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Victor Paschoalin, MD1, Flavia Mrad, MD1, Lorena Caires, MD1, Marcia Bessa, MD1, Ricardo Tiraboschi, MD1, Jose Murillo Netto, MD2, Jose de Bessa Jr., MD1.
1UEFS, Feira de Santana, Brazil, 2Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil.

Purpose: The optimal diagnostic imaging approach following a child’s initial febrile urinary tract infection (UTI) is controversial. Recently the top-down approach has been proposed to avoid “unnecessary” voiding cystourethrography. The aim of this meta-analysis was to evaluate the diagnostic accuracy of 99m technetium dimercapto-succinic acid renal (99mTc DMSA) scan in identifying high grade vesicoureteral reflux (VUR) in these children after a first episode of UTI.
Method: MEDLINE, EMBASE, Scopus and other databases were searched for relevant original articles published until August 2013. Sixteen relevant cohorts with patient based analysis was identified representing 4463 patients. Meta-Disc®, was used to obtain pooled estimates of sensitivity, specificity, "Odds Ratio" diagnostic with 95% confidence interval..
Results: The pooled analysis of data showed a global prevalence of high-grade VUR 17.22%. The pooled sensitivity of 99mTc DMSA scan for identifying VUR was 85,85% [83-87] 95% CI and pooled specificity 60.64% [58-62] 95% CI. Positive likelihood ratio was 2.18 [1.94-2.33] 95%CI, and negative likelihood ratio was 0.46 [0.31-0.63 ]95%CI and " Diagnostic Odds Ratio" diagnostic was9.34 . The overall accuracy was 64.98% [63.82-66,76] 95% CI. The positive predictive value (PPV) was 31.22% [30.4-32.3%] 95% and negative predictive value (NPV) was 95.37[94.2-97.6%] 95% CI.
Conclusion: DMSA scan has moderate accuracy in diagnosing high grade VUR, with high sensitivity and low specifity. The 99mTc DMSA scan in acute febrile UTI does not replace voiding cystourethrogram (VCUG) in the diagnosis of VUR, but is a useful test in the initial evaluation of these children. Children with negative DMSA may not need VCUG in the initial evaluation and the VCUG can be safeguarded for diagnostic and specific situations such as the presence of hydronephrosis and recurrent UTI confirmation.

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