Purpose or Case Report: The investigation of vesicoureteral reflux (VUR) has been a long standing practice in pediatric radiology, traditionally accomplished using voiding cystourethrogram (VCUG). However, our institution demonstrates that the days of lead aprons and iodinated radiation may be behind us. Contrast-enhanced voiding urosonography (CeVUS) offers a safer, more sensitive alternative to VCUG in the diagnosis of VUR. Residents practicing at this children’s hospital are exposed to and assist with CeVUS at an early stage in their training, enabling their familiarity and understanding of the modality to facilitate medical society’s shift from fluoroscopic technique.

Residents on their pediatric radiology rotation are expected to engage in the performance of CeVUS exams and in the dictation of associated reports. They quickly learn that the technical aspects of VCUG and CeVUS are very similar involving aseptic bladder catheterization, intravesicular instillation of contrast, and subsequent imaging of the urinary tract system. The sonographic contrast agent of choice is Lumason, a safe second generation microbubble formulation. Trainees also learn that the international grading system of VUR is maintained across the two modalities. Most importantly, however, is the lesson that CeVUS more frequently captures the clinically significant grades of VUR. This concept may be two fold. Firstly, the reflux of microbubbles into the kidney has greater visibility than that of its iodinated counterpart on fluoroscopy. Secondly, in order to reduce radiation-associated adverse effects of VCUG, radiologists will perform “pulse sequencing”, which potentiates missed episodes of VUR.

The field of pediatrics is certainly amidst a cultural shift with increasing awareness of the benefits and utility of contrast-enhanced ultrasonography. CeVUS is simply one example. Radiology residents at this institution are actively involved with this newer modality early in their training. This report demonstrates radiology residents performing these exams with supervision by the attending radiologist. CeVUS has been added to the teaching curriculum in pediatric radiology at our institution.
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