Infección de vías urinarias en pacientes pediátricos de 0 a 14 años de edad. Experiencia del Departamento de Imagen del Hospital Metropolitano, año 2014 / Urinary tract infection in pediatric patients aged 0-14 years old. Experience Image Department Metropolitan Hospital, 2014

Resumen: La infección del tracto urinario (ITU) en pacientes pediátricos es una enfermedad común. A todos los niños con infección urinaria febril se recomienda someterse a estudios de imagen en busca de infección renal, cicatrices renales o anomalías del tracto urinario. Los estudios de imagen no son agradables para los niños y originan estrés en los padres y su aporte en la fase aguda es mínimo. Las pruebas de imagen deberían estar sustentadas en las guías NICE de ITU que intentar demostrar que uno de los pilares más importantes para evitar las secuelas renales es el diagnóstico oportuno y un tratamiento eficaz. Palabras claves: infección del tracto urinario, ecografía renal, uretrocistografía, gammagrafía renal.

Abstract: Urinary tract infection (UTI) pediatric patients is a common disease. All the children with febril UTI were recommended to undergo imagenological studies looking for renal infection, renal scarring or urinary tract abnormalities. The imagenological studies are nice for children and distressing for their parents and their contribution in the acute phase is minimal. Imaging tests should be based on ITU NICE guidelines that attempt to show that one of the most important pillars to prevent renal sequelae is early diagnosis and effective treatment. Key words: urinary tract infection, renal ultrasonography, urethrocystography, renal scintigraphy

Signo radiológico: el lirio caído / Radiology sign: the drooping lily

Abstract: the drooping lily sign, also known as wilting flower, corresponds to an imaginological alteration reported over 40 years ago. Initially described in excretory urography, it represents the appearance of the inferior ureteropelvic renal system with a duplicated collecting system, in which the renal pelvis is horizontal and calices are discreetly directed towards caudal. Despite the current limited use of excretory urography, the drooping lily sign remains valid and of diagnostic use in voiding cystourethrograms (VCUG) (also micturating cystourethrogram (MCUG)), computed tomography urography (CTU) and magnetic resonance urography (MRU).

El signo del lirio caído (drooping lily en la literatura anglosajona), también llamado "flor marchita", corresponde a una alteración imaginológica reportada hace más de 40 años. Inicialmente descrito en pielografía de eliminación, representa el aspecto que adquiere el sistema pieloureteral inferior de un riñón con doble sistema excretor, dado por una pelvis renal de orientación horizontal y cálices que se dirigen discretamente hacia caudal. A pesar de la escasa utilización de la pielografía de eliminación en la actualidad, el signo de lirio caído sigue vigente y resulta de utilidad diagnóstica en uretrocistografía miccional, urografía por tomografía computarizada (UroTC) y urografía por resonancia magnética (UroRM).

Fibrossarcoma uretral primário em cadela / Primary urethral fibrosarcoma in a female dog

Relatou-se um caso de fibrossarcoma localizado na uretra média de uma cadela, sem raça definida, que apresentava sinais de polaquiúria, estrangúria e hematúria no início da micção. O animal também apresentava poliúria, polidipsia, êmese e anorexia há dois dias. Os exames complementares levaram ao diagnóstico de hidronefrose bilateral, hipoplasia renal direita e massa em uretra causando dilatação dorsal de sua porção média. A biópsia não foi realizada antemortem devido ao estado geral do paciente, que, mesmo com a instituição de tratamento para doença renal crônica, não apresentou progresso. A uretrocistografia retrógrada e a histologia foram os exames decisivos para detectar o fibrossarcoma uretral. A ultrassonografia e a citologia por sondagem traumática não foram conclusivos, devido ao fato de a massa apresentar-se em região media de uretra e o caráter pouco esfoliativo da neoplasia.

A case of fibrosarcoma located at medium portion of the urethra of a female dog which presented pollakiuria, estranguria and hematuria at the beginning of urination was reported. The patient also presented polyuria, polydipsia, emesis and anorexia for two days. The complementary exams lead to the diagnosis of bilateral hydronephrosis, right renal hypoplasy and a mass in the urethra causing a dorsal dilatation at its medium portion. A biopsy was not performed antemortem because the general condition of the patient, which even with the institution of treatment for chronic kidney disease, showed no progress. The retrograde cystourethrography and histopathology examinations were decisive to detect urethral fibrosarcoma. Ultrasonography and cytology through traumatic probe were inconclusive, due to the mass location and its exfoliating properties.

Radiographic diagnosis of traumatic urethrorectal fistula in dog / Diagnóstico radiográfico de fístula uretroretal traumática em cão

A dog with abdominal trauma had an urethrorectal fistula and secundary bilateral hidronephrosis and hydroureter, identified by urethrocistography and excretory urography. According to our researches, only two cases of traumatic urethrorectal fistula had been reported until now in veterinary medicine.

Um cão com trauma abdominal desenvolveu fístula uretroretal, hidronefrose e hidroureter bilaterais secundários, identificados por uretrocistografia e urografia excretora. Na literatura veterinária, há somente dois casos de fístulas uretroretais traumáticas descritos até o momento.

Uretrocistografía en niños: percepción de los padres / Uretrocystography in children: parents' perception

Voiding cystourethrography (VCUG) has been usually considered as a painful and badly tolerated procedure in children. This opinion is not agreed with local experience of the authors. Objective: To evaluate the parent's perception about VCUG in children before and after the procedure. Methods: In 2009, parents of children who carne to Radiology Department for a VCUG completed an anonymous survey, including age and sex of their children, physician referent specialty, information received about the exam, expectation before and opinion after the procedure. Results: During 12 months 86 surveys were evaluated; patient's age was ranged between 1 month to 8 years with 52.3 percent> (45) girls and 47.7 percent> (41) males. Patients were referred from general pediatric in 59 percento or nephrology practice in 33 percent>; 20 percent> of the patients did not receive any information about the procedure before. About the expectation of VCUG, previous the exam, parents considered the examination as a pediatrician visit in 2.3 percent, uncomfortable in 26.7 percent>, a little painful in 16.3 percent, painful in 21 percent and aggressive or terrible in 33.7 percento. After the examination, parents' opinion was: 24.4 percent> as a pediatrician visit, 45.3 percent> uncomfortable, 22.1 percento a little painful, 4.7 percent> painful and 3.5 percent> aggressive or terrible. The global parents' perception about VCUG after the exam improved in 66 percent> cases, did not change in 29 percent> and went worse in 5 percent. Conclusion: Parent's perception about VCUG in children significantly improves after the procedure; in 91.8 percent> the examination was considered uncomfortable or only a little painful.

Con frecuencia se califica a la uretrocistografía miccional (UCG) como un examen doloroso y mal tolerado por los niños, lo que resulta discordante con la experiencia de los autores. Objetivo: Evaluar la percepción de los padres de las UCG efectuadas a sus hijos, antes y después del examen. Durante el año 2009, en el Servicio de Radiología de Clínica Las Condes, se solicitó a los padres contestar anónimamente una encuesta que incluía: edad y sexo del niño, especialidad médico solicitante, información recibida respecto del examen, explicitar expectativas antes del examen y opinión posterior. Se evaluaron 86 encuestas; edades: 1 mes a 8 años; 52,3 por ciento (45) niñas y 47,7 por ciento (41) varones; pediatra deriva 59 por ciento y nefrólogo 33 por ciento; 20 por ciento no recibió información del solicitante. Antes del examen: 2,3 por ciento como una visita al pediatra, 26,7 por ciento molesto, 16,3 por ciento un poco doloroso, 21 por ciento doloroso y 33,7 por ciento agresivo/terrible. Después de la UCG: 24,4 por ciento como una visita al pediatra, 45,3 por ciento molesto, 22,1 por ciento un poco doloroso, 4,7 por ciento doloroso y 3,5 por ciento agresivo/terrible. Post-examen: 66 por ciento mejora la percepción, 29 por ciento mantiene y 5 por ciento empeora. Conclusiones: La percepción de los padres mejora significativamente después de efectuado el examen; el 91,8 por ciento considera el examen como molesto o un poco doloroso.

Reflujo vesicoureteral asociado a dilatación del tracto urinario fetal / Vesicoureteral reflux associated with dilation of fetal urinary tract

El objetivo del presente estudio fue presentar los porcentajes de reflujo vesicoureteral encontrados en niños a los cuales se detectó dilatación del tracto urinario superior durante el período fetal, en el seguimiento de un embarazo normal. MÉTODOS. En los niños con dilatación grave o moderada, confirmada después del nacimiento, se realizó uretrocistografía miccional para precisar la existencia de reflujo vesicoureteral como causa de la dilatación prenatal. Cuando no se pudo medir la pelvis en los ultrasonidos prenatales y sólo se informó ½ dilatación, se hizo el estudio atendiendo a los resultados del primer ultrasonido renal. En las dilataciones ligeras sólo se realizó uretrocistografía miccional si el niño se infectó, si la dilatación progresó o si existían síntomas asociados que indicaban una probable obstrucción urinaria baja. En las dilataciones bilaterales se estudiaron unidades renales con dilatación ligera, si en el riñón contralateral la dilatación era de mayor grado. RESULTADOS. Entre enero de 2002 y diciembre de 2007 fueron remitidos a la Consulta de Nefrología 119 niños a los que, mediante el seguimiento ultrasonográfico de un embarazo normal, se les había detectado una anomalía dilatante del tracto urinario. Diez niños abandonaron el seguimiento antes de que se precisara el diagnóstico y 109 fueron estudiados. En los 119 niños remitidos se encontraron 187 unidades dilatadas, ya que 78 tenían dilatación bilateral prenatal. De los 109 estudiados, 69 fueron varones con 118 unidades renales dilatadas y 40, niñas con dilatación en 69 unidades. Se encontró reflujo vesicoureteral en 22 pacientes (20,1 por ciento) y 33 unidades refluyentes, pues en 11 niños el reflujo era bilateral. Predominó el reflujo de alto grado (IV y V). CONCLUSIÓN. Entre las dilataciones del tracto urinario que se pesquisan en el período prenatal es necesario buscar un posible reflujo vesicoureteral, el cual està presente en el 20 % de los casos...

The aim of present study was to shows percentages of vesicoureteral reflux found in children presenting with dilation of upper urinary tract during fetal period in follow-up of normal a pregnancy. METHODS: In children with a severe o moderate dilation, confirmed after birth, we carried out a micturition urethra-cystography to set existence of vesicoureteral reflux as cause of prenatal dilation. When it was impossible to measure pelvis in prenatal USs, and only dilation reported, we made study considering results of first renal US. In slight dilations a micturition cystoureterogram if the child was infected, if dilation progressed or if there were associated symptoms signaling a probable lower urinary obstruction. In case of bilateral dilations we studied kidney units with slight dilations, if in contralateral kidney dilation was of a greater degree. RESULTS: Between January 2002 and December 2007, 119 children were referred to Nephrology consulting room in which by means of a ultrasonic follow-up of normal pregnancy, it was detected an expansive anomaly of urinary tract. Ten children left follow-up before specify exactly the diagnosis, and 109 were studied. In 119 children referred it was found 187 dilated units, since 78 had a prenatal bilateral dilation. Of 109 children studied, 69 were of male sex with 118 dilated kidney units, and 40 were of female sex presenting with dilation in 69 units. We found vesicoureteral reflux in 22 patients (20, 1 percent) and 33 flowed back units, since in 11 children reflux was bilateral. There was a predominance of high degree reflux (IV and V). CONCLUSIONS: Among dilations of urinary tract followed in prenatal period, it is necessary to find a possible vesicoureteral reflux, which is present in 20 percent of cases. Many of these patients may to have congenital renal affection.

Avaliação das doses de radiação em uretrocistografia miccional de crianças / Evaluation of radiation dose in voiding cystourethrography in children

OBJETIVO: Analisar o produto dose-área, a dose de entrada na pele do paciente e as doses relativas à fluoroscopia e às radiografias em exames de cistouretrografia miccional em crianças. MATERIAIS E MÉTODOS: Foram avaliados os procedimentos em 37 pacientes, realizados por quatro médicos do serviço. As medições foram realizadas com um equipamento composto de uma câmara de ionização acoplada diretamente à saída do tubo de raios X e um eletrômetro (Diamentor) ligado diretamente ao computador, para a coleta dos dados. RESULTADOS: Foi observada alguma heterogeneidade na realização do procedimento, que não segue padrão de técnica radiográfica. São realizadas em média 11 radiografias por exame, usando tempo longo de fluoroscopia, com dose média final mais alta que a encontrada em referências da literatura. CONCLUSÃO: A adoção da técnica de alta quilovoltagem nas radiografias e o uso restrito da fluoroscopia podem proporcionar importante redução das doses durante a realização deste procedimento, porque o maior contribuinte para as altas doses verificadas foi a utilização da fluoroscopia.

OBJECTIVE: To evaluate dose-area product, skin entrance dose and doses from fluoroscopy and radiography in voiding cystourethrography studies of pediatric patients. MATERIALS AND METHODS: Procedures performed in 37 patients by four physicians of the institution were evaluated. Measurements were performed with an equipment including an ionization chamber directly coupled to the x-ray tube window and an electrometer (Diamentor) connected to a computer for data collection. RESULTS: Some procedures heterogeneity was observed and guidelines for good radiographic techniques were not followed. On average, 11 radiographies are performed for each study, with extended fluoroscopy time delivering a higher average final dose than those reported in the literature. CONCLUSION: The adoption of radiography with high kilovoltage technique and restricted utilization of fluoroscopy can result in a significant reduction of doses during this procedure, considering that the major contribution to the final dose comes from fluoroscopy.

Válvula da uretra posterior associada a urinoma perinefrético e ascite urinária / Posterior urethral valve associated to perinephric urinoma and urinary ascitis

A válvula de uretra posterior é a principal causa de obstrução do fluxo urinário na infância. Relatamos um caso de válvula de uretra posterior diagnosticada por uretrocistografia e ultra-sonografia, cuja função renal foi poupada devido a incomuns mecanismos redutores das pressões endovesicais.Seu diagnóstico e tratamento precoces foram decisivos no prognóstico do paciente.

The posterior urethral valve is the main cause of urinal flow obstructionin childhood. Here we report a case of a posterior urethral valve diagnosed by urethrocystography and ultrasonography,whose renal function was saved due to unusual reducing mechanisms of endovesical pressures. The diagnosis and early treatment were decisive in the prognosis of the patient.