Jeanne S. Chow

Sonographic findings of ovarian torsion in children

BackgroundThe clinical diagnosis of ovarian torsion is challenging and findings on pelvic sonography can be pivotal in making the correct diagnosis.ObjectiveTo determine the sonographic characteristics in children of surgically and pathologically proven ovarian torsion.Material and methodsWe performed a retrospective review of the sonograms and medical records of 41 patients with surgically and pathologically proven ovarian torsion at a pediatric hospital between 1994 and 2005. All sonograms were reviewed retrospectively by two pediatric radiologists with attention to the size, echotexture, location, presence of peripheral round cysts, and evidence of flow on Doppler sonography within the torsed ovary. The amount of free pelvic fluid was also recorded.ResultsThe most common sonographic finding of ovarian torsion was an enlarged ovary/adnexal mass. All torsed adnexa were larger than the normal contralateral ovary, with the median volume 12 times that of the normal contralateral side. The majority (61%, n = 25) of the torsions occurred on the right. Color flow, either venous or arterial, was present in 62% (n = 21/34) of the torsed ovaries for which flow on Doppler sonography was documented. In 63% of the torsed ovaries (n = 26), the torsed adnexa appeared heterogeneous. Ovarian or para-ovarian pathology that may have acted as a potential lead point was present in 55% (n = 24) of torsed ovaries. The volume ratio of the torsed to normal ovary can predict the presence of an ovarian mass within the torsed ovary. In 70% of torsed ovaries with a volume ratio greater than 20, an ovarian mass was present, and in approximately 90% of those with a volume ratio less than 20, an internal mass was absent.ConclusionAn enlarged heterogeneous appearing ovary is the most common finding in ovarian torsion. The presence or absence of flow by Doppler sonography is not helpful in the diagnosis. The volume ratio of the torsed to the normal ovary can predict the presence of an internal mass within the torsed adnexa.

Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system)

OBJECTIVE Urinary tract (UT) dilation is sonographically identified in 1-2% of fetuses and reflects a spectrum of possible uropathies. There is significant variability in the clinical management of individuals with prenatal UT dilation that stems from a paucity of evidence-based information correlating the severity of prenatal UT dilation to postnatal urological pathologies. The lack of correlation between prenatal and postnatal US findings and final urologic diagnosis has been problematic, in large measure because of a lack of consensus and uniformity in defining and classifying UT dilation. Consequently, there is a need for a unified classification system with an accepted standard terminology for the diagnosis and management of prenatal and postnatal UT dilation. METHODS A consensus meeting was convened on March 14-15, 2014, in Linthicum, Maryland, USA to propose: 1) a unified description of UT dilation that could be applied both prenatally and postnatally; and 2) a standardized scheme for the perinatal evaluation of these patients based on sonographic criteria (i.e. the classification system). The participating societies included American College of Radiology, the American Institute of Ultrasound in Medicine, the American Society of Pediatric Nephrology, the Society for Fetal Urology, the Society for Maternal-Fetal Medicine, the Society for Pediatric Urology, the Society for Pediatric Radiology and the Society of Radiologists in Ultrasounds. RESULTS The recommendations proposed in this consensus statement are based on a detailed analysis of the current literature and expert opinion representing common clinical practice. The proposed UTD Classification System (and hence the severity of the UT dilation) is based on six categories in US findings: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. The classification system is stratified based on gestational age and whether the UT dilation is detected prenatally or postnatally. The panel also proposed a follow-up scheme based on the UTD classification. CONCLUSION The proposed grading classification system will require extensive evaluation to assess its utility in predicting clinical outcomes. Currently, the grading system is correlated with the risk of postnatal uropathies. Future research will help to further refine the classification system to one that correlates with other clinical outcomes such as the need for surgical intervention or renal function.

Frequency and nature of structural anomalies in fetuses with single umbilical arteries.

Published studies differ concerning the rate of anomalies occurring in the presence of a single umbilical artery and the significance of the single umbilical artery as an isolated sonographic finding. We assessed the frequency, nature, and sonographic detection of structural anomalies in fetuses with a single umbilical artery. We identified all cases in which prenatal sonography diagnosed a single umbilical artery. Cases were excluded if postnatal physical or pathologic examination demonstrated a three‐vessel cord, yielding a study population of 167 cases. For each case, we recorded the gestational age at diagnosis of single umbilical artery and the findings of the sonographic fetal anatomic survey. We recorded postnatal clinical and pathologic information when available. Gestational age at time of diagnosis ranged from 16.8 to 41.1 weeks (mean, 29.2 +/‐ 6.5 weeks). Twenty of the 167 fetuses (12%) were twins, and the remainder were singletons. Among 118 cases with postnatal information, 37 (31%) had structural abnormalities, often involving multiple organs. The most common organ systems involved were the heart (19 cases) and the gastrointestinal (14 cases) and central nervous systems (nine cases). Five of the anomalous fetuses had abnormal karyotypes. The sonographic survey was abnormal in 31 of the 37 anomalous fetuses (84%). Among 85 cases with apparently isolated single umbilical artery at sonography and known fetal outcome, six (7%) proved to be anomalous at birth. We had two sonographic false‐positive results (mild hydronephrosis, suspected skeletal dysplasia). In summary, approximately one third of fetuses with single umbilical artery have structural anomalies, most often cardiac. Even when the single umbilical artery is an apparently isolated sonographic finding, the likelihood that the neonate will prove to have structural anomalies is considerable (7% in our series).

Ultrasound Versus Computerized Tomography for Evaluating Urolithiasis

PURPOSE We prospectively evaluated the precision of ultrasound and computerized tomography to diagnose urinary stones in children and determined whether these differences in radiological findings have any impact on clinical management. MATERIALS AND METHODS A total of 50 consecutive patients with suspected urolithiasis underwent computerized tomography and ultrasound. Two radiologists reviewed each study independently in blinded fashion. When a difference in findings was detected, 8 pediatric urologists reviewed the case. Clinical management was based on the results of each radiological test independently. Statistical analysis was performed using Fishers exact test. RESULTS Compared to computerized tomography ultrasound had 76% sensitivity and 100% specificity. In 8 patients stone(s) seen on computerized tomography was not seen on ultrasound. The average size of missed stones was 2.3 mm. In 7 patients computerized tomography showed stones bilaterally but stone was seen on only 1 side on ultrasound. When evaluating the clinical impact, the ultrasound/computerized tomography discrepancy did not result in any significant change in clinical management except in 4 cases. In these cases ultrasound findings suggested that additional imaging was required and, thus, stone(s) in the distal ureter would have been identified on subsequent imaging. CONCLUSIONS Although computerized tomography is more sensitive for detecting urolithiasis than ultrasound, the difference in usefulness between the 2 radiological tests may not be clinically significant. Given concerns for the potentially harmful cumulative long-term effect of radiation, ultrasound should be considered the first imaging test in children with suspected urolithiasis.

Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI

BACKGROUND: The 2011 American Academy of Pediatrics guidelines state that renal and bladder ultrasound (RBUS) should be performed after initial febrile urinary tract infection (UTI) in a young child, with voiding cystourethrogram (VCUG) performed only if RBUS shows abnormalities. We sought to determine test characteristics and predictive values of RBUS for VCUG findings in this setting. METHODS: We analyzed 3995 clinical encounters from January 1, 2006 to December 31, 2010 during which VCUG and RBUS were performed for history of UTI. Patients who had previous postnatal genitourinary imaging or history of prenatal hydronephrosis were excluded. Sensitivity, specificity, and predictive values of RBUS for VCUG abnormalities were determined. RESULTS: We identified 2259 patients age <60 months who had UTI as the indication for imaging. RBUS was reported as “normal” in 75%. On VCUG, any vesicoureteral reflux (VUR) was identified in 41.7%, VUR grade >II in 20.9%, and VUR grade >III in 2.8%. Sensitivity of RBUS for any abnormal findings on VCUG ranged from 5% (specificity: 97%) to 28% (specificity: 77%). Sensitivity for VUR grade >III ranged from 18% (specificity: 97%) to 55% (specificity: 77%). Among the 1203 children aged 2 to 24 months imaged after a first febrile UTI, positive predictive value of RBUS was 37% to 47% for VUR grade >II (13% to 24% for VUR grade >III); negative predictive value was 72% to 74% for VUR grade >II (95% to 96% for VUR grade >III). CONCLUSIONS: RBUS is a poor screening test for genitourinary abnormalities. RBUS and VCUG should be considered complementary as they provide important, but different, information.

Frequency of a monochorionic pair in multiple gestations: relationship to mode of conception.

To determine whether the mode of conception affects the frequency of monochorionicity in multiple gestations.

The Clinical Presentation and Surgical Management of Adnexal Torsion in the Pediatric and Adolescent Population

STUDY OBJECTIVE To determine the history, clinical presentation, physical exam, and laboratory findings of ovarian and/or tubal torsion in the pediatric and adolescent population and to examine the surgical management of adnexal torsion. DESIGN Descriptive, retrospective chart review. SETTING Academic childrens hospital. PARTICIPANTS Children and adolescents, aged 3-21 years, with the surgical diagnosis of ovarian and/or tubal torsion. MAIN OUTCOME MEASURES Pain, physical exam, and laboratory characteristics and surgical outcomes. RESULTS Of the 82 cases, there was a higher rate of right-sided adnexal torsion (64%). The most commonly reported duration of pain was 24 hours. Most (91%) stated the pain has sudden onset and 69% qualified the pain as severe. Eighty-three percent complained of nausea and 67% had vomiting. There was a higher rate of tachycardia in younger patients (P = 0.003). On exam, 91% of subjects presented with tenderness, usually in the right lower quadrant (61%). A longer duration of pain was associated with a higher rate of oophorectomy and/or salpingectomy. There was no difference in the rates of the removal of adnexal structures between gynecologists and pediatric surgeons. CONCLUSIONS Most pediatric or adolescent patients with adnexal torsion present with acute onset of severe, intermittent pain lasting for 24 hours. Nausea and vomiting, as well as abdominal tenderness were common. Our findings will facilitate the accurate diagnosis of adnexal torsion and may contribute to more expedient surgical management.

Dextranomer/hyaluronic acid copolymer (Deflux) implants mimicking distal ureteral calculi on CT.

Periureteral or subtrigonal injection of dextranomer/hyaluronic acid (Dx/HA) copolymer (Deflux, Q-Med, Uppsala, Sweden) is an increasingly common endoscopic treatment for vesicoureteral reflux. We report a confusing radiographic finding of bilateral calcified Dx/HA injections initially thought to represent bilateral distal ureteral stones in a boy who presented with intermittent periumbilical pain. Urologists, radiologists, and emergency room physicians should be aware of the potential for calcification of ureteral implants of Dx/HA, and of the potentially confusing radiographic images that may result.

Variations in Management of Mild Prenatal Hydronephrosis Among Maternal-Fetal Medicine Obstetricians, and Pediatric Urologists and Radiologists

PURPOSE There are no current guidelines for diagnosing and managing mild prenatal hydronephrosis. Variations in physician approach make it difficult to analyze outcomes and establish optimal management. We determined the variability of diagnostic approach and management regarding prenatal hydronephrosis among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. MATERIALS AND METHODS Online surveys were sent to mailing lists for national societies for each specialty. Participants were surveyed regarding criteria for diagnosing mild prenatal hydronephrosis and recommendations for postnatal management, including use of antibiotic prophylaxis, followup scheduling and type of followup imaging. RESULTS A total of 308 maternal-fetal medicine obstetricians, 126 pediatric urologists and 112 pediatric radiologists responded. Pediatric urologists and radiologists were divided between Society for Fetal Urology criteria and use of anteroposterior pelvic diameter for diagnosis, while maternal-fetal medicine obstetricians preferred using the latter. For postnatal evaluation radiologists preferred using personal criteria, while urologists preferred using anteroposterior pelvic diameter or Society for Fetal Urology grading system. There was wide variation in the use of antibiotic prophylaxis among pediatric urologists. Regarding the use of voiding cystourethrography/radionuclide cystography in patients with prenatal hydronephrosis, neither urologists nor radiologists were consistent in their recommendations. Finally, there was no agreement on length of followup for mild prenatal hydronephrosis. CONCLUSIONS We observed a lack of uniformity regarding grading criteria in diagnosing hydronephrosis prenatally and postnatally among maternal-fetal medicine obstetricians, pediatric urologists and pediatric radiologists. There was also a lack of agreement on the management of mild intermittent prenatal hydronephrosis, resulting in these cases being managed inconsistently. A unified set of guidelines for diagnosis, evaluation and management of mild intermittent prenatal hydronephrosis would allow more effective evaluation of outcomes.

Postnatal longitudinal evaluation of children diagnosed with prenatal hydronephrosis: insights in natural history and referral pattern

Clinical significance and management of prenatal hydronephrosis (PNH) are sources of debate. Existing studies are flawed with biased cohorts or inconsistent follow‐up. We aimed to evaluate the incidence of pathology in a large cohort of PNH and assess the biases and outcomes of this population.