Abstract: Significant debate persists regarding the appropriate workup in children with an initial urinary tract infection. Greatly preferable to all or none approaches in the current guideline would be a model to identify children at highest risk for a recurrent urinary tract infection plus vesicoureteral reflux to allow for targeted voiding cystourethrogram while children at low risk could be observed. We sought to develop a model to predict the probability of recurrent urinary tract infection associated vesicoureteral reflux in children after an initial urinary tract infection.We included subjects from the RIVUR (Randomized Intervention for Children with Vesico-Ureteral Reflux) and CUTIE (Careful Urinary Tract Infection Evaluation) trials in our study, excluding the prophylaxis treatment arm of the RIVUR. The main outcome was defined as recurrent urinary tract infection associated vesicoureteral reflux. Missing data were imputed using optimal tree imputation. Data were split into training, validation and testing sets. Machine learning algorithm hyperparameters were tuned by the validation set with fivefold cross-validation.A total of 500 subjects, including 305 from the RIVUR and 195 from the CUTIE trials, were included in study. Of the subjects 90% were female and mean ± SD age was 21 ± 19 months. A recurrent urinary tract infection developed in 72 patients, of whom 53 also had vesicoureteral reflux (10.6% of the total). The final model included age, sex, race, weight, the systolic blood pressure percentile, dysuria, the urine albumin-to-creatinine ratio, prior antibiotic exposure and current medication. The model predicted recurrent urinary tract infection associated vesicoureteral reflux with an AUC of 0.761 (95% CI 0.714-0.808) in the testing set.Our predictive model using a novel machine learning algorithm provided promising performance to facilitate individualized treatment of children with an initial urinary tract infection and identify those most likely to benefit from voiding cystourethrogram after the initial urinary tract infection. This would allow for more selective application of this test, increasing the yield while also minimizing overuse.

Abstract: Vesicoureteral reflux, retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urological diagnoses in the pediatric population. Diagnosis and subsequent management of urinary reflux have become increasingly debated in the past decade, with divergent opinions over which patients should be evaluated for reflux, and when detected, which children should receive intervention. Although some argue that vesicoureteral reflux is a "phenotype" that often resolves without intervention, others contest that untreated reflux has the potential to cause irreversible renal damage over time. Voiding cystourethrogram images the urethra and bladder during both bladder filling and emptying, as well as the ureters and kidneys when reflux is present, and is considered the gold standard for diagnosing vesicoureteral reflux. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without low-dose antibiotic prophylaxis to a variety of operative interventions. Management should be based on a multitude of factors including patient age, risk of subsequent urinary tract infections, risk of renal parenchymal injury, a given child's projected clinical course and parental preference. Over the past two decades, investigators have elucidated many crucial voiding cystourethrogram findings in addition to grade that provide significant prognostic information and are useful in determining the best course of action for a child on a more individualized basis.

Abstract: Severe (grades IV and V) vesicoureteral reflux (VUR) is a risk factor for acute pyelonephritis, renal scars, and renal failure. This study evaluates albumin and N-acetylglucosaminidase (NAG) urinary excretion, and renal concentrating ability as screening tools to select patients for voiding cystourethrogram (VCUG). Children (111 M, 52 F) aged 10.97 ± 21.17 months (mean + SD), diagnosed with UTI, and who had undergone renal ultrasound and a VCUG, underwent a desmopressin test and had albumin/creatinine and NAG/creatinine urinary excretion measured. Urine osmolality was significantly lower in 27 children with severe VUR (375.3 ± 171.8 mOsm/kg; mean + SD) compared to 100 patients with normal VCUG (611.5 ± 175.8 mOsm/kg), p < 0.001, and to 36 patients with VUR grades I to III (636.2 ± 180.2 mOsm/kg), p < 0.001. NAG/creatinine ratio was significantly elevated in 20 children with severe VUR (26.4 (28.3) U/g); median and interquartile range compared to 67 children with normal VCUG (10.8 (17.9) U/g), p = 0.003, and to 20 patients with VUR grades I to III (7.6 (21.1) U/g), p = 0.009. Conclusions: Urinary osmolality is significantly decreased and urinary excretion of NAG is significantly increased in patients with severe VUR. These tests could select patients for VCUG to assess for severe VUR.

Abstract: To determine the performance of late dimercaptosuccinic acid (DMSA) renal scans in identifying high-grade (III-V) vesicoureteral reflux (VUR) in children aged over 3 y with a febrile urinary tract infection (fUTI) history that has not been timely investigated. In this retrospective study of diagnostic accuracy, the clinical records of children aged between 3 and 18 y with fUTI history evaluated consecutively at Nephrology Unit of Hospital General de Ninos Pedro de Elizalde, Argentina between 2006 and 2016 were reviewed. Patients with previously diagnosed renal or urinary tract abnormalities or who underwent previous postnatal genitourinary imaging were excluded. Only those assessed by renal and bladder ultrasound (RBUS), voiding cystourethrogram (VCUG) and late 6-mo DMSA scan were analyzed. The ability of the scintigraphy in identifying high-grade VUR was determined by comparing its findings with those of VCUG. In 122 children (median age 5.37 y, 88.5% girls) RBUS was abnormal in 53 (43.4%) and 58 (47.5%) had VUR (30 of high-grade). Abnormal DMSA scan findings (70 patients, 57.4%) were associated with all grade (p = 0.00001) and with high-grade VUR (p = 0.00001). Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of late DMSA scans for all grades VUR were 93.1%, 75%, 92.3% and 77.1%, respectively. Only 4 patients with low-grade VUR had normal scans. For high-grade VUR, sensitivity and NPV reached 100%. In older children, the normal late DMSA scan predicted the absence of high-grade VUR, obviating the need for a VCUG. This approach could be a possible strategy for children not studied at acute infection time.

Abstract: Introduction Delayed presentation of posterior urethral valves (PUVs) is a rare condition. Presentation and diagnosis of the patients with late PUVs are challenging. Voiding cystourethrogram (VCUG) is mainly practiced. In this study, we aimed to evaluate the children with late-presented PUVs, and the reliability of VCUG in this group. Materials and Methods Between January 2003 and December 2017 records of patients who were diagnosed with late-presented PUVs were analyzed. Delayed presentation of PUV was defined as patients who were diagnosed and treated after infancy. Cases were examined in terms of age at diagnosis, presenting symptoms, urinalysis, urinary ultrasound, urodynamic studies, VCUG, and dimercaptosuccinic acid scintigraphy findings. Postoperative follow-up conditions were also assessed. Results Seventeen boys were diagnosed with late-presented PUVs (mean age was 7.35 years). The most common symptoms at presentation were frequency (58.8%), day and nighttime incontinence (47%), and febrile urinary infection (41%). PUV was noted by VCUG in 10 patients alone. The classical sign of dilated posterior urethra was detected in 9 patients. The 10th patient had posterior urethral irregularity. Urethra could not be evaluated due to unsuccessful voiding in one patient. Six patients had normally appearing urethra on VCUG. Reflux was detected in nine (52.9%) patients. Conclusion Late-presented PUVs may be missed on VCUG. Whether a PUV might be present is crucial in boys with a history of recurrent urinary infection, persistent reflux, and repetitive daytime incontinence. Based on our results, we conclude that cystoscopic examination should be preferred for those cases to diagnose PUVs regardless of VCUG results.

Abstract: Objective: The purpose of this study is to detect vesicoureteral reflux (VUR) noninvasively using an electrical impedance tomography (EIT). VUR is characterized by the backflow of urine from the bladder to the kidneys. Methods: Using porcine models, small quantities of a solution mimicking the electrical properties of urine were infused into each ureter. EIT measurements were taken before, during and after the infusion using electrodes positioned around the abdomen. The collected data from 116 experiments were then processed and time-difference images reconstructed. Objective VUR detection was determined through statistical analysis of the mean change in the voltage signals and EIT image pixel intensities. Results: Unilateral VUR was successfully detected in 94.83% of all mean voltage signals and in over 98.28% of the reconstructed images. The images showed strong visual contrast between the region of interest and the background. Conclusion: In animal models, EIT has the capability to detect reflux in the kidneys with high accuracy. The results show promise for EIT to be used for screening of VUR in children. Significance: VUR is the most common congenital urinary tract abnormality in children. The condition predisposes children to urinary tract infections and kidney damage. The current gold standard diagnostic test, a voiding cystourethrogram, is invasive and uses ionizing radiation; therefore, there is a need for new tools for identifying VUR in children. This study presents a noninvasive method to detect VUR in animal models, illustrating the potential for EIT as a screening tool in clinical scenarios.

Abstract: Introduction Vesicoureteral reflux (VUR) is one of the most common ureteric complications after kidney transplantation that might cause symptomatic infections which deteriorate graft function. Surgical reimplantation has been the standard treatment; recently, endoscopic injection has been an alternative approach. We report our endoscopic treatment results and analyze the long-term outcome, even in patients with less optimal graft function. Materials and methods A total of 16 patients and 19 symptomatic VUR were diagnosed at mean time of 88.3 months after their transplantation. The distribution of VUR grade was 1, 2, 8, 6, and 2 for grade I to V, respectively, with a mean VUR grade of 3.26 according to their voiding cystourethrogram images. Endoscopic Deflux injections were performed by a single urologist via rigid cystoscope with a beveled needle system. They were followed monthly thereafter. Result The average number of admissions due to symptomatic urinary tract infection was 2.68/person, and the mean creatinine level before endoscopic treatment was 1.63 mg/dL. The amount of Deflux injection was 0.7 to 1.2 mL per affected ureter; the mean creatinine level after endoscopic treatment was 1.41 mg/dL. The eGFR remained stationary in both eGFR > 60 and eGFR Conclusion Endoscopic dextranomer-hyaluronic acid injection is a safe and feasible treatment option for VUR after kidney transplantation. Our data showed its efficacy in recipients whose eGFR is less than 60 mL/min.

Abstract: 1. Halima S. Janjua, MD* 2. Suet Kam Lam, MD, MPH, MS† 3. Vedant Gupta, DO‡ 4. Sangeeta Krishna, MD† 1. *Center for Pediatric Nephrology, 2. †Department of Pediatric Hospital Medicine, 3. ‡Department of Pediatrics, Cleveland Clinic Children’s, Cleveland, OH * Abbreviations: ARPKD: : autosomal recessive polycystic kidney disease CAKUT: : congenital anomalies of the kidney and urinary tract ESRD: : end-stage renal disease MCDK: : multicystic dysplastic kidney PUV: : posterior urethral valve RBUS: : renal and bladder ultrasonography UPJ: : ureteropelvic junction UTI: : urinary tract infection UVJ: : ureterovesical junction VCUG: : voiding cystourethrogram VUR: : vesicoureteral reflux Several congenital anomalies of the kidney and urinary tract are incidental findings. An understanding of when to suspect and how to diagnose, manage, and use timely and appropriate investigations and consults is necessary. After completing this article, readers should be able to: 1. Develop an awareness of various congenital anomalies of the renal system, including embryology, prevalence, and risk factors. 2. Describe the clinical presentation and management of renal and urinary tract anomalies, including which anomalies warrant further evaluation and the timing and utility of imaging modalities. 3. Develop an awareness of genetic syndromes affecting the kidneys and urinary tract with associated extrarenal manifestations. Congenital anomalies of the kidney and urinary tract (CAKUT) include a wide spectrum of anomalies, with a reported incidence of up to 2% of births. (1) CAKUT account for almost one-fourth of all birth defects. (2) These are major causes of kidney disease in children and account for more than 40% of end-stage renal disease (ESRD). CAKUT are usually detected by routine prenatal ultrasonography, although some cases are not diagnosed until adulthood. (3) When renal disease is suspected, a complete physical examination should be performed with particular focus on accurate blood pressure measurement; the abdomen for palpable kidneys and a distended bladder; the genitalia for the position of the meatus, penile abnormalities, and urine flow; and the back for signs of neural tube defects. Genetics play a major role in the etiology of CAKUT as family history is identified in 10% to 50% of affected children (Table). (4)(5) Similarly, 23% of asymptomatic first-degree relatives are found to be affected on screening. (4) Many environmental …

Abstract: Recently, it has been reported that anorectal malformation with rectourethral fistula in male neonates can be managed by primary neonatal reconstruction without colostomy. To prevent urethral injury during anorectoplasty, the fistula’s location is important. To date, the use of voiding cystourethrograms to determine the presence and location of fistulas in neonates with anorectal malformations has not been studied. To compare the accuracy of ultrasound (US) and voiding cystourethrogram for determining the presence and location of fistulas in neonates with anorectal malformation. We included 21 male neonates with anorectal malformation with rectourethral fistula (n=16), rectovesical fistula (n=1) or no fistula (n=4) who underwent US and voiding cystourethrogram preoperatively on the day of surgery. Fistula imaging was classified into three grades (0–2), and grades 1–2 were considered fistula positive. We compared the imaging-based location of the fistula with surgical findings. US performed significantly better than voiding cystourethrogram for determining the presence of fistulas (area under the receiver operating characteristic curve, 0.90 vs. 0.71, respectively; P=0.044) (diagnostic accuracy 85.7%, 95% confidence interval [95% CI] 63.7–97.0% and 52.4%, 95% CI 29.8–74.3%, respectively). In cases with fistulas detected by either modality, the accuracy of locating the fistula by US was 50.0% (95% CI 24.7–75.3%) and by voiding cystourethrogram was 100% (95% CI: 59.0–100%). US accurately detected, but did not accurately locate, fistulas in neonates with anorectal malformation. When planning primary neonatal reconstruction of anorectal malformation without colostomy, voiding cystourethrogram could provide additional information about fistula location.

Abstract: Objective: To determine if infants diagnosed with urinary tract infection (UTI) in the neonatal intensive care unit (NICU) require a routine voiding cystourethrogram (VCUG).Study design: Retrospect...

Abstract: Urethral duplication (UD) is a rare anomaly with about 300 cases reported to date, usually seen in males and often associated with a number of anomalies involving other organs.1 Effmann's classification2 has described three types of urethral duplication. One out of three patients has an associated vesicoureteric reflux (VUR).3 In type I which is also the most common type, the urethra is partially duplicated and is almost always asymptomatic, requiring no further treatment. In type II, complete duplication of the urethra is observed. Type II urethral duplication is further classified as type IIA1 if both urethras arise from the separate bladder necks, type IIA2 (Y-type duplication) if one channel arises from the other, and type IIB if duplication with one meatus is observed. Type III urethral duplication comprises complete duplication of the urethra and bladder.3 The exact embryogenesis of urethral duplication is not well understood. Symptoms vary depending on the type of duplication. Symptoms could include recurrent urinary tract infections (UTI), epididymitis, and urinary incontinence.4 Diagnosis is usually made on voiding cystourethrogram (VCUG) and/or retrograde urethrogram (RUG). We report a case of type IIA2 urethral duplication in a male child with multiple other anomalies.

Abstract: AIM A top-down approach is widely used for detecting vesicoureteral reflux (VUR) in children with febrile urinary tract infections. We evaluated the diagnostic value of renal scintigraphy in predicting VUR in children with antenatal hydronephrosis (AHN). METHODS The voiding cystourethrogram (VCUG) and renal scintigraphy results of 125 AHN patients (76% male) admitted to the Children's Hospital of Helsinki University, Finland, from 2003 to 2013 were analysed. Of those, 94 had nonrefluxing hydronephrosis, nine had low-grade VUR and 22 had high-grade VUR. RESULTS Scintigraphy was performed at a median age of 1.4 (0.8-15.6) months. In patients with high-grade VUR, the differential renal function (DRF) of the worse kidney was significantly lower than in patients without VUR, with a median of 35% and interquartile range (IQR) of 20-45 versus 47% (IQR: 44-49), (p < 0.001). There was no difference between patients with low-grade VUR and patients without VUR (p = 0.181). DRFs below 44% showed a sensitivity of 73% and specificity of 79% and predicted significantly high-grade VUR (odds ratio 9.82, 95% confidence interval 3.44-28.05, p < 0.001) in the univariate analysis. CONCLUSION A DRF below 44% predicted high-grade VUR in patients with AHN and supported the decision to perform VCUG.

Abstract: BACKGROUND The strong association between kidney and urinary tract anomalies and childhood urinary tract infection (UTI) often leads to imaging tests being performed. -Objective: To describe the epidemiology, characteristics, and imaging findings in Thai children with UTI and compare results between boys and girls. METHODS We retrospectively reviewed the medical records of children with UTI aged < 15 years. Demographic characteristics and findings of investigations are presented. RESULTS One hundred seventy-eight boys and 170 girls with 432 UTI episodes were identified. The median (interquartile range) age at presentation was 1.4 (0.6-3.4) years, 1.0 for boys and 2.1 for girls (p < 0.001). Renal ultrasound, voiding cystourethrogram and 99mTc dimercaptosuccinic acid (DMSA) renal scans were performed in 273, 223 and 113 children, respectively. Overall, 283 children (81.3%) had at least one imaging study done and anomalies of the kidney and urinary tract were detected in 158 (45.4%). Primary vesicoureteral reflux was detected in 73 (32.7%) children. The remaining abnormalities were hydronephrosis (n = 54). DMSA scans detected 54 children with dysplastic or scarred kidneys. CONCLUSIONS First UTI in a group of Thai children occurred in approximately equal proportion in boys and girls but boys were younger at diagnosis. Kidney and urinary tract anomalies were detected in half of the children.

Abstract: Background: Antenatal hydronephrosis (AHN) is diagnosed in 0.5%–1% of pregnancies. Hydronephrosis has many causes, but vesicoureteral reflux (VUR) remains an important cause, as it could lead to serious damage to the kidneys. Screening for VUR by voiding cystourethrogram (VCUG) is done in infants with congenital hydronephrosis to detect VUR that could lead to repeated urinary tract infections (UTIs). Objectives: The aim of the study was to investigate the value of VCUG as a screening tool for VUR in infants with various grades of hydronephrosis. Materials and Methods: This is a retrospective chart review for all infants with antenatal hydronephrosis between January 2010 and December 2015 at King Abdulaziz Medical City-Riyadh. Comparisons were made between hydronephrosis grades and VUR. Differences, therefore, were assessed for statistical significance using Chi-square test as appropriate. Analysis was performed using SPSS version 22. Results: During the study periods, 203 infants (75% of the study population) underwent VCUG. VUR was diagnosed in 21% of all infants who had VCUG. VUR was significantly higher in infants with high grade compared to low-grade hydronephrosis (30% versus 14.40%, P = 0.005). On the other hand, no significant difference found between high-grade hydronephrosis and low-grade hydronephrosis in the severity of VUR (P = 0.169). Meanwhile, high-grade hydronephrosis was significantly more associated with UTI 27.20% (25/92) than low-grade hydronephrosis 14.70% (26/177). Conclusion: Infants with antenatal hydronephrosis (HN) suffer greater morbidity as reflected by the increased incidence of VUR and UTI at follow-up. For high-grade HN, our recommendation clearly goes with the current practice for doing VCUG to all high-grade patients. On the other hand, the risk of VUR and UTI, although higher in infants with high-grade HN is still substantial in infants with low-grade HN. However, it is still controversial to do VCUG for them. Hence, we recommend further big researches about low-grade HN and VCUG to come up with clear conclusion for this HN group.

Abstract: We report a case of urethrovaginal fistula following impacted foreign body in vagina. Fistula was suspected on the basis of history and examination and was later on confirmed by voiding cystourethrogram. Cystourethroscopy was done and the fistula was repaired transvaginally in layers. We are reporting this case because of its rarity.

Abstract: Congenital bladder diverticulum is rare and is usually observed in male children. An 8-year-old Japanese boy was referred to a hospital with fever and gross hematuria and was treated with a course of antibiotics. Because the dilatation of the ureter was suspected by abdominal ultrasonographic examination, he was referred to our hospital. We diagnosed congenital bladder diverticulum by computed tomographic scan and carried out laparoscopic bladder diverticulectomy and extravesical ureteral reimplantation. Four years later, there was no recurrence of gross hematuria or urinary tract infection.

Abstract: Posterior urethral valve (PUV) is the most common congenital cause of bladder outflow obstruction in male neonates. We report a preterm neonate with PUV who presented as nonimmune fetal hydrops with intestinal obstruction in the antenatal period. The mother of our patient is a 33-year-old woman who started her prenatal care at our hospital at 30 weeks' gestation. Her sonogram done at 32 weeks in our hospital revealed fetal hydrops. It showed polyhydramnios, mild pyelectasis of right kidney, normal left kidney, and fetal ascites. Amniocentesis revealed bile stained amniotic fluid. Ultrasound during the procedure showed dilated fetal bowel loops with increased echoes. Following delivery at 32 weeks postnatal exam showed ascites with absence of skin edema, pleural, or pericardial effusion. The abdominal sonogram showed distended urinary bladder and bilateral hydroureteronephrosis. Bladder catheterization was done which relieved the bladder outlet obstruction. Voiding cystourethrogram was done later which confirmed PUV and bilateral grade 5 vesicoureteral reflux. The formation of urinary ascites in PUV serves as a pop-off mechanism to relieve the intravesical and intrarenal pressure. When this happens by mechanisms other than bladder rupture, it can lead on to transient intestinal obstruction and hepatic synthetic defects.

Abstract: Introduction: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center. Methods: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed. Results: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology. Conclusion: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.

Abstract: Introduction: Appearance or persistence of vesicoureteral reflux (VUR) and other obstructive complications after open reimplantation of ureters is well known and up to 7.5% of cases require reoperation. In this study, we have assessed children presenting with recurrent urinary tract infection (UTI) following open reimplantation for VUR. Materials and Methods: We retrospectively collected hospital data of 14 children referred to us for management of recurrent UTIs following open ureteric reimplantation for vesicoureteric reflux from January 2006 to December 2015. Results: Fourteen children presented to our center at a mean age of 31.85 ± 10.17 months. The mean serum creatinine was 0.77 ± 0.26 mg% (range 0.5–1.3). Urine culture was positive in all with Escherichia coli being the most common organism grown on culture. Two children had obstruction at the vesicoureteric junction, and the remaining twelve children had 14 ureteral units with VUR. Two children underwent reimplantation into Boari flap, five underwent open reimplantation, and the remaining seven underwent endoscopic Deflux injection. Repeat voiding cystourethrogram done within 1 year of surgery revealed no VUR in any child. Conclusions: Appearance or persistence of VUR and obstructive complications after open reimplantation surgery is a matter of great concern for the parents of these children as well as the treating pediatric urologists. Appropriately selected open/endoscopic treatment can help in resolving these complications.

Abstract: Based on five case scenarios encompassing common clinical questions in pediatric radiology the added value achieved through radiological expertise input will be highlighted. Clinic algorithms help in the imaging management of infants and children with urinary tract infection, like avoidance of urgent imaging in simple urinary tract infection. The scenarios address situations where the radiologist could help improve the outcomes, like the use of contrast-enhanced voiding urosonography as an alternative to voiding cystourethrogram, in detecting alterations in the urinary tract without the use of ionizing radiation. A case of pneumonia complicated with empyema highlights that ultrasound is the best method in the diagnosis and characterization of pleural effusions and can detect lung consolidation, necrotizing pneumonia and abscess (avoiding computed tomography in some cases). Pediatric cervical lymphadenopathies are common and radiologists can add value identifying the lymph nodes with suspicious US features that should prompt biopsy, helping in a faster diagnosis and reducing unnecessary follow-up US. A case of suspected appendicitis with a non-visualized appendix on US illustrates the added value of reporting the absence or presence of appendiceal secondary signs.