Purpose or Case Report: Fluoroscopic voiding cystourethrography (VCUG) and radionuclide cystography (RNC) are conventional techniques used for the diagnosis of vesicoureteral reflux (VUR) in children. Contrast-enhanced voiding urosonography (ceVUS) is a radiation-free alternative to the traditional VCUG. ceVUS has gained acceptance in Europe, but has not yet been widely adopted in the USA.

The purpose of this educational review is to describe our initial experience with ceVUS using the second generation US contrast agent Optison™, with a focus on optimization of examination technique, utility in the depiction of a variety of pathological entities, and a discussion of potential pitfalls.
Methods & Materials: Using our experience with 80 ceVUS studies, performed as a paired exam with VCUG [42 girls and 38 boys, age range 2 days to 10 years (mean age 11 months, median 3 months)], we summarize our observations, including both successful and unsuccessful approaches.
Results: Excluding bladder catheterization, ceVUS takes 5-6 minutes on average. Excessive bowel gas makes the exam more challenging and “practice” sonographic views of the kidneys and bladder prior to instillation of contrast are helpful. As with VCUG, careful attention to exclusion of air from connecting tubing and complete bladder emptying prior to contrast instillation is key. If one is facile with sonography and VCUG, the technique is easily learned. Examples of VUR, intrarenal reflux, ectopic ureterocele, ureteral duplication, posterior urethral valves, and spinning top urethra will be discussed. Interpretive challenges, including vaginal reflux, gas in the bowel and visible intrarenal vessels will also be addressed.
Conclusions: The high-sensitivity, safety, and ease of performance of ceVUS has the potential to largely replace conventional fluoroscopic VCUG for diagnosis of VUR which requires exposure to ionizing radiation.