The Northeastern Society of Plastic Surgeons

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Hakan Bahadır Haberal, MD, Burak ıtamak, MD, Mesut Altan, MD, Ali Cansu Bozacı, MD, Taner Ceylan, MD, Hasan Serkan Doğan, Prof., Serdar Tekgl, Prof..
Hacettepe University, Ankara, Turkey.

Background: The use of the positioned the instillation of contrast (PIC) cystogram has been proposed for revealing occult vesico-ureteric reflux (VUR), which is not demonstrated by conventional voiding cystourethrogram (VCUG). Its use and clinical importance has been an area of debate. This study retrospectively reviews PIC data in our institution and tries to outline its benefit in clinical practice.
Methods: Since March 2007, 176 patients underwent PIC cystogram with negative VCUG. PIC has been done in a standard fashion contrast material being given with gravity at 100 cm high with a cystoscope right 1-2 cm in front each orifice. The patients were categorized into five different groups as stated in the table 1. Preoperative, intraoperative and postoperative features of the patients were compared.
Results: The mean age at the time of surgery was 86.12 3.96 months and female/male ratio was 139/37 (Table 1). Vesico-ureteric reflux was determined in 85 patients (48.2%) and sting was performed in 66 patients (37.5%), while ureteroneocystostomy was performed in 18 patients (10.2%). 33 patients (54.1%) were completely symptom free while 17 patients (27.9%) had partial symptom improvement in follow-up period for patients presented with urinary tract infection (Table 2). There is not any statistically significant relationship between the presence of scar in dimercaptosuccinic acid scan (DMSA) and reflux in PIC cystogram (p=0.304). The reflux rates in PIC cystogram for renal units with scar and without scar in DMSA were 44.8% and 37.5%, respectively (Table 3). When the factors for predicting the contralateral reflux were examined, only the cystoscopic view of ureteral orifice compatible with the insufficiency was found to be significant (p=0.002). However age, gender and reflux grade in the known side in VCUG were not statistically effective in predicting contralateral reflux (p=0.264, p=0.551, p=0.231).
Conclusions: The PIC cystogram is an effective diagnostic method for revealing occult reflux that the conventional VCUG cannot demonstrate. However clinical significance of this finding is not remarkable. In those patients with urinary tract infection symptoms but no reflux on VCUG PIC has a value in diagnosing occult reflux and clearing the symptoms in more than half. Yet the symptom free state in the follow up is slightly higher but no more significant than those with no reflux diagnosed (58% vs 48%, p=0.296).
Table 1. Demographic features of patients underwent PIC cystogram.

Contralateral Reflux InvestigationDMSA Positive / VCUG NegativeDMSA Negative / VCUG Negative
Patient Numbers92 (42.2%)49 (22.5%)35 (16.1%)
Female/Male Ratio67/2542/730/5
Mean Age (months)77.4 597.4 7.893 9.6
Hospitalization (day)3.1 0.21.5 0.30.97 0.1
Follow-up Period (months)31.6 3.318.8 2.719.8 4.3
Hospitalization History for IV Antibiotics19 (20.7%)20 (40.8%)14 (40%)
Voiding Dysfunction21 (35.5%)17 (48.6%)10 (47.6%)
Reflux Rates in PIC36 (39.1%)29 (59.2%)20 (57.1%)

Tablo 2. The symptom improvement rates in patients with urinary tract infection and negative VCUG.
Positive in PICNegative in PIC
No improvement7 (19.4%)4 (16%)
Partial Symptom Improvement8 (22.2%)9 (36%)
Symptom Free21 (58.3%)12 (48%)

Tablo 3. The relationship between the presence of scar in DMSA and reflux in PIC cystogram.
Positive in PICNegative in PICp
With DMSA Scar26 (44.8%)32 (55.2%)0.304
Without DMSA Scar15 (37.5%)25 (62.5%)

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