ESPR uroradiology task force imaging recommendations in paediatric uroradiology, part VII: standardised terminology, impact of existing recommendations, and update on contrast-enhanced ultrasound of the paediatric urogenital tract
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Our purpose is to harmonise and standardise terminology in paediatric uroradiology, to provide and update recommendations for contrast-enhanced US to standardise imaging and encourage further research, and to assess the impact of the existing recommendations in paediatric urogenital imaging. Based on thorough review of literature and variable practice at several centres and after discussion within urogenital imaging groups as well as with other subspecialties, we propose a standardisation of terminology in urogenital imaging. An update with recommendations on paediatric contrast-enhanced US has been issued based on available literature and reports. Finally, a questionnaire has been used to assess the knowledge, applicability and usefulness of, and the adherence to existing recommendations of the European Society of Paediatric Radiology (ESPR) Uroradiology Task Force. In conclusion, the ESPR is working to improve patient safety and optimise paediatric urogenital imaging. Standardisation of terminology and provision of updated knowledge on contrast-enhanced US in childhood will contribute to this task, ideally reducing the need for invasive or radiating imaging. Not all existing recommendations are commonly known, which limits adherence to these recommendations and the availability of comparable data and evidence for future adaptation of imaging strategies in paediatric uroradiology.
KeywordsUroradiology Child Terminology Standardisation Contrast-enhanced ultrasound Contrast-enhanced voiding urosonography Imaging recommendations Procedural recommendations
The European Society of Paediatric Radiology (ESPR) Uroradiology Task Force has worked diligently in creating multiple imaging and procedural recommendations addressing a large variety of common queries in paediatric urogenital radiology.
The objective of this work in cooperation with the European Society of Urogenital Radiology Paediatric Working Group is to standardise imaging and to prevent unnecessary radiation and potentially invasive investigations without losing diagnostic reliability, not only in terms of improving diagnostic imaging but also to create a common platform to allow more evidence from future research to update existing recommendations. All these recommendations are in the form of open-access articles freely accessible on the Internet.
The presented projects include (1) an effort to harmonise and standardise terminology in paediatric uroradiology, to avoid potentially misleading and unsafe perceptions and communications, (2) to update information on contrast-enhanced US in the paediatric genitourinary tract and (3) to try to assess whether all these efforts have an impact on daily imaging on a larger scale.
Standardizing terminology in paediatric uroradiology
In practice, one might commonly observe that general practice clinicians are not familiar with some common paediatric uroradiology terms. Additionally, radiologists, urologists and nephrologists do not always use the same terms with exactly the same meaning. An example is hydronephrosis, which is basically only a descriptive term. However, it is sometimes misunderstood as an implication of pathology, thus wrongly indicating further imaging or treatment.
Examples of proposed standardisation of terms: recommended terms, synonyms not recommended and comments for enhanced understanding, definition or explanation
Not recommended synonyms
Pole describes the (upper/lower) part of a non-duplicated kidney. Not to be confused with a moiety.
- Duplicated ureter
- Duplex system
- Double kidney
Definition: renal unit with two ureters, each with a separate vesicoureteric junction
- Ureteral bifidity
- Bifid ureter
- Duplex system
- Double kidney
Definition: renal unit with two ureters but a single shared vesicoureteric junction
The term moiety is used when there is incomplete or complete duplication
Ureterocele of the upper moiety ureter
- Fetal ureterocele
- Ectopic ureterocele
This is ureterocele of the upper moiety ureter in the setting of complete ureteral duplication
- Adult ureterocele
- Simple ureterocele
Ureterocele in the absence of complete duplication
High-grade vesico-ureteric reflux
- Secondary megaureter
- Refluxing megaureter
High-grade vesico-ureteric reflux (≥III) is defined by dilatation of the proximal renal tracts
Dilatation often occurs without chronic obstruction
Not necessarily associated with obstruction
Loss of corticomedullary differentiation
Dysplasia is a histological term
Suggested standardisation of terminology: comparison of recommended terms and terms that are better avoided. These terms are solely descriptive; none of them implies that obstruction is present. Hydronephrosis is grading by the adapted ESPR classification based on the Hofmann ultrasonography grading and the Society for Fetal Urology proposal
Terms to avoid
Dilatation of calyces
Dilatation of calyces and renal pelvis
Pelvicaliceal dilatation, hydronephrosis
Dilatation of renal pelvis alone
Pelvic dilatation, hydronephrosis grade 1
Dilatation of calyces, renal pelvis and ureter
Dilatation of ureter alone
Ureteral dilatation, Hydroureter
A few terms are not radiologic, such as those pertaining to lower urinary tract functional disorders, but also have to be known and understood by paediatric radiologists and thus will be included. The proposed glossary is being assessed by a panel of renowned European (paediatric) urologists and nephrologists. Their comments will then be integrated to provide for a better description of pathological disorders and better communication between (paediatric) radiologists, (paediatric) urologists and surgeons, and paediatricians or (paediatric) nephrologists. More information on the confusion of terms can be found in the literature listed in the end of this paper.
Update on contrast-enhanced ultrasound
Since the introduction of stable US contrast agents nearly two decades ago, they have been increasingly applied in examinations of the paediatric urogenital tract. Since the withdrawal of the first-generation US contrast agent Levovist® (Schering, Berlin, Germany) from the market, the US contrast agents used in children have included SonoVue® (Bracco, Milan, Italy), mostly in Europe and Asia, and Optison® (GE Healthcare, Milwaukee, WI) in the United States; but neither is registered for use in children. Thus all paediatric US contrast agent applications are off-label, requiring informed consent in some jurisdictions.
Contrast-enhanced voiding urosonography
Intravenous contrast-enhanced urosonography
Impact of procedural recommendations in paediatric urogenital radiology
To assess the impact and appreciation of the ongoing work of the task force a questionnaire was distributed by email to 700 members of ESPR and the Society for German Speaking Paediatric Radiologists. The questionnaire asked to subjectively report on knowledge, adherence, adequacy and impact of the existing recommendations of the ESPR Uroradiology Task force and European Society of Urogenital Radiology Paediatric Working Group. Respondents were requested to tell us whether these were useful or potentially in need of an update. Further, the questionnaire tried to evaluate which of the professional groups endorses the recommendations: paediatric radiologists, general radiologists or clinicians.
The survey was conducted from October 2012 to March 2013. Responses where received, most of them using SurveyMonkey, an Internet-based online survey tool and software (SurveyMonkey, Portland, OR; http://www.surveymonkey.com). It yielded a response rate of only 9%, not sufficient for definite conclusions. The answers generally came from throughout Europe, including Eastern Europe, but also a few from the United States, Canada and other countries. Forty-four members reported that they knew the recommendations from meetings, 15 from the literature and 26 from the Internet. Personal communications or visits to various departments were reported to have helped to spread the recommendations.
A list of clarified terms used in paediatric uroradiology has been provided and discussed. This work is ongoing and requires feedback from and agreement among the specialties involved: (paediatric) radiologists, (paediatric) urologists and surgeons, paediatricians and (paediatric) nephrologists.
Contrast-enhanced US is still (and probably will be for the next few years) an off-label investigation throughout childhood. However, many applications have been reported. Their use and application as well as the respective research are now also promoted by the new International Contrast Ultrasound Society. Thus, growing attention needs to be paid to this development, reasonable recommendations have to be issued, probably more dose findings studies and analysis of defined patients cohort (e.g., using multi-centre patient registries, as presently promoted by the European Federation of Societies for Ultrasound in Medicine and Biology) have to be performed to properly understand and document the utility of intravenous contrast-enhanced US. This will allow further definition of its role in the armamentarium of imaging modalities applicable throughout infancy and childhood and in the consideration of first reports of some rare but nevertheless severe side effects like anaphylactic reactions that require adequate precautions for proper and professional handling of such events.
The existing 10 paediatric procedural recommendations and the 11 proposals for imaging algorithms in paediatric uroradiology are somewhat known to most paediatric radiologists, less to general radiologists, and the least to clinicians — with concordant voting for the other aspects such as use and impact. This implies a need for better communication with general radiologists and even more with clinicians to increase awareness of existing recommendations and the rationale behind these approaches. Enhanced communication is also needed to discuss applicability, and — eventually — feedback to enable a respective update of recommendations based on or leading to a wider acceptance. Paediatric radiologists need to engage in creating clinical guidelines so that the paediatric radiology recommendations impact those guidelines that are most commonly used by clinicians.
Finally, because all these aspects are a work in progress, we invite all readers’ comments and suggestions on these and earlier recommendations in order to improve these recommendations and thus contribute to the task force work.
Conflicts of interest
Standardisation of terminology
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Update on contrast-enhanced ultrasound in childhood
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Recommendations in paediatric uroradiology
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