British Journal of UroloKy (1978), 50, 164-168
A Radioisotope Method of Assessing Uretero-ureteric Reflux P. H. O’REILLY, R. S. LAWSON, R. A. SHIELDS, H. J. TESTA, E. CHARLTON EDWARDS and R. N. P. CARROLL Departments of Urology, Nuclear Medicine and Medical Ph ysics, Manchester Royal Infirmary, Manchester
Summary - A simple radioisotope method of assessing the presence and type of uretero-ureteric reflux in incomplete duplication of the upper urinary tract is described. The application of the technique in 2 cases is demonstrated. It is suggested that this simple, non-invasive, non-toxic technique may possess some advantages over conventional methods of evaluating this condition.
Duplication of the upper urinary tract is the commonest congenital abnormality of the genitourinary system. Most cases are incomplete, the ureters joining before reaching the bladder, and such systems are prone to reflux of urine between the 2 moieties. This may be of the simple “upand-down” type, where urine is propelled from a dominant moiety to a passive one, or “see-saw” where reflux occurs back and forth between the 2 systems (Tresidder et al., 1970) (Fig. 1). We discuss here 2 patients with uretero-ureteric reflux who have been assessed by a simple, non-invasive isotope technique which appears to be highly useful in this situation.
injection of the radiopharmaceutical (I3’I-hippuran or mTechnetium-DTPA). Subsequently, regions of interest were defined over the upper and lower moieties of the duplication using a light pen. This allowed renogram curves to be derived for each moiety separately, and from these curves, periods during which activity was markedly different in the 2 moieties were selected. The data were then summed over these periods, and the resultant image used to identify the 2 regions more precisely. The renograms were then recalculated.
Method Routine 1311-hippuranrenography was first performed using a simple system of probe detectors. Analogue recordings were made with a 3 sec time constant. This procedure will detect the presence of reflux as activity passes in and out of the field of view of the detectors, the resultant renogram showing characteristic saw-tooth waves. Such a finding in a patient with incomplete duplication and absent vesico-ureteric backflow is indicative of uretero-ureteric reflux. Following this test, a dynamic gamma camera study was performed using a General Electric Radicamera with Med I1 computer system. Data were collected and stored in the computer as 15 sec frames over a period of 30 min after the Received 13 October 1977. Accepted for publication 19 October 1977.
Fig. 1 Uretero-ureteric reflux.
164
165
A RADIOISOTOPE METHOD OF ASSESSING URETERO-URETERIC REFLUX
Right kidney
A
Left kidney
Bladder
I
20
10
30
Minutes Fig. 3 Initial probe 13'I-hippuran renogram from Case 1 showing rapid fluctuations of activity suggestive of reflux.
flow. Figure 4 shows the result of the subsequent gamma camera study using 150 pCi of 1311-hippuran. The computerderked renograms for the 2 moieties clearly show that activity is see-sawing from 1 moiety to the other and back again. This is illustrated by the 3 scintigrams representing activity summed over the periods 5-695, 6%-8 and 8-9% min.
Case Report 2
Fig. 2 Excretion urogram from patient with left incomplete duplication of the upper tract (Case 1).
Case Report 1 A 23-year-old female was referred for investigation after 3 years of intermittent loin pain which was increasing. There were few associated symptoms, although the pain had been previously put down to recurrent pyelonephritis. Excretion urography had shown a normal right upper tract and a duplex system on the left, with ureters joining at about 2 cm above the ischial spine (Fig. 2). Micturating cystourethrography had disclosed no vesico-ureteric reflux. Cystoscopy and retrograde pyelography were essentially normal. Initial probe renography demonstrated the rapid fluctuations of activity in the left kidney suggestive of reflux pig. 3). Although the bladder activity increased in steps, there was no sudden decrease in counts, confirming the absence of vesico-ureteric back-
A 13-year-old female was referred with a long history of recurrent urinary tract infections and left loin pain. Excretion urography had shown a left duplex system with ureters joining at the level of the fifth lumbar vertebra (Fig. 5 ) . Initial renography using the probe system showed the saw-toothed waves characteristic of uretero-ureteric reflux (Fig. 6).Gamma camera studies in this patient using 5 mCi of %Tc-DTPA (Diagnostic Isotopes Inc.) showed that reflux was confined to the lower moiety. Excretion from the upper moiety was normal whereas urine was demonstrated to be passing from the lower moiety to the ureteric confluence and back up the same ureter (Fig. 7-see p. 168).
Discussion Duplication o f the upper urinary tract has been reported in 6% of urological cases admitted to hospital (Thompson and Amar, 1958). About three-quarters of these are unilateral and incomplete duplication, with ureters joining some distance above the bladder, is twice as common as the complete form. Such incomplete duplications are prone to uretero-ureteric reflux, and this is more likely the nearer the confluence is to the
166
BRITISH JOURNAL OF UROLOGY
bladder (Lenaghan, 1962; Amar, 1968). Clinicopathological changes secondary to the abnormality occur more often in females than males (Amar and Hutch, 1968). Operation is necessary if corn-
plications such as calculus, infection or pain supervene; pain may be caused by the first 2, or by dilatation of the pelvicaliceal system, which can amount to a Dietl’s crisis.
I 1
LEFT UPPER MOIETY
e w
5
-
6 6% min
-
6% 8 min
TIME ( min 1
LEFT LOWER MOIETY
10
15
8 - 9% min
Fig. 4 Gamma camera studies from Case 1 showing computerderived renograms from the 2 moieties along with scintigrams at 5-6%, 6%-8 and 8-9%min.
A RADIOISOTOPE METHOD OF ASSESSING URETERO-URETERIC REFLUX
167
P b 4
Right kidney
4 10 Time (min)
20
Fig. 6 Initial probe "'1-hippuran renogram from Case 2, again demonstrating saw-tooth waves in the left renogram.
to demonstrate reflux in patients using both I3IIhippuran and mTc-DTPA, but the former gives the better result. The simplicity of this technique may give it a definite advantage over existing methods of evaluation, although this remains to be proved. Nevertheless, it can be recommended that this isotope assessment be considered in all patients with symptomatic duplication of the upper urinary tract before proceeding to more invasive investigations. Fig. 5 Excretion urogram from patient with left incomplete duplication of the upper tract (Case 2).
The nature of the corrective surgery depends on the type of reflux and the effect it has had on the renal substance (Tresidder et al., 1970). This assessment has hitherto been dependent on high dose excretion urography with image intensification, which entails a high radiation dose, or on cystoscopy and retrograde pyelography, which is invasive. The isotope method described here carries a low radiation dose, is simple and quick to perform, is non-invasive, requiring only 2 small intravenous injections and gives a quantitative, functional evaluation of the situation. It will demonstrate the reflux and enable its type, whether up-and-down or see-saw, to be ascertained. Renograms can also be derived for the individual moieties of the duplication. It has been possible
Acknowledgements This work was supported in part by a grant from the Independent Order of Odd Fellows and the Manchester and North West Region Kidney Research Association.
References Amar, A. D. (1968). Reflux in duplicated ureters. Brifish Journal of Urology, 40,385-401, Amar, A. D. and Hutch, J. D. (1968). Anomalies of the Ureter. In Encyclopedia of Urology - Malformafions, VII/l, Berlin: Springer-Verlag. pp. 98-164. Lenaghan, D. (1962). Bifid ureters in children: an anatomical, physiological and clinical study. Journal of Urology, 87, 808-8 17.
Thompson, 1. M. and Amar, A. D. (1958). Clinical importance of ureteral duplication and ectopia. Journal of the American Medical Association, 168, 881-886. Tresidder, G. C., Blandy, J. P. and Murray, R. S. (1970). Pyelo-pelvic and uretero-ureteric reflux. Brifish Journal of Urology, 42, 728-735.
168
BR lTlSH JOU H NAI. O F UROLOGY
8
6 LEFT LOWER MOIETY
J J A-
0
0,
r
X
r 4
z
13
8
I
2
LEFT UPPER MOIETY
n
/ ,+\
LEFT URETERIC CONFLUENCE
7
TIME ( m i n )
-
1
10
15
-
-
6% 6 min 6 6% min 6% 6% rnin the corresponding curve from the left ureteric confluence, along with scintigrams at 5 % 4 , 6 4 % and 6%-6% min.
The Authors P. H. O’Reilly, MD, FRCS, Urological Research Fellow. Now Senior Registrar in Urology. R. S. Lawson, PhD, Physicist, Department of Medical Physics. R. A. Shields, MSc, Principal Physicist, Department of Medical Physics.
H.J. Testa, MD, PhD, Consultant in Nuclear Medicine. E. Charlton Edwards, MCh. MD, FRCS, Consultant Urologist. R. N. P. Carroll, BSc, FRCSE, Consultant Urologist. Requests for reprints to: Dr H.J. Testa, MD, PhD, Department of Nuclear Medicine, Manchester Royal Infirmary, Manchester
.
A Radioisotope Method of Assessing Uretero-ureteric Reflux P. H. O’REILLY, R. S. LAWSON, R. A. SHIELDS, H. J. TESTA, E. CHARLTON EDWARDS and R. N. P. CARROLL Departments of Urology, Nuclear Medicine and Medical Ph ysics, Manchester Royal Infirmary, Manchester
Summary - A simple radioisotope method of assessing the presence and type of uretero-ureteric reflux in incomplete duplication of the upper urinary tract is described. The application of the technique in 2 cases is demonstrated. It is suggested that this simple, non-invasive, non-toxic technique may possess some advantages over conventional methods of evaluating this condition.
Duplication of the upper urinary tract is the commonest congenital abnormality of the genitourinary system. Most cases are incomplete, the ureters joining before reaching the bladder, and such systems are prone to reflux of urine between the 2 moieties. This may be of the simple “upand-down” type, where urine is propelled from a dominant moiety to a passive one, or “see-saw” where reflux occurs back and forth between the 2 systems (Tresidder et al., 1970) (Fig. 1). We discuss here 2 patients with uretero-ureteric reflux who have been assessed by a simple, non-invasive isotope technique which appears to be highly useful in this situation.
injection of the radiopharmaceutical (I3’I-hippuran or mTechnetium-DTPA). Subsequently, regions of interest were defined over the upper and lower moieties of the duplication using a light pen. This allowed renogram curves to be derived for each moiety separately, and from these curves, periods during which activity was markedly different in the 2 moieties were selected. The data were then summed over these periods, and the resultant image used to identify the 2 regions more precisely. The renograms were then recalculated.
Method Routine 1311-hippuranrenography was first performed using a simple system of probe detectors. Analogue recordings were made with a 3 sec time constant. This procedure will detect the presence of reflux as activity passes in and out of the field of view of the detectors, the resultant renogram showing characteristic saw-tooth waves. Such a finding in a patient with incomplete duplication and absent vesico-ureteric backflow is indicative of uretero-ureteric reflux. Following this test, a dynamic gamma camera study was performed using a General Electric Radicamera with Med I1 computer system. Data were collected and stored in the computer as 15 sec frames over a period of 30 min after the Received 13 October 1977. Accepted for publication 19 October 1977.
Fig. 1 Uretero-ureteric reflux.
164
165
A RADIOISOTOPE METHOD OF ASSESSING URETERO-URETERIC REFLUX
Right kidney
A
Left kidney
Bladder
I
20
10
30
Minutes Fig. 3 Initial probe 13'I-hippuran renogram from Case 1 showing rapid fluctuations of activity suggestive of reflux.
flow. Figure 4 shows the result of the subsequent gamma camera study using 150 pCi of 1311-hippuran. The computerderked renograms for the 2 moieties clearly show that activity is see-sawing from 1 moiety to the other and back again. This is illustrated by the 3 scintigrams representing activity summed over the periods 5-695, 6%-8 and 8-9% min.
Case Report 2
Fig. 2 Excretion urogram from patient with left incomplete duplication of the upper tract (Case 1).
Case Report 1 A 23-year-old female was referred for investigation after 3 years of intermittent loin pain which was increasing. There were few associated symptoms, although the pain had been previously put down to recurrent pyelonephritis. Excretion urography had shown a normal right upper tract and a duplex system on the left, with ureters joining at about 2 cm above the ischial spine (Fig. 2). Micturating cystourethrography had disclosed no vesico-ureteric reflux. Cystoscopy and retrograde pyelography were essentially normal. Initial probe renography demonstrated the rapid fluctuations of activity in the left kidney suggestive of reflux pig. 3). Although the bladder activity increased in steps, there was no sudden decrease in counts, confirming the absence of vesico-ureteric back-
A 13-year-old female was referred with a long history of recurrent urinary tract infections and left loin pain. Excretion urography had shown a left duplex system with ureters joining at the level of the fifth lumbar vertebra (Fig. 5 ) . Initial renography using the probe system showed the saw-toothed waves characteristic of uretero-ureteric reflux (Fig. 6).Gamma camera studies in this patient using 5 mCi of %Tc-DTPA (Diagnostic Isotopes Inc.) showed that reflux was confined to the lower moiety. Excretion from the upper moiety was normal whereas urine was demonstrated to be passing from the lower moiety to the ureteric confluence and back up the same ureter (Fig. 7-see p. 168).
Discussion Duplication o f the upper urinary tract has been reported in 6% of urological cases admitted to hospital (Thompson and Amar, 1958). About three-quarters of these are unilateral and incomplete duplication, with ureters joining some distance above the bladder, is twice as common as the complete form. Such incomplete duplications are prone to uretero-ureteric reflux, and this is more likely the nearer the confluence is to the
166
BRITISH JOURNAL OF UROLOGY
bladder (Lenaghan, 1962; Amar, 1968). Clinicopathological changes secondary to the abnormality occur more often in females than males (Amar and Hutch, 1968). Operation is necessary if corn-
plications such as calculus, infection or pain supervene; pain may be caused by the first 2, or by dilatation of the pelvicaliceal system, which can amount to a Dietl’s crisis.
I 1
LEFT UPPER MOIETY
e w
5
-
6 6% min
-
6% 8 min
TIME ( min 1
LEFT LOWER MOIETY
10
15
8 - 9% min
Fig. 4 Gamma camera studies from Case 1 showing computerderived renograms from the 2 moieties along with scintigrams at 5-6%, 6%-8 and 8-9%min.
A RADIOISOTOPE METHOD OF ASSESSING URETERO-URETERIC REFLUX
167
P b 4
Right kidney
4 10 Time (min)
20
Fig. 6 Initial probe "'1-hippuran renogram from Case 2, again demonstrating saw-tooth waves in the left renogram.
to demonstrate reflux in patients using both I3IIhippuran and mTc-DTPA, but the former gives the better result. The simplicity of this technique may give it a definite advantage over existing methods of evaluation, although this remains to be proved. Nevertheless, it can be recommended that this isotope assessment be considered in all patients with symptomatic duplication of the upper urinary tract before proceeding to more invasive investigations. Fig. 5 Excretion urogram from patient with left incomplete duplication of the upper tract (Case 2).
The nature of the corrective surgery depends on the type of reflux and the effect it has had on the renal substance (Tresidder et al., 1970). This assessment has hitherto been dependent on high dose excretion urography with image intensification, which entails a high radiation dose, or on cystoscopy and retrograde pyelography, which is invasive. The isotope method described here carries a low radiation dose, is simple and quick to perform, is non-invasive, requiring only 2 small intravenous injections and gives a quantitative, functional evaluation of the situation. It will demonstrate the reflux and enable its type, whether up-and-down or see-saw, to be ascertained. Renograms can also be derived for the individual moieties of the duplication. It has been possible
Acknowledgements This work was supported in part by a grant from the Independent Order of Odd Fellows and the Manchester and North West Region Kidney Research Association.
References Amar, A. D. (1968). Reflux in duplicated ureters. Brifish Journal of Urology, 40,385-401, Amar, A. D. and Hutch, J. D. (1968). Anomalies of the Ureter. In Encyclopedia of Urology - Malformafions, VII/l, Berlin: Springer-Verlag. pp. 98-164. Lenaghan, D. (1962). Bifid ureters in children: an anatomical, physiological and clinical study. Journal of Urology, 87, 808-8 17.
Thompson, 1. M. and Amar, A. D. (1958). Clinical importance of ureteral duplication and ectopia. Journal of the American Medical Association, 168, 881-886. Tresidder, G. C., Blandy, J. P. and Murray, R. S. (1970). Pyelo-pelvic and uretero-ureteric reflux. Brifish Journal of Urology, 42, 728-735.
168
BR lTlSH JOU H NAI. O F UROLOGY
8
6 LEFT LOWER MOIETY
J J A-
0
0,
r
X
r 4
z
13
8
I
2
LEFT UPPER MOIETY
n
/ ,+\
LEFT URETERIC CONFLUENCE
7
TIME ( m i n )
-
1
10
15
-
-
6% 6 min 6 6% min 6% 6% rnin the corresponding curve from the left ureteric confluence, along with scintigrams at 5 % 4 , 6 4 % and 6%-6% min.
The Authors P. H. O’Reilly, MD, FRCS, Urological Research Fellow. Now Senior Registrar in Urology. R. S. Lawson, PhD, Physicist, Department of Medical Physics. R. A. Shields, MSc, Principal Physicist, Department of Medical Physics.
H.J. Testa, MD, PhD, Consultant in Nuclear Medicine. E. Charlton Edwards, MCh. MD, FRCS, Consultant Urologist. R. N. P. Carroll, BSc, FRCSE, Consultant Urologist. Requests for reprints to: Dr H.J. Testa, MD, PhD, Department of Nuclear Medicine, Manchester Royal Infirmary, Manchester
.
