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Introduction
Clinical presentation
Clin. aproach to ivestig. and menag. of UTI
Cortical scintigraphy in urinary tract infection
Cystigraphy in urinary tract infection
Vesicourethral reflux (VUR)
The grading systems for vesicourethral eflux
Detection of vesicourethral reflux
Micturating cystourethrography (MCUG)
Radionucleotide cystography (RNC)
Direct radionuclide cystography (DRC)
Indirect radionuclide cystography (IRC)
Dynamic renal scintigraphy in UTI
Practical problems in pediatric nucl.med.
Preparation
Dose schedule
Injection
Imobilisation/ sedation
Conclusion

4.1.2. THE GRADING SYSTEMS FOR VESICOURETERAL REFLUX

IfVUR is present it should be graded to the extent possible using the standard international grading system. The Report of the International Study Classification of Reflux (1981) describes five anatomical grades of reflux. These grades are based on the anatomical appearance of the ureters and the renal pelvis and can be visualized by contrast cystography. Because scintigraphy does not have the resolution to visualize calyceal morphology, it relies on the criteria of level reached, dilatation and tortuosity of the ureter, and degree of dilatation of the renal pelvis for the grading reflux. For radionuclide cystography to be accepted by clinical physicians and for it to replace contrast cystography, clinicians must be able to compare scintigraphic results to prior contrast studies. The data from a series of radionuclide cystograms on 844 refluxing ureters are similar ( with the exception for the grade I refluxes) to the severity of reflux reported from a series of micturating cystourethrograms, and when grades II and III are combined into low-grade reflux and grades IV and V into high-grade reflux, the correlation was 100%[2]. In addition, Treves et al observe three degrees of reflux in RNC. In the less severe degree (RNC grade I), reflux is limited to the distal portion of ureter without reaching the renal pelvis. This corresponds grade I of the international, classification. Distal reflux can be detected only if the reflux is more than about 0.2 ml and is 2 cm away from bladder. More distal reflux cannot be distinguished from scattered radiation from the, bladder. A higher degree of severity ( RCN grade 2) is characterized by small amount of tracer, reaching the renal collecting system, with either minimal or nonvisualiation of the ureter. This corresponds to grade II or II of the international classification. If the radionuclide cystogram reveals a large amount of radiotracer refluxing into a dilated and tortuous ureter accompanied by frank dilatation of the pelvicalyceal system, this is classified as RNC grade 3 and corresponds to the appearance of contrast grade IV and V in the international classification!^ 10]. Also, there is a scintigraphic grading system of reflux into mild, moderate and high grade reflux ( see Table 2).

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