Fall 2012 - 09 Resized.pdf 648 | 1Department of Urology, Sina Hospital, Tehran Uni- versity of Medical Sciences, Tehran, Iran 2Urology Research Center, Sina Hospital, Tehran Uni- versity of Medical Sciences, Tehran, Iran 3Research Development Center, Sina Hospital, Teh- ran University of Medical Sciences, Tehran, Iran 4Department of Epidemi- ology and Bioinformatics, Sina Hospital, Tehran Uni- versity of Medical Sciences, Tehran, Iran Seyed Mohammad Kazem Aghamir,1 Seyed Saeed Modaresi,1 Alborz Salavati,1 Mehdi Aloosh,2,3 Ali Pasha Meysami4 Is Intravenous Urography Required When Ultrasonography and KUB Evidence a Ureteroscopy Plan? Corresponding Author: Seyed Saeed Modaresi, MD Sina Hospital, Hassan Abad Sq., Imam khomeyni Ave., Tehran, Iran Tel: +98 912 404 6303 E-mail: modaresis@razi. tums.ac.ir Received May 2011 Accepted May 2011 Purpose: - kidneys, ureters, and bladder (KUB) plus an ultrasonography in the case of ureteral calculi. Materials and Methods: From October 2005 to November 2007, 139 USE candidates were se- lected based on ultrasonography and KUB, and were randomly divided into two groups. Each patients underwent an IVU pre-operatively and were evaluated for the second time by the other of a density in the probable tract of the ureter on KUB, and previous episodes of renal colic were - ity to contrast media, and serum creatinine > 1.5 mg/dL. Results: candidate for USE. According to secondary IVU-based planning, of 139 patients, 127 (91.3%) required USE, 10 (7.1%) ureteroscopy, and 2 (1.4%) non-operative treatment. About 8.7% of treat- P = .35). Positive predic- tive value of ultrasonography plus KUB to diagnose a ureteral stone which needed USE was 92.8% Conclusion: Intravenous urography is not useful enough to be performed routinely before entire USEs. Keywords: ultrasonography, ureteroscopy, hydronephrosis, ureteral obstruction, patient safety ENDOUROLOGY AND STONE DISEASE Endourology and Stone Disease 649Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L INTRODUCTION U -monly used endourological procedure in the treatment of ureteral calculi. Furthermore, it has been revealed that open surgery is necessary in a consider- able portion of ureteral stones.(1-3) Despite the high sensitiv- ity of spiral computed tomography (CT) scan for detecting renal calculi, intravenous urography (IVU) is still consid- ered as the gold standard imaging modality for evaluation - approach comprising of ultrasonography plus a plain ab- colic in many countries.(1,4) This prospective study was designed to determine whether performing IVU as the routine pre-USE evaluation can sig- KUB and ultrasonography or not. MATERIALS AND METHODS After receiving the approval from Tehran University of Med- ical Sciences’ medical ethics committee, the current study was conducted on a consecutive group of patients with renal colic who presented to the department of emergency of Sina Hospital from October 2005 to November 2007. All the patients underwent ultrasonography, KUB, and uri- nalysis. Due to our limited accessibility to CT scan, we did not perform spiral CT scan for all the patients. Computed to- mography was only done for diagnosing non-opaque stones. - phy, a density in the probable tract of the ureter on KUB, and previous episodes of renal colic were considered as inclusion hypersensitivity to contrast media, and serum creatinine > 1.5 mg/dL. - - tients who did not respond to this conservative treatment were planned to undergo USE. One hundred and thirty-nine ultrasonography and KUB results. All of these patients were admitted to the department of urology and underwent IVU on the same day. Patients were randomly divided into two groups. Group A consisted of 70 patients and group B composed of the rest endourologists. While ultrasonography and KUB of patients group was assessed by the second endourologist. They made their decisions about patients’ treatments. Thereafter, the pa- tients in each group underwent an IVU pre-operatively and were evaluated for the second time by the other urologist considering IVU. At last, we compared treatment plans of these patients that were once provided by ultrasonography plus KUB and another time by IVU. Data were analyzed by SPSS software (the Statistical Pack- age for the Social Sciences, Version 13.0, SPSS Inc, Chicago, Illinois, USA), and P values less than .05 were considered RESULTS Patients consisted of 84 (60.4%) men and 55 (39.6%) wom- en, with the mean age of 43 years (range, 19 to 75 years). Mean serum level of creatinine was 1.3 mg/dL (range, 0.7 to 1.5 mg/dL). One hundred and thirty-two (94.9%) patients had hematuria. Ultrasonography revealed mild hydronephrosis in 20 (14.3%), moderate hydronephrosis in 67 (48.2%), and severe hydronephrosis in 52 (37.4%) patients. All of these patients had one or more densities with a mean size of 10 mm (range, 4 to 20 mm) in the probable tract of the ureter on the KUB. Intravenous urography revealed mild, moderate, and severe hydronephrosis in 18 (12.9%), 67 (48.2%), and 52 (37.4%) patients, respectively. Intravenous urography was normal in 2 (1.4%) patients, while these patients had mild hydrone- phrosis on ultrasonography and a 5-mm density in the dis- tal ureter on KUB, which resembled a stone. On the other hand, intravenous urography evidenced hydronephrosis in 10 (7.1%) patients, while those densities were not inside the ure- for ureteroscopy and not for USE (Figure). According to IVU, 127 (91.3%) patients were candidate for IVU before Ureteroscopy? | Aghamir et al 650 | USE. The indications for USE in these patients are shown in Table. If we postulate that the acceptable limit of plan change with IVU is 10%, only 8.7% of plans was changed by IVU in our P = .35). Posi- tive predictive value of ultrasonography plus KUB to diag- nose a ureteral stone which needed USE was 92.8% while 93.22). DISCUSSION 1923,(5) is a diagnostic test of choice for many indications. Intravenous urography has been a mainstay of urologic im- aging for several years.(1) Current literature suggests that performing IVU is mandatory prior to endourological pro- cedures and it should be done routinely before USE.(2) Intra- venous urography is still indicated when a urologist requests a map of the urinary tract for percutaneous, endoureteral, or surgical procedures. Intravenous urography is indicated when: 1) Ultrasonography evidences hydronephrosis in the absence of a stone on the KUB; 2) A stone is suspected on the KUB in the absence of any evidence of stones or hydro- nephrosis on ultrasonography; and 3) The colic recurs with negative KUB and ultrasonography.(6,7) However, IVU should not be performed routinely because with a mean imaging time of 75 minutes.(8) Furthermore, bowel preparation is needed and a pregnancy test may be required. Intravenous urography requires an intravenous can- nulation and injection of the contrast media, which is bother- some for the patient. Intravenous urography utilizes ionizing radiation and contrast media, which carry health risks, mor- bidity, and mortality.(9) The risk of contrast reaction during IVU is between 5% and 10%, with a mortality rate of ap- (10) Another negative point of IVU Indications for ureteroscopic stone extraction in 127 patients. Indication for uretero- scopic stone extraction Definition Number of patients Unresponsiveness to expectant management No spontaneous stone passage after 2 weeks of medical therapy 59 Prolonged symptoms Colic pain > 1 month prior to the first visit 29 Large ureteral stone Not probably passing spontaneously (> 9 mm) 19 Impacted stones No change in stone po- sition within 2 months 11 Severe acute symptoms refractory to medical treatment 6 Single kidney 2 Special considerations Like hazardous occupa- tions, such as pilot 1 Endourology and Stone Disease Treatment plans based on intravenous urography. 651Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L IVU before Ureteroscopy? | Aghamir et al MSV for an IVU.(11) In the current study, all the patients who had hydronephrosis on ultrasonography and a density in favor of calculi in the course of the ureter on KUB were planned for USE. There- (1.4%) patients did not need any endourologic procedure. This means, only the plan of two patients was changed signif- icantly and they were not transferred to the operating room, - cedure (USE for 127 and ureteroscopy for 10 patients). Costs and complications of IVU make it more reasonable to conclude that performing IVU is a redundant test in these conditions. Consequently, IVU did not change the treatment - dure. CONCLUSION We concluded that IVU should not be performed routinely before the entire USEs. CONFLICT OF INTEREST None declared. 6. Dalla Palma L. What is left of i.v. urography? Eur Radiol. 2001;11:931-9. 7. Pollack HM, Banner MP. Current status of excretory urography. A premature epitaph? Urol Clin North Am. 1985;12:585-601. 8. Thomson JM, Glocer J, Abbott C, Maling TM, Mark S. Computed tomography versus intravenous urography in diagnosis of acute flank pain from urolithiasis: a rand- omized study comparing imaging costs and radiation dose. Australas Radiol. 2001;45:291-7. 9. Andrews SJ, Brooks PT, Hanbury DC, et al. Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospec- tive incident cohort study. BMJ. 2002;324:454-6. 10. Lindbloom EJ, Chang SI. Clinical inquiries. What is the best test to diagnose urinary tract stones? J Fam Pract. 2001;50:657-8. 11. Homer JA, Davies-Payne DL, Peddinti BS. Randomized prospective comparison of non-contrast enhanced heli- cal computed tomography and in-travenous urography in the diagnosis of acute ureteric colic. Australas Radiol. 2001;45:285–90 REFERENCES 1. Chew BH, Denstedt JD. Ureteroscopy and Retrograde Ureteral Access. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. Vol 2. 9 ed. Philadelphia: Saunders; 2007:1508-25. 2. Bichler KH, Lahme S, Strohmaier WL. Indications for Open Stone Removal of Urinary Calculi. Urol Int. 1997;59:102–8. 3. Aghamir SK, Mohseni MG, Ardestani A. Treatment of ureteral calculi with ballistic lithotripsy. 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