specially trained radiology nurse. ...
A child undergoing a fluoroscopic voiding cystourethrogram (VCUG) can be at an increased risk for a kidney infection (pyelonephritis) or disseminated infection (urosepsis). Nurses responsible for the required catheterization are obligated to provide care according to best practice. Radiology nurses practicing in the fluoroscopy department at the Division of Diagnostic Imaging & Radiology of the Children's National Health System, located in Washington, DC, designed and implemented a performance improvement project. The goal of this project was to determine if it is best practice to perform a point-of-care dipstick urinalysis for all specimens before a VCUG or only for those that were suspicious for a urinary tract infection (UTI) based on the assessment of the patient's urine and clinical history. During a 5-month study period between May 1, 2015 and September 30, 2015, nurses collected data on patients undergoing a VCUG. Urine specimens collected before VCUG were assessed for color, clarity, and odor. The time since last fever was also determined. Point-of-care testing (POCT) for urine dipsticks was used in suspected cases of active UTI based on the urine and fever assessments. A partnership with our urology clinic was created to help secure a pathway to POCT for urine dipsticks. The data were displayed on a performance board within the department to keep the nursing team apprised of monthly findings. Of 266 VCUG examinations performed in a 5-month study period, three urine specimens were tested, and of those, two were positive for UTI. Of the two positive dipsticks, one examination was cancelled and the other was completed at the request of urology. Based on our findings, the fluoroscopy team determined that because of a low occurrence of positive urine dipsticks, performing a dipstick only on suspicious specimens as opposed to every specimen is best nursing practice.
Objective
To assess whether antibiotic reduces voiding cystourethrogram (VCUG)-associated urinary tract infection (UTI).
Design
Open-labelled randomised controlled trial.
Setting
Tertiary paediatric nephrology centre.
Patients
120 children (age 2 months–5 years) undergoing VCUG.
Interventions
Children were randomised into group A (antibiotic, n=72) or group B (no antibiotic, n=48) in 3:2 ratio. Group A received oral antibiotic (cephalexin if <6 months or co-trimoxazole if >6 months old) a day prior to VCUG and continued for 1 day post VCUG.
Main outcome measures
The main outcome measure is incidence of VCUG-associated UTI. Urine was checked on day 3 after VCUG and UTI was defined as significant growth of a single organism in a symptomatic child.
Results
The median age was 8 months (IQR 13 months) with 68% male. Indication for undertaking VCUG was history of UTI (first UTI in infancy=43, recurrent UTI=49) and congenital anomaly of kidney and urinary tract without any UTI (n=28). Post-VCUG UTI was significantly higher among group B in comparison to group A (17% (n=8) vs 1.4% (n=1); p=0.01, OR=14.2 (95% CI 1.7 to 117)). Multivariate binary logistic regression analysis found an abnormal pre-VCUG ultrasound scan to be a significant independent risk factor for post-VCUG UTI (p=0.02, OR=9.51, 95% CI 1.43 to 63.4). The number needed to treat with antibiotic to prevent one post-VCUG UTI was 6.5, which reduced to 4 if only the group with abnormal pre-VCUG ultrasound scan was included.
Conclusions
Antibiotic significantly reduces post-VCUG-acquired UTI especially in those with abnormal ultrasound scans.
Trial registration number
Clinical Trial Registry of India: CTRI/2017/03/00824.
The most concerning issue in children with urinary tract infection(UTI) is the probability of underlying genitourinary anomalies and vesicoureteral reflux(VUR), which is frequently associated with renal scarring and eventually end-stage renal disease. Therefore, voiding cystourethrography(VCUG) is usually recommended at the earliest convenient time for children with UTI. However, VCUG is an invasive procedure that requires catheterization and exposure to X-ray. In this study, we aimed to determine the predictability of clinical, laboratory and imaging parameters for VUR in children with UTI.
This study was performed to assess necessity of voiding cystourethrography (VCUG) for infants with urinary tract infection(UTI) who had both normal renal sonography and normal DMSA renal scans.
The voiding cystourethrogram (VCUG) is the investigation of choice in detecting the vesicoureteral reflux in urinary tract infections in children. As it is a potentially distressing and invasive test, most of the parents are so concerned about the child's stress. In this study, we compared the difference of the state of anxiety of parents before and after the VCUG.
The increasing use of ultrasonography has allowed for an increase in the of the detection of congenital hydronephrosis, and the clinical outcomes of congenital hydronephrosis are widely varied. In this study, the necessity of voiding cystourethrography in neonate with hydronephrosis to rule out vesicoureteral reflux (VUR) was evaluated.
The 12-lipoxygenase (12-LO) pathway of arachidonic acid metabolism is implicated in extracellular matrix (ECM) synthesis, but its role in podocytes has not been studied. This study tested whether 12-LO induction by diabetes or by high glucose (HG) in cultured podocytes alters glomerular basement membrane by activating signal transduction pathways culminating in ECM synthesis. Sprague-Dawley rats received an injection of diluent (control [C]) or streptozotocin 65 mg/kg (DM) and were killed at 1 or 4 mo. Glomerular 12-LO mRNA and protein levels were higher in DM than in C glomeruli at 1 and 4 mo, and 12-LO localized predominantly in podocytes. Glomerular p38 mRNA and protein were higher in DM at months 1 and 4, but phospho-p38 mitogen-activated protein (MAPK) was increased only at month 1. Glomerular collagen α5(IV)/glutaraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA ratio was increased in DM at month 1 but not at month 4, whereas collagen α5(IV) protein was higher at both 1 and 4 mo. Mouse podocytes were cultured in media with 25 mM glucose (HG) with or without the 12-LO inhibitor cinnamyl-3,4-dihydroxy-cyanocinnamate (CDC) or with 5.5 mM glucose + 19.5 mM mannitol (low glucose [LG+M]) for 10 d at 37°C. 12-LO mRNA and protein levels were higher in HG than in LG+M as was the p38 MAPK/GAPDH mRNA ratio. Phospho-p38 MAPK protein but not total p38 MAPK was higher in HG compared with LG+M. Collagen α5(IV)/GAPDH mRNA ratio and protein were higher in HG than in LG+M. 12-LO inhibition by CDC decreased HG-induced phospho-p38 MAPK and the phospho-p38/total p38 MAPK ratio, collagen α5(IV)/GAPDH mRNA ratio, and collagen α5(IV) protein expression. In summary, diabetes in vivo and exposure of podocytes to HG in vitro stimulated 12-LO, p38 MAPK, and collagen α5(IV) mRNA and (activated) protein. 12-LO inhibition by CDC diminished the expression of podocyte phospho-p38 MAPK and collagen α5(IV) mRNA and protein. These findings implicate 12-LO and the p38 MAPK signaling pathway in the mediation of ECM synthesis by podocytes in diabetes.
The frequency, nature, and duration of postprocedural symptoms in 100 children who underwent voiding cystourethrography (VCUG) after administration of 17.2% wt/vol iothalamate meglumine, 100 children who underwent radionuclide cystography (RNC) after administration of saline and technetium-99m pertechnetate, and 28 children catheterized before diuretic renal scintigraphy (DRS) were prospectively assessed with telephone follow-up. All children were aged 2 years or older; 61 were boys, 167 were girls. Postprocedural symptoms occurred in 80 children (35.1%). The frequency of postprocedural symptoms was nearly identical in the VCUG group and the two other groups. Boys (n = 33 [54%]) had symptoms significantly more often than girls (n = 47 [28%]) (P less than or equal to .0005). Dysuria was the most common symptom (n = 75 [32.9%]) and was frequently accompanied in younger children by anxiety over going to the bathroom. Symptoms disappeared within 24 hours in 32 of 80 children (40%) and lasted 4-10 days in eight children. It is concluded that most postprocedural symptoms in children who undergo VCUG, RNC, or DRS are secondary to catheterization rather than to the use of iodinated contrast material.
Two children are described who developed an apparent cutaneous contact reaction to contrast material in urine. Both children had undergone uneventful voiding cystourethrography with diatrizoate meglumine injection USP 18% followed by intravenous urography with diatrizoate meglumine injection USP 60%. Approximately 1 hour after urography cutaneous bullae and surrounding erythema of the buttocks (one case) or foreskin (one case) were noted. This reaction resembled a superficial chemical burn.
Standardization of the bladder capacities of children will improve the precision of urodynamic evaluation. In an attempt to develop a practical guide to predict the normal bladder capacity during childhood the bladder capacities of 132 children without a clinically abnormal pattern of voiding were measured. When the bladder capacities are correlated by age the following linear relationship exists: normal bladder capacity (ounces) equals age (years) plus 2. The bladder capacities of 68 children with primary enuresis, frequency or infrequent voiding were then measured. Children with clinically infrequent voiding demonstrated large bladder capacities and those with frequency or enuresis demonstrated small bladder capacities compared to normal children. The formula appears to be a useful guide to predict normal bladder capacity by age and also to aid in the diagnosis of abnormal voiding patterns.
A case of contrast extravasation during voiding cystourethrography (VCUG) in a patient without a history of renal failure or "unused" bladder is presented. The subject of extravasation during VCUG is reviewed.
Radionuclide voiding cystography is generally advocated for the reevaluation of proved vesicoureteral reflux. The purpose of this study was to assess the efficacy of tailored low-dose fluoroscopic voiding cystourethrography for this purpose.
Forty-five girls (2 years 9 months to 19 years 7 months old; mean, 7.4 years) who had proved reflux were examined with tailored low-dose voiding cystourethrography. The technique used a low-dose fluoroscopic system and a computer-based video frame grabber that produced frame-averaged digital video fluoroscopic hard copies. A tailored voiding cystourethrographic protocol was designed to minimize ovarian radiation dose. Digital images were compared with standard 105-mm spot films in a similar group of 25 children.
The tailored low-dose fluoroscopic technique produced diagnostically adequate images in all patients that were comparable in quality to standard spot films. The ovarian dose was 1.7-5.2 mrad (0.017-0.052 mGy) with a mean of 2.9 mrad (0.029 mGy). This compared favorably with the lowest reported doses with the radionuclide technique.
Tailored low-dose fluoroscopic voiding cystourethrography is an attractive and practical alternative to the radionuclide technique in girls with proved vesicoureteral reflux.
Contrast media can be absorbed across the urothelium in amounts sufficient to cause severe anaphylactoid reactions. We report 2 cases of anaphylactoid reactions during voiding cystourethrography (VCUG) or retrograde pyelography (RGP). A retrospective review of 783 consecutive VCUGs or RGPs performed at our institution over the last five years revealed no other systemic contrast media reactions. Although our findings and a review of the literature discloses that the incidence appears to be extremely low, urologists and radiologists need to be aware that an anaphylactoid or vagal contrast medium reaction may develop during VCUGs or RGPs. In addition, these physicians need to be prepared to treat a reaction should one occur.
To assess the reliability of a frequently used formula for calculating bladder capacity in children, bladder capacity was measured prospectively at voiding cystourethrography in 274 consecutive healthy infants and children. Bladder volume index (BVI) was then calculated by dividing the measured capacity by the predicted capacity. Bladder capacity increased dramatically after 18 months and reached a plateau between 3 and 4 months of age, after which there was no further significant increase in capacity until approximately 9 years. BVI abruptly increased from 1.03 in children aged less than 18 months to 1.50-1.60 in children aged between 18 months and 4 years (P < or = .0001). Because bladder capacity increases sharply during infancy and early childhood and levels off once toilet training is complete, linear models used to predict bladder capacity on the basis of age alone significantly underestimate bladder capacity in infants and younger children.
Complications of voiding cystourethrography are infrequent. We report a rare complication of knotting of the catheter within the bladder, necessitating surgical removal of the catheter through the urethra.