RESEARCH HIGHLIGHTS Nature Reviews Urology 11, 185 (2014); published online 25 February 2014; doi:10.1038/nrurol.2014.45
PAEDIATRICS
To screen or not to screen—the role of VCUG in infant UTI New research has found that, for infants presenting with their first febrile UTI, renal and bladder ultrasonography (RBUS) has low positive predictive value for abnormalities determined by voiding cystourethrogram (VCUG), confirming previous results and questioning the current diagnostic framework.
‘‘
We should not return to an aggressive imaging protocol for all children…
’’
In 2011, the American Academy of Pediatrics (AAP) updated their guidelines for the treatment of children aged 2–24 months with a first febrile UTI, to recommend that RBUS be used to identify genitourinary anomalies, with VCUG only to confirm suspected abnormalities indicative of vesicoureteral reflux (VUR), or on recurrence of UTI. Previously, screening combined both procedures. The rationale behind this change is that
VCUG represents overtreatment in the first instance, as the incidence of highgrade VUR is low in this population overall, but much higher in those with recurrent UTI. With watchful waiting until recurrence, the discomfort and potentially harmful radiation burden of VCUG can be restricted to those infants most likely to have high-grade VUR. The latest research, led by Caleb Nelson of Harvard Medical School, was undertaken to see if RBUS is an appropriate screen for VUR. The researchers identified 2,259 patients aged III according to VCUG ranged from 18% to 55%, although the higher sensitivity was only seen when a low threshold was set for anomalies on RBUS. 1,203 of the children were aged 2–24 months, and in this group the positive predictive value of RBUS for VUR grade >III was only 13–24%, but the
NATURE REVIEWS | UROLOGY
negative predictive value was 95–96%. “With a normal RBUS, we can confidently exclude those refluxes at higher risk of recurrent UTIs and possible renal damage,” comments Giovanni Montini, of Bologna, Italy, who was not involved in the research. Nelson et al. suggest that RBUS and VCUG should be considered complementary, but they do not suggest how patients who would benefit from early VCUG can be selected. The updated AAP guidelines recommend noninvasive RBUS and watchful waiting to identify patients at high-risk for VUR. “We should not return to an aggressive imaging protocol for all children following a urinary infection,” concludes Montini. Sometimes, waiting is better than screening. Robert Phillips Original article Nelson, C. P. et al. Ultrasound as a screening test for genitourinary anomalies in children with UTI. Pediatrics doi:10.1542/peds.2013-2109
VOLUME 11 | APRIL 2014 © 2014 Macmillan Publishers Limited. All rights reserved
PAEDIATRICS
To screen or not to screen—the role of VCUG in infant UTI New research has found that, for infants presenting with their first febrile UTI, renal and bladder ultrasonography (RBUS) has low positive predictive value for abnormalities determined by voiding cystourethrogram (VCUG), confirming previous results and questioning the current diagnostic framework.
‘‘
We should not return to an aggressive imaging protocol for all children…
’’
In 2011, the American Academy of Pediatrics (AAP) updated their guidelines for the treatment of children aged 2–24 months with a first febrile UTI, to recommend that RBUS be used to identify genitourinary anomalies, with VCUG only to confirm suspected abnormalities indicative of vesicoureteral reflux (VUR), or on recurrence of UTI. Previously, screening combined both procedures. The rationale behind this change is that
VCUG represents overtreatment in the first instance, as the incidence of highgrade VUR is low in this population overall, but much higher in those with recurrent UTI. With watchful waiting until recurrence, the discomfort and potentially harmful radiation burden of VCUG can be restricted to those infants most likely to have high-grade VUR. The latest research, led by Caleb Nelson of Harvard Medical School, was undertaken to see if RBUS is an appropriate screen for VUR. The researchers identified 2,259 patients aged III according to VCUG ranged from 18% to 55%, although the higher sensitivity was only seen when a low threshold was set for anomalies on RBUS. 1,203 of the children were aged 2–24 months, and in this group the positive predictive value of RBUS for VUR grade >III was only 13–24%, but the
NATURE REVIEWS | UROLOGY
negative predictive value was 95–96%. “With a normal RBUS, we can confidently exclude those refluxes at higher risk of recurrent UTIs and possible renal damage,” comments Giovanni Montini, of Bologna, Italy, who was not involved in the research. Nelson et al. suggest that RBUS and VCUG should be considered complementary, but they do not suggest how patients who would benefit from early VCUG can be selected. The updated AAP guidelines recommend noninvasive RBUS and watchful waiting to identify patients at high-risk for VUR. “We should not return to an aggressive imaging protocol for all children following a urinary infection,” concludes Montini. Sometimes, waiting is better than screening. Robert Phillips Original article Nelson, C. P. et al. Ultrasound as a screening test for genitourinary anomalies in children with UTI. Pediatrics doi:10.1542/peds.2013-2109
VOLUME 11 | APRIL 2014 © 2014 Macmillan Publishers Limited. All rights reserved
