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Positioning the Instillation of Contrast Cystography: Does It Provide Any

Clinical Benefit?

Article  in  Urology · November 2017

DOI: 10.1016/j.urology.2017.10.034

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Accepted Manuscript

Title: Positioning the Instillation of Contrast Cystography: Does It Provide

Any Clinical Benefit?

Author: Hakan Bahadir Haberal, Burak Çitamak, Mesut Altan, Ali Cansu
Bozaci, Taner Ceylan, Hasan Serkan Doğan, Serdar Tekgül

PII: S0090-4295(17)31177-9
DOI: https://doi.org/10.1016/j.urology.2017.10.034
Reference: URL 20735

To appear in: Urology

Received date: 9-9-2017

Accepted date: 28-10-2017

Please cite this article as: Hakan Bahadir Haberal, Burak Çitamak, Mesut Altan, Ali Cansu
Bozaci, Taner Ceylan, Hasan Serkan Doğan, Serdar Tekgül, Positioning the Instillation of
Contrast Cystography: Does It Provide Any Clinical Benefit?, Urology (2017),
https://doi.org/10.1016/j.urology.2017.10.034.

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POSITIONING THE INSTILLATION OF CONTRAST CYSTOGRAPHY: DOES IT

PROVIDE ANY CLINICAL BENEFIT?

HAKAN BAHADIR HABERAL1, BURAK ÇITAMAK1, MESUT ALTAN1, ALİ CANSU

BOZACI1, TANER CEYLAN1, HASAN SERKAN DOĞAN1, SERDAR TEKGÜL1

1. Department of Urology, Hacettepe University School of Medicine, Ankara, Turkey

Corresponding author: Hakan Bahadır Haberal: e-mail: bahadirhaberal@gmail.com

Phone Number: +905330391907

Fax Number: +903123112262

Department of Urology, Hacettepe University School of Medicine, 06230, Altındağ,

Ankara, Turkey

Abstract word count: 218

Manuscript word count: 2819

ACKNOWLEDGMENTS: None.

Keywords: positioning the instillation of contrast cystography; vesico-ureteral reflux;

febrile urinary tract infection; occult reflux; voiding cystourethrography

Page 1 of 15
ABSTRACT

Objectives: To outline positioning the instillation of contrast cystography (PICC)’s

benefits in clinical practice.

Methods: 198 patients underwent PICC with the following indications: patients with

positive preoperative conventional voiding cystourethrography (VCUG) for single

ureteric side, patients with urinary tract infection, and negative VCUG for both

ureteric sides. Patients with positive VCUG served as the control group.

Preoperative, intraoperative, and postoperative features of all patients were

compared.

Results: The reflux rate for the contralateral vesico-ureteric reflux (VUR)

investigation group was 39.1%. Only the cystoscopic view of the anatomically

deficient ureteric orifice was found a significant predictor of contralateral reflux

(p=0.002). For patients who presented with UTI, the reflux rate was 58.3%.

Resolution of infection was assessed for patients who presented with UTI and 54.1%

of them had complete response in the follow-up period. When the patients were

classified as PICC positive and negative, infection free rates were 58.3% and 48%,

respectively (p=0.296).

Conclusions: PICC is an effective diagnostic method for revealing occult reflux.

However, the clinical significance of this finding is vague. In patients with UTI, PICC

was useful for diagnosing occult VUR and clearing the symptoms in more than half of

the patients. Further, the symptom-free state in the follow up period was slightly

higher but not more significant than it was in those with no VUR diagnosed.

Page 2 of 15
INTRODUCTION

Vesico-ureteral reflux (VUR) is an anatomic and/or a functional disorder that can lead

to renal scarring, hypertension, and renal failure.1 Voiding cystourethrography

(VCUG) is the standard diagnostic procedure for the diagnosis of VUR. 1 However,

VUCG does not reveal the expression of occult reflux in patients who had VUR. 2 The

use of positioning the instillation of contrast cystography (PICC) was proposed for

revealing occult reflux.2 In addition to this, PICC is used as an efficient diagnostic tool

in patients with febrile urinary tract infection and in those with negative VCUG in

VUR.3, 4
However, the utility and clinical importance of PICC has been an area of

debate. In the present study, we retrospectively analyzed the demographic features

and PICC results of patients who underwent PICC for different indications, and we

investigated the effect of this method on reflux detection, treatment, and long-term

outcomes in patients.

MATERIAL AND METHODS

PICC was performed on 198 patients for various indications between March 2007

and November 2016. The data of these patients were analyzed retrospectively.

The patients with lower urinary tract dysfunction (LUTD) in preoperative period

primarily were treated for this situation, after then the surgical interventions were

applied. In the preoperative period, investigations such as urine analysis and urine

cultures were performed for all patients, and surgical interventions were performed

only during absence of UTI. PICC was performed by using a 9.5F or 11F pediatric

cystoscope in the dorsal lithotomy position. The urethra, bladder neck, and bilateral

ureteral orifice configurations were examined based on the cystoscopic view.

Subsequently, PICC was conducted in a standard fashion, by the administration of

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contrast material with gravity, at 100 cm high, using a cystoscope about 1–2 cm in

front each orifice. The occurrence of reflux was determined by the intermittent scopic

image. The bladder was emptied before conducting the procedure for the other ureter

side. According to the PICC result, appropriate surgical treatment was applied to the

patient. In our routine clinical practice, the use of prophylactic antibiotics was

continued for 3-6 months postoperatively. At the end of this time, antibiotic therapy

was stopped and patients were under follow-up without any prophylaxis.

Patients were classified into the following three groups according to PICC indications:

1: Patients with positive preoperative VCUG for single ureteric side (for investigation

of possible contralateral reflux);

2: Patients with UTI, negative VCUG, and positive DMSA; and

3: Patients with UTI, negative VCUG, and negative DMSA.

The patients with positive VCUG served as the control group.

The indication groups were compared in terms of gender, operation age, surgical

intervention history, preoperative VCUG features, preoperative DMSA features,

presence of LUTD for patients older than 5 years old, PICC results, surgical

interventions after PICC, ureteral orifice configurations, duration of follow-up period,

and infection improvement in the follow-up period.

While assessing the reflux grades in VCUG and PICC, patients with Grade 4–5 reflux

were considered as having “high grade reflux,” and those with Grade 1–3 reflux were

considered as having “low grade reflux.” Presence of any scar in the kidney was

considered to indicate DMSA positivity. Accompanying daytime symptoms like

urgency, hesitancy, and wetting with holding maneuvers and constipation was

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regarded as indicative of LUTD. In our study, PICC was performed for patients with at

least one febrile UTI. Thus, those who presented with UTI were categorized in two

groups to assess symptom improvement in the follow-up period based on their

complaints and urine culture positivity. Responders were the patients who were free

of UTI postoperatively while the remainders with no improvement or partial

responders with any type or number of UTI were accepted as non-responders.

All statistical analyses were performed using the SPSS 17.0 program for Windows.

p<0.05 was considered as the statistical significance level. For univariate analysis,

the chi-square test was used for nominal data, the t-test was used for parametric

variables, and the Mann-Whitney U test was used for nonparametric variables.

Mean±standard deviation was used for parametric variables while median±range was

used for nonparametric variables.

RESULTS

The mean age of the patients at the time of surgery was 84.9±3.6 months and

female:male ratio was 152:46. The mean follow-up period was 28.1±2.1 months. The

demographic and surgical characteristics of the patients have been presented in

Table 1. VUR was detected in 107 patients (54%) and 106 patients (53.5%)

underwent surgical intervention after PICC. Endoscopic injection (STING) was

performed in 79 patients (74.5%), while ureteroneocystostomy (UNC) was performed

in 27 patients (25.5%). The reflux rates detected with PICC based on renal units have

been presented in Table 2.

Results according to PICC indications:

Contralateral reflux investigation:

Page 5 of 15
Ninety-two patients with unilateral reflux in preoperative VCUG underwent PICC for

scanning contralateral reflux. PICC revealed a contralateral VUR rate of 39.1%

(36/92). All detected VURs were of low-grade. STING was performed on 17 patients

(53.1%), while UNC was performed on 15 patients (46.9%). No surgical intervention

was required for four patients with VUR because of three of them had Grade 1 reflux

and one had Grade 2 reflux after PICC. When the factors predicting the contralateral

VUR were examined, only the cystoscopic view of the insufficient ureteral orifice was

found to be significant (p=0.002). However, age, gender, presence of scarring in

preoperative DMSA for the renal unit that underwent contralateral reflux investigation,

LUTD, and VUR grade in the known side in VCUG were not statistically significant

predictors of contralateral reflux (p=0.264, p=0.551, p=0.074, p=0.525, and p=0.231,

respectively) (Table 3).

UTI patients with preoperative negative VCUG:

Eighty-four patients with febrile UTI and negative preoperative VCUG underwent

PICC. It revealed a VUR rate of 58.3% (49/84). STING was performed on 94.2% of

these patients, while UNC was performed on 5.8%. Only the cystoscopic view of the

insufficient ureteral orifice was found to be a significant predictor of VUR (p<0.001).

Age, gender, and LUTD were not statistically significant predictors of reflux (p=0.884,

p=0.339, and p=0.123, respectively).

Infection improvement was assessed for patients who presented with UTI. Amongst

patients who presented with UTI, 54.1% of them had complete response. Patients in

whom VUR was detected in PICC underwent surgical intervention. Among

responders, STING was performed on 19 patients while 2 patients underwent UNC.

Page 6 of 15
When the patients were classified as PICC positive and negative, the infection free

rates were 58.3% and 48%, respectively (p=0.296) (Table 4).

UTI patients with preoperative negative VCUG and positive DMSA findings:

Forty-nine patients underwent PICC due to febrile UTI, negative VCUG, and existing

renal scars in DMSA. PICC detected VUR in 29 patients (59.2%). STING was

performed on 90.3% of these patients, while UNC was performed on 9.7%. VUR

rates after PICC for the renal units with and without scarring were 44.8% (26/58) and

37.5% (15/40), respectively (p=0.304). Only the cystoscopic view of the insufficient

ureteral orifice was found to have a significant relationship with reflux for the renal

units with scar in preoperative DMSA (p<0.001). Age, gender, and presence of LUTD

were not significantly associated with reflux (p=0.855, p=0.293 and p=0.448,

respectively). Nine patients had bilateral scar on DMSA and VUR was detected in

38.9% of renal units. Within patients with unilateral scar, reflux rates for the scarred

and unscarred renal units in the PICC were 47.5% (19/40) and 37.5% (15/40),

respectively (p=0.249). Totally, VUR was observed in 41 renal units, and only 8

(8.2%) of these were of high grade. Presence of LUTD was not significantly

associated with postoperative response rates (p=0.560).

UTI patients with preoperative negative VCUG and negative DMSA findings:

PICC was performed on 35 patients with febrile UTI but negative VCUG and DMSA.

VUR was detected in 20 patients (57.1%). Further, when the renal units were

evaluated, VUR was detected in 44.3% of the renal units (31/70) and STING was

performed on all renal units with VUR. Only one patient had high grade VUR

according to PICC. The univariate analysis revealed that the cystoscopic view of the

insufficient ureteral orifice and absence of LUTD were associated with VUR (p=0.025

Page 7 of 15
and p=0.002, respectively). Gender and age at the time of operation were not

statistically significant predictors of reflux (p=0.640 and p=0.439, respectively). Only

the absence of LUTD was associated with VUR in the multivariate analysis (p=0.013,

HR: 0.084).

Technical confirmation group:

Twenty-two patients underwent PICC despite positivity in preoperative VCUG. VUR

was detected in all patients (100%) after PICC. After classifying refluxes as low and

high grade, it was observed that PICC was correlated with VCUG for all renal units.

STING was performed on 13 patients (59%), while 9 patients (41%) underwent UNC.

COMMENT

VCUG is the standard diagnostic method for the detection of VUR. 1 This method

grades the extent of VUR and provides anatomical information about the bladder and

urethra.1 In 2003, Rubenstein et al. suggested the use of PICC for detecting occult

reflux in patients with febrile UTI but negative VCUG.2 PICC revealed VUR in all

patients who had negative VCUG preoperatively, and exhibited 91% accuracy in that

study.2 However, Rubenstein et al.’s study did not have data on the renal

scintigraphy status, and it had been evaluated only by ultrasonography. 2 In our study,

we included DMSA status, which provided us the opportunity to evaluate the effect of

DMSA on PICC findings.

It is known that, the new onset contralateral reflux rate for patients with unilateral

VUR in VCUG is 7%–33%.5-7 In a study on 395 patients with unilateral ureteral

reimplantation, Hubert et al. demonstrated that younger age and low observed versus

predicted bladder capacity were the major risk factors for the new onset of

contralateral reflux.6 In another study, Barroso et al. investigated new onset

8

Page 8 of 15
contralateral reflux in patients treated conservatively for unilateral reflux. 8 They stated

that, the reflux grade in the known side in VCUG was the main factor for the

contralateral side.8 Together, these studies show that PICC is an important test for

detecting occult contralateral VUR and for preventing new onset VUR in VCUG in the

follow-up period.9, 10
However, despite the high VUR rates, most of these

contralateral VURs were benign, and up to 75% of them resolved spontaneously. 6 On

the other hand, Matsumoto et al. performed PICC in patients with unilateral VUR

immediately before ureteral reimplantation and showed 47% VUR on the

contralateral side.10 Patients who were detected with contralateral VUR underwent

bilateral ureteral reimplantation. In the follow-up period, for patients with negative

PICC, no VUR was detected by postoperative VCUG. Thus, the use of PICC for this

purpose reduces the need for future recurrent VCUGs to investigate the new onset of

contralateral VUR. In our study, the contralateral VUR rate was 39.1% (36/92) and

only the cystoscopic view of the insufficient ureteral orifice was found as a significant

risk factor. STING was performed on 17 patients (53.1%), while UNC was performed

on 15 patients (46.9%). All refluxes detected in these patients were of low grade.

Surgical procedures performed on the contralateral side were concordant with the

reflux-known side. Although, PICC inherently carries the potential of overtreatment of

contralateral VUR, this approach decreases the future need of VCUGs and possible

procedures that need to be conducted under general anesthesia.

Studies have demonstrated that PICC is an effective method for patients with

scarring in DMSA but negative VCUG.11 In a study of patients with acute

pyelonephritis, 52% of the patients had a permanent renal scar with negative

VCUG.12 Berger et al. performed PICC in 154 renal units of 81 patients. 11 VUR rates

for the scarred and unscarred renal units were 86% and 83.8%, respectively, in their

Page 9 of 15
study. In our study, PICC was performed on 49 patients with febrile UTI who had

negative VCUG and positive DMSA in the 58 renal units. VUR for the renal units with

scar was 44.8% (26/58) and only the cystoscopic view of the insufficient ureteral

orifice was found to be significant. Another interesting finding is that 37.5% of the

unscarred renal units had VUR. Berger et al. suggested a correlation between PICC

grades and DMSA scar severity.11 Nevertheless, when the content of the article is

examined it can be seen that, VUR rates for scarred and unscarred renal units were

fairly close to each other. This outcome is compatible with our findings. Scar in one

renal unit indicates risk of VUR for both renal units. In our study, there was no

statistically significant relationship between the presence of scar in DMSA and reflux

in PICC. It should be considered that VUR can be seen in both kidneys independent

of renal scarring, and therefore, bilateral PICC should be performed for these

patients. PICC is an important diagnostic test for patients with renal scarring in DMSA

and negative VCUG considering that VUR was detected in more than half of these

patients.

The present study was different from other previous studies in that the PICC method

was used for patients with negative DMSA and VCUG. Reflux rates in PICC and

symptom improvement rates could be determined separately for these patients. VUR

was detected in 20 patients (57.1%) and 31 renal units (44.3%) in PICC. There was

no statistically significant difference between these two groups with similar

characteristics in terms of PICC results. Further, PICC showed VUR in more than half

of the patients with febrile UTI, and negative DMSA and VCUG. Therefore, PICC is

an important diagnostic and treatment method for patients with febrile UTI, owing to

its effectiveness in diagnosing VUR and possibly preventing renal scarring.

10

Page 10 of 15
The present study also found that, in patients with UTI, VUR can be detected in more

than half of the patients regardless of their DMSA status. Further, majority of the

high-grade refluxes were observed in the DMSA positive group. The absence of the

relationship between PICC findings and DMSA status may be attributed to the

presence of low grade VUR in most of the patients, indicating that low grade VUR

carries less risk of affecting the upper tract, as shown by Caione et al.13 We also

found DMSA positivity in the non-refluxing unit, and this finding may be a missing part

of the puzzle. Another explanation for the absence of this relationship may be the

regression of an initial high grade VUR affecting the kidney to a lower grade VUR that

cannot be detected by conventional VCUG.

VUR can be closely associated with LUTD. We detected a relationship between the

lower urinary tract status and VUR detected by PICC in UTI patients with negative

VCUG and DMSA. However, VUR was detected more often in the PICC in patients

without LUTD (90% vs. 20% for those with LUTD), which shows that the anatomic

component is more important in these groups of patients.

The use of PICC in UTI patients with negative VCUG provided infection free status in

54.1% of the patients. However, this infection free rate was no more significant than

that for those with no reflux diagnosed. Thus, while PICC provides diagnostic

advantage, its clinical benefit is not clear yet. It would be interesting to see how

clinical improvement would change if these patients were followed-up without any

intervention. One can argue that an endoscopic examination itself, even without the

presence of reflux, may lead to some clinical improvement.

The need for general anesthesia seems to be a disadvantage of PICC. It is important

to note that an examination performed under general anesthesia does not create

11

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exactly the same physiological conditions. However, like PICC, VCUG is an

examination in which physiological conditions are not replicated. Therefore, in this

context, PICC is advantageous in that it allows us to conduct surgical intervention in

the same session.

The retrospective nature of the present study is the main limitation. Another important

limitation is that the long-term outcomes of the refluxes detected in PICC cannot be

evaluated for some patients because of the lack of long term follow-up data. Owing to

the retrospective nature of the study, some data could not be evaluated for all

patients. Further, LUTD could not be graded properly, and therefore, it was only

classified as positive or negative.

CONCLUSION

PICC is an effective diagnostic method for revealing occult VUR that the conventional

VCUG cannot demonstrate. Especially, the utility of PICC for detecting contralateral

VUR for patients with unilateral VUR in VCUG is an important argument. Unilateral

scar represents a risk for bilateral renal units, and VUR in the scarred renal unit is an

important predictor for reflux in the unscarred renal unit. Therefore, bilateral PICC

should be performed in patients with unilateral renal scarring in preoperative DMSA,

due to the high VUR rates observed in the unscarred renal units. Further, PICC is a

convenient diagnostic method for detecting occult VUR in patients with febrile UTI,

and negative VCUG and DMSA. However, the clinical significance of this finding is

not remarkable. In patients with UTI symptoms but no reflux on VCUG, PICC has a

value in diagnosing occult VUR and in clearing the symptoms in more than half of the

patients. However, though the symptom-free state in the follow up was slightly higher,

it was not significantly different from those with no reflux diagnosed.

12

Page 12 of 15
REFERENCES

1. Tekgul S, Riedmiller H, Hoebeke P, et al. EAU guidelines on vesicoureteral reflux in children.

Eur Urol. 2012;62(3):534-42.
2. Rubenstein JN, Maizels M, Kim SC, Houston JT. The PIC cystogram: a novel approach to
identify "occult" vesicoureteral reflux in children with febrile urinary tract infections. J Urol.
2003;169(6):2339-43.
3. Hagerty JA, Maizels M, Cheng EY. The PIC cystogram: its place in the treatment algorithm of
recurrent febrile UTIs. Adv Urol. 2008:763620.
4. Edmondson JD, Maizels M, Alpert SA, et al. Multi-institutional experience with PIC
cystography--incidence of occult vesicoureteral reflux in children with febrile urinary tract infections.
Urology. 2006;67(3):608-11.
5. Kumar R, Puri P. Newly diagnosed contralateral reflux after successful unilateral endoscopic
correction: is it due to the pop-off mechanism? J Urol. 1997;158(3 Pt 2):1213-5.
6. Hubert KC, Kokorowski PJ, Huang L, et al. New contralateral vesicoureteral reflux after
unilateral ureteral reimplantation: predictive factors and clinical outcomes. J Urol. 2014;191(2):451-
7.
7. Sparr KE, Balcom AH, Mesrobian HG. Incidence and natural history of contralateral
vesicoureteral reflux in patients presenting with unilateral disease. J Urol. 1998;160(3 Pt 2):1023-5.
8. Barroso U, Jr., Barroso VA, de Bessa J, Jr., Calado AA, Zerati Filho M. Predictive factors for
contralateral reflux in patients with conservatively treated unilateral vesicoureteral reflux. J Urol.
2008;180(1):297-9; discussion 9.
9. Palmer BW, Hemphill M, Wettengel K, Kropp BP, Frimberger D. The Value of PIC Cystography
in Detecting De Novo and Residual Vesicoureteral Reflux after Dextranomer/Hyaluronic Acid
Copolymer Injection. Int J Nephrol. 2011;2011:276308.
10. Matsumoto F, Shimada K, Matsui F, Itesako T. Positioning the instillation of contrast at the
ureteral orifice cystography can be useful to predict postoperative contralateral reflux in children
with unilateral vesicoureteral reflux. Int J Urol. 2011;18(1):80-2.
11. Berger C, Becker T, Koen M, et al. Positioning irrigation of contrast cystography for diagnosis
of occult vesicoureteric reflux: association with technetium-99m dimercaptosuccinic acid scans. J
Pediatr Urol. 2013;9(6 Pt A):846-50.
12. Orellana P, Baquedano P, Rangarajan V, et al. Relationship between acute pyelonephritis,
renal scarring, and vesicoureteral reflux. Results of a coordinated research project. Pediatr Nephrol.
2004;19(10):1122-6.
13. Caione P, Ciofetta G, Collura G, Morano S, Capozza N. Renal damage in vesico-ureteric reflux.
BJU Int. 2004;93(4):591-5.

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Table 1. Demographic and surgical characteristics of patients according to different

indications.

Contralateral UTI patients UTI patients VCUG

Reflux with DMSA with DMSA Positive
Investigation Positive/VCUG Negative/VCU (control)
Negative G Negative
Patient (n) 92 (46.4%) 49 (24.7%) 35 (17.6%) 22 (11.1%)
Female:Male Ratio 67:25 42:7 30:5 13:9
Mean Age (months) 77.4±5 97.4±7.8 93±9.6 75.9±8.24
Follow-up Period 31.6±3.3 18.8±2.7 19.8±4.3 47.6±8
(months)
Lower Urinary Tract 35.5% 48.6% 47.6% 33.3%
Dysfunction*
Reflux Rates in 39.1% 59.2% 57.1% 100%
PICC
Endoscopic 53.1% 90.3% 100% 59%
Injection After PICC
Reimplantation 46.9% 9.7% 0% 41%
After PICC
*Percentages for available data
VCUG, voiding cystourethrogram; PICC, Positioning the Instillation of Contrast
Cystography; DMSA, dimercaptosuccinid acid scan; UTI, urinary tract infection.

Table 2. Reflux grades detected in PICC based on renal units.

VUR Contralateral Reflux DMSA Positive / VCUG DMSA Negative / VCUG

grad Investigation Negative Negative
e
0 60.9% 58.1% 55.7%
1 10.9% 9.2% 20%
2 15.2% 13.2% 15.7%
3 13% 11.3% 7.2%
4 0% 4.1% 1.4%
5 0% 4.1% 0%
DMSA, dimercaptosuccinid acid; VCUG, voiding cystourethrogram; PICC, Positioning
the Instillation of Contrast Cystography.

14

Page 14 of 15
 Table 3. Factors predicting contralateral reflux in PICC

Positive in Negative in p
PICC PICC
Age, median (range) 79 (2–348) 68.5 (11–134) 0.264
Gender Female 38.8% 61.2% 0.551
Male 40% 60%
Presence of Scar Positive 61.5% 38.5% 0.074
in DMSA* Negative 35.6% 64.4%
Known Side Low 35.6% 64.4% 0.231
Reflux Grade* High 45.5% 54.5%
Lower Urinary Positive 42.9% 57.1% 0.525
Tract Dysfunction* Negative 36.8% 63.2%
Cystoscopic View Insufficiency 76.9% 23.1% 0.002
of Ureteral Orifice* Normal 29.5% 70.5%
*Percentages for available data
DMSA, dimercaptosuccinid acid; PICC, Positioning the Instillation of Contrast
Cystography.

Table 4. Infection improvement rates in patients with urinary tract infection and
negative VCUG.

Non-responders* Responders* p
PICC Positive* 41.7% 58.3% 0.296
PICC Negative* 52% 48%
PICC Positive/DMSA Positive* 50% 50% 0.485
PICC Negative/DMSA Positive* 56.3% 43.7%
PICC Positive/DMSA Negative* 31.2% 68.8% 0.407
PICC Negative/DMSA Negative* 44.4% 55.6%
*Percentages for available data
VCUG, voiding cystourethrogram; PICC, Positioning the Instillation of Contrast
Cystography; UTI, urinary tract infection.

15

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