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Contrast-enhanced voiding urosonography in the diagnosis of intrarenal reflux

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Although contrast-enhanced urosonography (ceVUS) has shown capable diagnostic accuracy for the diagnosis of vesicoureteral reflux (VUR) in children, the ability of ceVUS to detect intrarenal reflux (IRR) is considered limited. The purpose of our study is to assess the ability of ceVUS to detect IRR as well as its association with age, gender, and the grade of VUR.


This study included 5153 children who were referred to our clinic for ceVUS. All children underwent sonographic examinations, which were performed on a LOGIQ S8 machine equipped with dedicated software for contrast-enhanced studies with harmonic imaging. Standard ultrasound of the urinary tract was followed by bladder catheterisation and instillation of physiological normal saline and the US contrast medium (SonoVue®, Bracco).


VUR was diagnosed by ceVUS in 1959 out of 5153 children (38%), of whom IRR was found in 233 of 1959 children (11.9%). A total of 285 ureteral units showing IRR were found. High grades of VUR (IV + V) with IRR were found in a total of 235 of 285 (82.81%) renal units. Bilateral IRR was found in 53 patients, usually with a high-grade VUR on both sides. Most children had VUR grade IV, predominantly those < 12 months. The younger the child, the higher the likelihood of higher-grade VUR (p = 0.02).


ceVUS, combined with harmonic imaging and second-generation ultrasound contrast media, enabled IRR detection in almost 12% of our patients with VUR. IRR is most commonly found in children under 1 year of age with VUR grades IV and V.

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Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.


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The authors declare that they did not receive any funding for this manuscript.

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Authors and Affiliations



AC-R was responsible for data, conceptualized the study, carried out analyses, drafted the initial manuscript, revised, and approved the final manuscript. DT carried out the statiscial analysis and interpretation of data, revised, and approved the final manuscript. DM conceptualized the study, revised and approved the final manuscript. IP collected and revised the data. GR conceptualized and designed the study, carried out the analyses, drafted the initial manuscript and approved the final manuscript as submitted.

Corresponding author

Correspondence to Daniel Turudic.

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The authors declare that they have no conflict of interest.

Ethical approval

This retrospective study has been approved by the Ethics committee of the Helena Clinic for Pediatric Medicine which waved the requirement for informed consent.

Consent to participate

Both parents/guardians and older children were informed in detail of the entire procedure before the examination. They were also provided with a written leaflet describing the whole procedure.

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The authors agree to publish this manuscript in the Journal of Ultrasound.

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Cvitkovic-Roic, A., Turudic, D., Milosevic, D. et al. Contrast-enhanced voiding urosonography in the diagnosis of intrarenal reflux. J Ultrasound 25, 89–95 (2022).

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