title: Increasing the Reliability of the Grading System for Voiding Cystourethrograms Using Ultrasonography: An Inter-Rater Comparison.
abstract: BACKGROUND
  To assess the effectiveness of the current vesicoureteral reflux (VUR) grading system according to the international classification of VUR (ICVUR) and to evaluate whether VUR grading accuracy could be improved by renal ultrasonography (RU) according to the Society for Fetal Urology (SFU) grading system.
  
  
  OBJECTIVE
  Therefore, this study assessed the accuracy of the current VCUG staging system by assessing inter-rater reliability among pediatric radiologists and urologists; it also evaluated whether accuracy is increased by RU without consensus (with respect to VCUG grading).
  
  
  METHODS
  Four pediatric urologists and four pediatric radiologists independently graded 120 voiding cystourethrograms (VCUGs). Middle VUR grades were divided into the following three groups: VUR consensus grade III (group 1), VUR consensus grade IV (group 3), and VUR non-consensus grades III and IV (group 2). All groups were compared with respect to hydronephrosis grade using RU.
  
  
  RESULTS
  The intraclass correlation coefficient (ICC) values ranging from 0.86 to 0.89 reflected good reliability. The lowest agreement was associated with middle grades (III and IV). A marked difference in sensitivity was observed between groups 1 and 3 (35% and 95%, respectively, P < 0.05), indexed by SFU hydronephrosis grade, suggesting that VCUG cases in group 2 (n = 16 at SFU 0 or 1) could be accepted as grade III, and SFU scores of 2, 3, or 4 could be considered grade IV.
  
  
  CONCLUSIONS
  Inter-rater accuracy could be improved at middle grades using renal ultrasonography (USG), which could promote communication between different specialists.
authors.affiliation: Department of Pediatric Surgery, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey.
authors.forename: Seyithan
authors.initials: S
authors.lastname: Ozaydin
authors.affiliation: Department of Pediatric Surgery, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey.
authors.forename: Suleyman
authors.initials: S
authors.lastname: Celebi
authors.affiliation: Department of Pediatric Radiology, Faculty of Medicine, Baskent University, Istanbul, Turkey.
authors.forename: Ismail
authors.initials: I
authors.lastname: Caymaz
authors.affiliation: Department of Pediatric Surgery, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey.
authors.forename: Cemile
authors.initials: C
authors.lastname: Besik
authors.affiliation: Department of Pediatric Surgery, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey.
authors.forename: Birgul
authors.initials: B
authors.lastname: Karaaslan
authors.affiliation: Department of Pediatric Surgery, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey.
authors.forename: Ozgur
authors.initials: O
authors.lastname: Kuzdan
authors.affiliation: Department of Pediatric Urology, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey.
authors.forename: Serdar
authors.initials: S
authors.lastname: Sander
keywords: Inter-Rater Reliability; International Classification of Vesicoureteral Reflux; Society for Fetal Urology; Ultrasonography; Vesicoureteral Reflux