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Interactive magnetic resonance voiding cystourethrography (iMRVC) for vesicoureteric reflux (VUR) in unsedated infants: a feasibility study

Abstract

Objectives

The current reference standard for diagnosing vesicoureteric reflux is the X-ray-based Micturating CystoUrethroGram (MCUG). The aim of this study was to evaluate the feasibility of performing interactive Magnetic Resonance voiding cysto-urethrography (iMRVC) in un-sedated infants.

Methods

Twelve infants underwent conventional single-cycle MCUG followed by iMRVC. In iMRVC, patients were examined using an in-house developed fluoroscopic pulse sequence, which allows on-the-fly control of image contrast and geometry. A single acquisition was performed during bladder filling, during and after micturition, with interactive control over imaging parameters. Images were assessed for diagnostic quality and presence of VUR.

Results

Every case of reflux identified with MCUG was identified on iMRVC (100% sensitivity). Over 24 renal units, there was 88% concordance (21/24) according to the presence of reflux between the two methods. There were three “false positives” detected by MRI, giving a specificity of 83.3%, PPV of 66.7% and NPV of 100%.

Conclusion

iMRVC is a feasible method for evaluating the renal tract in infants without the need for radiation or sedation. A formal evaluation is required to establish its diagnostic potential.

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Abbreviations

CEUS:

Contrast-enhanced ultrasound

DAP:

Dose-area product

DRC:

Direct radionuclide cystography

ED:

Effective dose

FIESTA:

Fast imaging employing steady state acquisition

FSPGR:

Fast radio-frequency spoiled gradient echo

iMRVC:

Interactive magnetic resonance voiding cystourethrography

IRC:

Indirect radionuclide cystography

IV:

Intravenous

MCUG:

Micturating cystourethrogram

MR:

Magnetic resonance

NPV:

Negative predictive value

PPV:

Positive predictive value

RTGS:

Real-time gradient and spin echo

SSFSE:

Single shot fast spin echo

UTI:

Urinary tract infection

VUR:

Vesicoureteric reflux

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Acknowledgements

OJA is funded by a Medical Research Council/Royal College of Radiologists Clinical Research Training Fellowship. This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0807-14149). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. The project was supported by the Addenbrookes Charitable Trust and the NIHR comprehensive Biomedical Research Centre award to Cambridge University Hospitals NHS Foundation Trust in partnership with the University of Cambridge.

Author information

Correspondence to David J. Lomas.

Electronic supplementary materials

Movies 1, 2 and 4 were created by capturing the MRI screen display at 5 frames-per-second and have been compressed to play back at approximately 5x normal speed. Movie 3 was created from individual DICOM images rather than acquired directly from the MRI screen display.

Using interactive MR to bookmark image locations. The movie demonstrates using the interactive interface to specify anatomical locations for bookmarking using short TEeff SSFSE images in a 1-month-old boy (see also e.g. Fig. 2a): 4 specific bookmarks locations are acquired - an axial plane through the renal pelvis, a coronal plane of the whole urinary tract, an axial plane through the bladder base, and a sagittal plane through the urethra. These can be re-prescribed at any time during the study (23 s; 5.6 Mb). (MPG 5,602 kb)

Sequence switching during bladder filling to confirm anatomical landmarks. The movie demonstrates switching between short TEeff SSFSE and T1w FSPGR imaging in a 1-month-old boy. During bladder filling, the sequence is interactively switched between FSPGR (demonstrating bladder filling), and SSFSE in the same sagittal location through the urethra (confirming anatomical landmarks), then between SSFSE and FSPGR in the same axial location through the bladder, and between FSPGR, SSFSE and back again in the original sagittal location. The ability to switch between these contrast parameters during bladder filling is useful to confirm that the patient has not moved out of the imaging plane (15 s, 3.6 Mb). (MPG 3,612 kb)

Sagittal FSPGR images acquired during micturition demonstrating a normal calibre urethra in a 1-month-old boy. The movie plays at the approximate acquisition speed of 2 frames per second (14 s; 2 Mb) (MPG 2,022 kb)

Using bookmarked locations to evaluate VUR. The movie demonstrates the use of previously bookmarked locations in a 1-month-old boy (movie 1). Initial sagittal FSPGR images were acquired at 4 pre-specified bookmarked locations (see movie 1) and confirm the absence of VUR in this patient (14 s; 3.4 Mb). (MPG 3,372 kb)

Movie 1

Using interactive MR to bookmark image locations. The movie demonstrates using the interactive interface to specify anatomical locations for bookmarking using short TEeff SSFSE images in a 1-month-old boy (see also e.g. Fig. 2a): 4 specific bookmarks locations are acquired - an axial plane through the renal pelvis, a coronal plane of the whole urinary tract, an axial plane through the bladder base, and a sagittal plane through the urethra. These can be re-prescribed at any time during the study (23 s; 5.6 Mb). (MPG 5,602 kb)

Movie 2

Sequence switching during bladder filling to confirm anatomical landmarks. The movie demonstrates switching between short TEeff SSFSE and T1w FSPGR imaging in a 1-month-old boy. During bladder filling, the sequence is interactively switched between FSPGR (demonstrating bladder filling), and SSFSE in the same sagittal location through the urethra (confirming anatomical landmarks), then between SSFSE and FSPGR in the same axial location through the bladder, and between FSPGR, SSFSE and back again in the original sagittal location. The ability to switch between these contrast parameters during bladder filling is useful to confirm that the patient has not moved out of the imaging plane (15 s, 3.6 Mb). (MPG 3,612 kb)

Movie 3

Sagittal FSPGR images acquired during micturition demonstrating a normal calibre urethra in a 1-month-old boy. The movie plays at the approximate acquisition speed of 2 frames per second (14 s; 2 Mb) (MPG 2,022 kb)

Movie 4

Using bookmarked locations to evaluate VUR. The movie demonstrates the use of previously bookmarked locations in a 1-month-old boy (movie 1). Initial sagittal FSPGR images were acquired at 4 pre-specified bookmarked locations (see movie 1) and confirm the absence of VUR in this patient (14 s; 3.4 Mb). (MPG 3,372 kb)

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Arthurs, O.J., Edwards, A.D., Joubert, I. et al. Interactive magnetic resonance voiding cystourethrography (iMRVC) for vesicoureteric reflux (VUR) in unsedated infants: a feasibility study. Eur Radiol 21, 1874 (2011). https://doi.org/10.1007/s00330-011-2124-4

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Keywords

  • Vesico-ureteric reflux
  • Vesico-ureteral reflux
  • Magnetic resonance imaging
  • Paediatric
  • Micturating cystourethrogram