VOIDING CYSTO URETHROGRAM

VOIDING CYSTO URETHROGRAM

1. VCUG
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. INTRODUCTION
•A voiding cystourethrogram(VCUG) is
performed to evaluate the anatomyand
physiologyof the bladderand urethra.
•The study provides valuable information
regarding the posterior urethra in pediatric
patients.
•VCUG has long been used to demonstrate
vesicoureteral reflux.
3Dept of Urology, GRH and KMC, Chennai.

4. INDICATIONS
•Evaluation of structural and functional bladder
outlet obstruction
•Evaluation of reflux
•Evaluation of the urethra in males and females
4Dept of Urology, GRH and KMC, Chennai.

5. TECHNIQUE
•It may be performed either with
–fluoroscopy and iodinated contrast medium or
–with nuclear imaging agents (usually technetium-
99m [99mTc] pertechnetate)
–Contrast or non contrast voiding sonography
5Dept of Urology, GRH and KMC, Chennai.

6. TECHNIQUE-FLOUROSCOPY
•The study may be performed with the patient
supine or in a semiuprightposition using a
table capable of bringing the patient into the
full upright position.
•The examination begins with an initial plain
film.
•This film should be inspected for bony
abnormalities, the presence of stones, and the
volume of stool.
6Dept of Urology, GRH and KMC, Chennai.

7. TECHNIQUE
•Historically performed without sedation,
clinicians have long recognized how invasive
this study is on children, and protocols have
been developed for mitigating pain and
anxiety.
•When obtained to evaluate UTI, it is regarded
as routine to defer VCUG at least until after
the patient has received several days of
antibiotics and is clinically improving.
7Dept of Urology, GRH and KMC, Chennai.

8. TECHNIQUE
•The bladder is catheterized, emptied, and low-
pressure infusion of the radio-opaque contrast
using physiologic filling pressures is begun
•In children, a 5-to 8-Fr feeding tube is used to
fill the bladder to the appropriate volume.
8Dept of Urology, GRH and KMC, Chennai.

9. TECHNIQUE
•After catheterization of the bladder, a brief
fluoroscopic image ensures proper placement of the
tip of the catheter in the bladder and that not too
much catheter has been advanced.
•Failure to visualize the catheter in the midline suggests
malposition, which might occur because of an
–abnormality of the utricle or posterior urethra in the male
or
–into an ectopic ureter in the female.
•Additionally, too much catheter in the bladder can
result in knotting of the catheter itself
9Dept of Urology, GRH and KMC, Chennai.

10. TECHNIQUE
•Patient comfort should be taken into account
when determining the appropriate volume.
•In the adult population a standard catheter
may be placed and the bladder filled to 200 to
400cc.
•The catheter is removed and a film is
obtained.
10Dept of Urology, GRH and KMC, Chennai.

11. TECHNIQUE
•During filling,
–oblique views -of the ostial area should be
obtained, particularly for demonstration of the
anatomy of the vesicoureteral junction (e.g.,
ureterocelesor diverticula).
–Lateral views-demonstrate low-degree VUR as
well as the anatomy of the male urethra to assess
for posterior urethral valves
11Dept of Urology, GRH and KMC, Chennai.

12. TECHNIQUE
•In refluxing units, the kidney must be evaluated
for the degree of calycealdistention, potential
intrarenal reflux, and anatomic variations (e.g.,
duplex systems).
•During voiding, AP and oblique films are
obtained.
•The urethra and bladder must be visualized
during voiding with attention to the bladder neck.
•The presence of a widened proximal urethra,
“spinning top urethra,” may be an important
indicator of dysfunctional voiding
12Dept of Urology, GRH and KMC, Chennai.

13. TECHNIQUE
•Postvoidevaluation should include
–assessment of drainage of refluxed material from
the upper collecting system,
–presence of any residual material in the bladder,
and vaginal voiding in girls.
–Cyclic filling enables a higher vesicoureteral reflux
detection rate
13Dept of Urology, GRH and KMC, Chennai.

14. TECHNIQUE-NUCLEAR CYSTOGRAPHY
•The radionuclide voiding cystourethrogrammay be
more sensitive for reflux detection but offers poorer
spatial resolution so that details of the urethra and
collecting system and degree of reflux may not be seen
•The main advantage of radionuclide voiding
cystourethrogramhas been the lower radiation
exposure compared with a fluoroscopic voiding
cystourethrogram.
•However, modern imaging technology and a tailored
examination has decreased the radiation exposure of
the fluoroscopic voiding cystourethrogram
14Dept of Urology, GRH and KMC, Chennai.

15. •However, it still requires urethral catheterization,
and is still a nonphysiologicmeasurement.
•Exact grading comparisons to VCUG can be
difficult but are certainly possible
•Indirect radionuclide cystography
–performed without catheterization after radionuclide
renography
–provides a noninvasive, physiologic test,
–but it is not as sensitive as direct methods so is not
routinely used for the purpose of VUR detection
TECHNIQUE-NUCLEAR CYSTOGRAPHY
15Dept of Urology, GRH and KMC, Chennai.

16. TECHNIQUE-VOIDING SONOGRAPHY
•Contrast-enhanced and noncontrastvoiding
sonography is proving its accuracy for detection of VUR
•But the technique is still in its infancy and not yet
widely performed
•It uses the detection of echogenic microbubbles
tracked in real time during voiding and bladder cycling.
•A 5-point grading system has been developed similar to
that used for VCUG
•It is associated with a higher cost because of time
consumption, but certainly promising as a nonionizing
detection and monitoring option for VUR
16Dept of Urology, GRH and KMC, Chennai.

17. 17Dept of Urology, GRH and KMC, Chennai.

18. VCUG-PAEDIATRIC UROLOGY
Kidney/Ureter
•Obstruction
–VCUG has been obtained routinely as part of the
evaluation of children with hydronephrosis; however,
the need to do so has been challenged
–Instead, most algorithms reserve VCUG when
hydronephrosisis seen along with dilated ureter(s).
•Cysts/Masses
–There is no renal cystic disease or mass that is
specifically evaluated by VCUG.
18Dept of Urology, GRH and KMC, Chennai.

19. VCUG-PAEDIATRIC UROLOGY
Kidney/Ureter
•Infection
–VCUG has been delayed between 4 and 6 weeks after UTI, when
it is indicated, on the premise that early MCUG/VCUG might
demonstrate mild transient VUR created by inflammatory
changes at the trigone.
–However, because it is rare for clinically significant VUR present
during infection to disappear after treatment and because the
identification of even transient VUR during UTI might be
clinically meaningful, a prolonged waiting period is not
necessary
–If VUR is detected on a MCUG performed early in the course of
febrile UTI, it should be considered that ureteral dilation caused
by endotoxin overestimates the degree of VUR
19Dept of Urology, GRH and KMC, Chennai.

20. VCUG-PAEDIATRIC UROLOGY
Kidney/Ureter
•Other Congenital Malformations
–There are no congenital malformations of the
kidney and ureter, other than ureterovesical
junction anomalies, that benefit from VCUG
evaluation.
•Trauma
–There is no renal or ureteral trauma that is
specifically evaluated by VCUG
20Dept of Urology, GRH and KMC, Chennai.

21. VCUG-PAEDIATRIC UROLOGY
BLADDER/ URETHRA
•Obstruction
–VCUG is an excellent high-resolution anatomic study
that is used to detect abnormalities such as those of
•bladder wall (e.g., trabeculation, ureterocele, diverticula,
bladder neck hypertrophy, tumors)
•urethra (posterior urethral valve, urethral stricture,
diverticulum), bladder stones, bladder rupture, and foreign
bodies.
–VCUG can be used to assess bladder emptying.
–The initial scout film can also identify many spinal
abnormalities
21Dept of Urology, GRH and KMC, Chennai.

22. 22Dept of Urology, GRH and KMC, Chennai.

23. 23Dept of Urology, GRH and KMC, Chennai.

24. 24Dept of Urology, GRH and KMC, Chennai.

25. 25Dept of Urology, GRH and KMC, Chennai.

26. 26Dept of Urology, GRH and KMC, Chennai.

27. VCUG-PAEDIATRIC UROLOGY
BLADDER/ URETHRA
•Cysts/Masses
–Among the dilations and masses identified on
VCUG, one finds
•urachal diverticula,
•bladder diverticula,
•dilated utricles
•fibroepithelialpolyps
27Dept of Urology, GRH and KMC, Chennai.

28. VCUG-PAEDIATRIC UROLOGY
BLADDER/ URETHRA
•Infection
–VCUG likely provides little added information in the
child with a single or few episodes of nonfebrileUTI
(cystitis or urethritis);
–however, with increasing severity or frequency of
recurrence, some would advocate for obtaining a
VCUG to exclude anatomic risk factors for UTI.
–In circumcised males, particularly, the risk for UTI is
exceedingly low such that any UTI in those patients
might deserve evaluation.
28Dept of Urology, GRH and KMC, Chennai.

29. VCUG-PAEDIATRIC UROLOGY
BLADDER/ URETHRA
•Other Congenital Malformations
–Positional instillation of contrast cystography is used
sparingly with good effect for diagnosis of occult VUR
in select children with a negative VCUG but persistent
febrile UTIs despite treatment of all other potential
etiologies
–It is important, however, to perform the test properly
with passive instillation of contrast at a height of 1
meter above the bladder as originally described to
avoid creation of purely iatrogenic VUR
29Dept of Urology, GRH and KMC, Chennai.

30. VCUG-PAEDIATRIC UROLOGY
Scrotum/Testes/Internal Genitalia
–VCUG is not useful in the evaluation of genital
anomalies with the exception of assessing
urethral, bladder, and internal genital anatomy in
cases of cloaca and urogenital sinus or differences
in sex development.
30Dept of Urology, GRH and KMC, Chennai.

31. VCUG-BLADDER DIVERTICULA
•VCUG may be performed as it offers a wealth
of information regarding
–the structural properties of diverticula (e.g.,
location, number) and
–the anatomic aspects of any underlying conditions
•A reliable estimate of diverticulum size is
offered by VCUG, which will influence
treatment selection.
31Dept of Urology, GRH and KMC, Chennai.

32. VCUG-BLADDER DIVERTICULA
•In addition, diverticula that may have been
missed on cystoscopicexamination, particularly
in the setting of heavy bladder trabeculation, may
be elucidated.
•The concomitant presence of reflux and the
proximity of the diverticulum to the ureter can be
reliably evaluated on VCUG as well;
–this offers insight into whether preoperative stent
placement is necessary to aid in
•identification and/or
•protection of the ureter or
•if a simultaneous ureteral reimplantationis necessary.
32Dept of Urology, GRH and KMC, Chennai.

33. VCUG-BLADDER DIVERTICULA
•Information on the presence of bladder neck
obstruction, such as that caused by
–bladder neck hypertrophy,
–function bladder neck obstruction,
–detrusor-bladder neck dyssynergia,
–posterior urethral valves, or
–urethral stricture disease,
•Can also be garnered from this study.
33Dept of Urology, GRH and KMC, Chennai.

34. 34Dept of Urology, GRH and KMC, Chennai.

35. 35Dept of Urology, GRH and KMC, Chennai.

36. VCUG-PUV
•VCUG remains the definitive radiologic study
in confirming the diagnosis of PUV.
•This study should be completed in the early
postnatal period after renal and bladder
sonography and as soon as an infant with
suspected prenatal findings of valves is
hemodynamically stabilized and able to
undergo the contrast study.
36Dept of Urology, GRH and KMC, Chennai.

37. •The bladder often appears thickened and trabeculatedwith
multiple diverticuli, mimicking the appearance of a
neuropathic bladder.
•High-grade vesicoureteral reflux may be seen in
approximately 50% of patients with valves at the time of
diagnosis
•Images obtained during the voiding phase will show
contrast traveling across a hypertrophied, elevated bladder
neck and grossly dilated posterior urethra
•The urethra funnels abruptly at a transverse membrane, or
cusp, representing the obstructing valve leaflets seen at
cystoscopy.
•These are the pathognomonic signs for PUV.
VCUG-PUV
37Dept of Urology, GRH and KMC, Chennai.

38. •The study commences with the insertion of an 8-Fr
feeding tube into the urethra
•this tube may curl within the capacious posterior
urethra or hypertrophied bladder neck, requiring the
use of a coudécatheter to advance into the bladder.
•Often a catheter may already be in place at the time of
the study, and it is important that the catheter be
withdrawn gradually distal to the posterior urethra
during the voiding phase of the study to offer
unobstructed views of that segment.
VCUG-PUV
38Dept of Urology, GRH and KMC, Chennai.

39. 39Dept of Urology, GRH and KMC, Chennai.

40. VUS-PUV
•Second-generation ultrasound contrast has
enabled ultrasound-guided dynamic imaging
of the lower urinary tract.
•This has been well established in the diagnosis
of reflux with contrast-enhanced voiding
ultrasonography (ceVUS) with some studies
reporting sensitivity exceeding the present
standard of care of fluoroscopic voiding
cystourethrogram.
40Dept of Urology, GRH and KMC, Chennai.

41. VUS-PUV
•This has led to an interest in imaging the
urethra to diagnose urethral pathology.
•There is significant evidence today to use
ceVUSfor imaging the urethra and reliably
diagnose PUV and other pathologic conditions
such as a urethral diverticulum
•effort to reduce radiation exposure in children
and find it to be a useful modality.
41Dept of Urology, GRH and KMC, Chennai.

42. VUS-PUV
42Dept of Urology, GRH and KMC, Chennai.

43. VCUG-ECTOPIC URETER,
URETEROCOELE
•The voiding cystourethrogram(VCUG)
provides the most definitive evaluation of the
bladder and urethra and often of the distal
ureters and is an obligatory imaging test.
•This should almost always be obtained before
any intervention to define the baseline
situation.
43Dept of Urology, GRH and KMC, Chennai.

44. VCUG-ECTOPIC URETER,
URETEROCOELE
•The unusual situation in which a VCUG may not be
obtained would be if decompression of a ureterocele
producing bladder outlet obstruction or severe
bilateral upper tract obstruction in an infant is urgently
indicated.
–It is unlikely that the findings on VCUG would alter
treatment, which would nearly always be transurethral
puncture.
•The presence of reflux may determine initial treatment
for some practitioners and is an important parameter
in clinical management after initial decompression of
the ureterocele.
44Dept of Urology, GRH and KMC, Chennai.

45. VCUG-ECTOPIC URETER,
URETEROCOELE
•In the setting of an ectopic ureter, ipsilateral
lower pole reflux is unlikely to resolve
spontaneously and will influence definitive
treatment options.
•After incision of a ureterocele, the presence
of reflux either ipsilaterallyor contralaterally
will be critical in therapeutic decision making
45Dept of Urology, GRH and KMC, Chennai.

46. 46Dept of Urology, GRH and KMC, Chennai.

47. 47Dept of Urology, GRH and KMC, Chennai.

48. 48Dept of Urology, GRH and KMC, Chennai.

49. 49Dept of Urology, GRH and KMC, Chennai.

50. 50Dept of Urology, GRH and KMC, Chennai.

51. 51Dept of Urology, GRH and KMC, Chennai.

52. VCUG-VUR
The two approaches
•Indirect cystogram
–Excretory urography
–Indirect RNC
•Direct cystograms
–VCUG
–Direct RNC
–Voiding sonography
•Doppler
•Echo-enhancing contrast agents
52Dept of Urology, GRH and KMC, Chennai.

53. VCUG-VUR
TECHNIQUE
•Bladder contrast is instilled by gravity after urethral
catheterization at a maximum height of 70cm of water
•Bladder capacity is recorded when contrast influx
ceases.
•Static images record
–bladder contour,
–presence of diverticula or ureteroceles,
–volume at which reflux occurs,
–grade of reflux,
–configuration and blunting of calyces, and
–intrarenal reflux, if present
53Dept of Urology, GRH and KMC, Chennai.

54. VCUG-VUR
•Passive or active reflux is demonstrated dynamically
during fluoroscopy while filling and voiding,
respectively.
•Delayed or postvoidfilms are crucial in documenting
clearance of contrast from the upper tracts because
retained contrast, particularly with dilated pelvicalyceal
systems, could signify the presence of a concomitant
UPJ obstruction (UPJO), either primarily or secondarily
as a result of distortion of the UPJ by massive
retrograde filling of the pelvis by the reflux
54Dept of Urology, GRH and KMC, Chennai.

55. VCUG-VUR
•Care should also be exercised in the child with
dilating reflux on a VCUG when there is
significant contrast dilution in a dilated ureter.
55Dept of Urology, GRH and KMC, Chennai.

56. 56Dept of Urology, GRH and KMC, Chennai.

57. 57Dept of Urology, GRH and KMC, Chennai.

58. RNC-VUR
•Require approximately 1% the radiation exposure
generated by the continuous fluoroscopy VCUG and
10% of that for pulsed fluoroscopy VCUG
•Lack of confounding imaging densities typical of
fluoroscopy
•ability to obtain prolonged exposures allow for greater
sensitivity of the RNC in grade 2 to 5 reflux.
•Ironically, grade I reflux into the distal ureter is often
poorly detected because of the overlying exposure
generated by contrast within the bladder
58Dept of Urology, GRH and KMC, Chennai.

59. 59Dept of Urology, GRH and KMC, Chennai.

60. 60Dept of Urology, GRH and KMC, Chennai.

61. PIC-VUR
•In a select group of patients who present with
recurrent febrile UTIs and no evidence of VUR
on VCUG, there is some evidence to suggest
that the positional instillation of contrast (PIC)
with fluoroscopy may have some benefit.
61Dept of Urology, GRH and KMC, Chennai.

62. PIC-VUR
•The technique of PIC cystography involves
cystoscopy while the child is under anesthesia.
•With the bladder empty, the cystoscope beak
is positioned close to and facing the ureteric
orifice.
•Contrast is instilled at the ureteric orifice using
the irrigation port of the cystoscope from a
height of 1 meter above the bladder.
62Dept of Urology, GRH and KMC, Chennai.

63. PIC-VUR
•Fluoroscopic spot imaging is done
simultaneously with the instillation.
•PIC-VUR is confirmed if retrograde flow of
contrast into the ureter/kidney pelvis is
observed.
•The bladder is emptied before the procedure
is repeated on the contralateral side.
63Dept of Urology, GRH and KMC, Chennai.

64. PIC-VUR
•It is conceivable that the antirefluxmechanisms
may be less robust in some patients with
recurrent UTI.
•The unique, but unphysiologic, nature of the PIC
technique may then reveal reflux in such cases.
•Furthermore, PIC cystography does not allow for
age-adjusted instillation pressures; some
pressures may be too high in younger patients
and may be creating iatrogenic reflux rather than
unmasking relevant, physiologically borderline
reflux.
64Dept of Urology, GRH and KMC, Chennai.

65. PAEDIATRIC UTI-VCUG
•In evaluation of the child with UTI, VCUG may be
performed as soon as the urine is sterile and the
child is asymptomatic and demonstrating typical
voiding
•A negative VCUG does not completely eliminate
the possibility of VUR.
•A cyclic VCUG, in which the bladder is filled, the
child voids, and the bladder is filled a second time
and is followed by voiding, increases the
sensitivity for VUR detection as well as the
detection of an ectopic ureter.
65Dept of Urology, GRH and KMC, Chennai.

66. PAEDIATRIC UTI-VCUG
66Dept of Urology, GRH and KMC, Chennai.

67. LIMITATIONS OF VCUG
•This study requires bladder filling using a catheter.
•This may be traumatic in children and difficult in some
patients with anatomic abnormalities of the urethra or
bladder neck.
•Filling of the bladder may stimulate bladder spasms at
low volumes, and some patients are unable to hold
adequate volumes for investigation.
•Bladder filling in patients with spinal cord injuries
higher than T6 may precipitate autonomic dysreflexia
67Dept of Urology, GRH and KMC, Chennai.

68. THANK YOU