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Review Article
41 (
1
); 78-86
doi:
10.25259/IJNM_113_25

Advances in Diuretic Renography Today: A Clinical Update

1Department of Nuclear Medicine, Cristo Re Hospital, Rome, Italy

*Corresponding author: Dr. Girolamo Tartaglione, Department of Nuclear Medicine, Cristo Re Hospital, 25 Via Delle Calasanziane, 00167 Rome, Italy. gtartaglione@hotmail.com

Received: , Accepted: ,
© 2026 Published by Scientific Scholar on behalf of Indian Journal of Nuclear Medicine
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms

How to cite this article: Tartaglione G. Advances in Diuretic Renography Today: A Clinical Update. Indian J Nucl Med. 2026;41:78-86. doi:10.25259/IJNM_113_25

Abstract

Diuretic renography was proposed in the late 1970s to distinguish between dilated, obstructed, and non-obstructed urinary tracts by measuring the Diuresis Excretion Index with a gamma camera. The test was originally performed with the patient seated and a dose of furosemide (0.50 mg/kg) administered 20 min after tracer injection (F+20 method), with the examination lasting for 15–20 min. However, many nuclear physicians opted for a supine, prone, or semi-recumbent position to reduce movement and avoid side effects such as diuretic-induced hypotension. Several methods (F-15, Well-Tempered F+20, F0, F+2, etc) have been proposed using varying furosemide dosages (0.5– 1 mg/kg) and diuretic administration times. Unfortunately, the supine position produces radiotracer stasis even when there is no obstruction, resulting in an inaccurate output index. Furthermore, high furosemide doses cause bladder fullness issues. The lack of technical standardization leads to ambiguous and incomparable results. The F+10 [seated position (sp)] method is a novel approach that assesses patients in a sitting position with shorter intervals and a lower dose of furosemide (0.25 mg/kg), resulting in improved compliance. It also enables accurate calculation of outflow data, such as the 20 min/peak ratio, which is favored by the gravity effect.

Keywords

Diuretic
Diuretic renography
Furosemide
Gravity
Hydronephrosis
Technetium-99 m-mag3

INTRODUCTION

Hydronephrosis and hydroureter are characterized by swelling of the renal calyces and pelvis or ureter due to urine buildup.[1] Hydronephrosis may be acute, chronic, unilateral, or bilateral. Ultrasound (US) scans and computed tomography (CT) scans are often used to identify hydronephrosis. However, it is not synonymous with blockage, and additional tests may be required to find the source of the condition. Hydronephrosis can be caused by urinary tract obstruction, although the dilatation of the renal pelvis and calyces may be an anatomical variant without obstruction or any significant clinical consequences. Postoperative hydronephrosis is a common occurrence after some surgical procedures involving the urinary tract, like pyelectomy, ureteral reimplantation, and ureteroscopy. [2] Swelling may be caused by various factors, including edema at the surgical site and decreased tonicity of the renal pelvis or ureter. The outcome of pyeloplasty can be reported as gradual improvement in hydronephrosis by traditional radiological imaging (US, CT-urography), which only provides a static anatomical evaluation. Complete resolution of hydronephrosis after pyeloplasty is uncommon and unpredictable, and dilatation may persist even after the obstruction is corrected.[3] Identifying patients who need postoperative imaging is crucial to avoid complications while also protecting patients from the side effects of imaging.[4]

Nuclear medicine will continue to play a vital role in evaluating suspected obstructive nephropathy cases by providing unique information on urine outflow essential for patient management and therapy in nephrourology.[5-9] Diuretic renography is a non-invasive nuclear medicine test that uses a radioactive tracer and a diuretic to assess kidney function and urinary drainage. It plays a critical role in managing and monitoring hydronephrosis by distinguishing between true obstruction, which requires surgery, and nonobstructed dilation that mimics obstruction but does not require require surgery.[10,11] Diuretic renography began in the late 1970s. The method evolved over time to increase accuracy while minimizing adverse effects. The accuracy of diuretic renography is affected by many variables, and procedural differences across centers and countries contribute to challenges in standardization and inconsistencies in result interpretation.[12] Diuretic renography techniques must be standardized, as has been acknowledged for many years. [13-15] This review examines various methods used in clinical practice, focusing on patient posture, furosemide dosage, diuretic administration timing, and interpretation criteria. While the primary focus is on adult patients, many of the recommendations are also applicable to pediatric patients.[16,17]

F+20

Method O’Reilly et al.[10] first suggested diuretic renography with the F+20 method. The original procedure involved the patient seated for a single 35-min continuous acquisition, with intravenous furosemide (0.5 mg/kg body weight, 40 mg in adults) administered 20 min after tracer injection. The Diuresis Excretion Index, a quantitative measure of the diuretic response that reflects the degree of flow impedance, is calculated by comparing radiotracer activity at the time of furosemide injection to that measured at 3 min and 6 min post-injection (normal value >45%).

As an alternative diagnostic criterion, the renography curve can be visually assessed following intravenous furosemide administration. Clinical interpretation is based on one of four drainage patterns, as follows: Normal, dilated non-obstructed, equivocal, or obstructed.[18]

This procedure has several drawbacks, such as diuretic-induced hypotension, bladder fullness, disruption of tests caused by voiding, and an excessively long time to complete. To minimize the risk of diuretic-induced hypotension, many centers prefer to conduct the study with patients in the supine position. In addition, a full bladder can increase pressure in the upper urinary tract, impeding urine flow into the ureter and potentially resulting in false-positive or equivocal findings for obstruction.[19]

Eight years later, O’Reilly[18] confirmed that this procedure can produce a high rate of ambiguous results (15%–30%).

F-15 Method

In 1987, English et al.[20] developed an alternative diuretic renography method to reduce the incidence of equivocal results with the traditional technique. This approach involved administering furosemide 15 min before the radiotracer, rather than 20 min after, and evaluating radiopharmaceutical elimination during peak diuresis, with the patient in a seated position. A dose of furosemide (0.5 mg/kg, 40 mg in adults) was administered intravenously 15 min before the start of the renogram (F-15). The patient was encouraged to empty his bladder before the renography, which was performed in a seated position. The diagnosis was based on the T1/2 measurement, defined as the time from the peak of the renogram until the activity fell to 50% of the maximum value (normal value <10 min).

When used in patients with equivocal F+20 values, this approach improves diagnostic accuracy and is considered the most accurate in diagnosing obstructive hydronephrosis. [21,22] However, it has significant disadvantages, such as diuretic-induced hypotension and issues related to bladder fullness.

In 1989, a postal survey by the British Nuclear Medicine Society in the United Kingdom found a substantial difference in ordinary renogram procedures used by nuclear medicine practitioners. A total of 56% of renogram practitioners preferred the supine posture to avoid movements and diuretic-induced hypotension, whereas 32% chose the seated position and 12% used other positions (prone or semi-recumbent).[23] Unfortunately, when renograms are performed in the supine position, the renal transit time[24] in the dilated urinary tract may be naturally slowed in the absence of obstruction due to unfavorable gravity. Physiological urine stasis in the dilated urinary tract causes urinary flow indices to be unreliable;[25] therefore, the diagnosis relies only on visual interpretation of the renogram curve, increasing equivocal results.

Well-Tempered F+20 Method

In 1992, Conway[26] introduced a new procedure called Well-Tempered diuretic renography to address physiological variables and technical limitations of the traditional technique. Key elements included intravenous hydration with a dilute glucose solution (15 mL/kg in 30 min, starting 15 min before tracer injection), continuous bladder catheterization, use of a uniform radiopharmaceutical (Tc-99 m MAG3), and administration of a higher diuretic dose (1 mg/kg, up to 80 mg intravenous) timed at 20 min after tracer injection (F+20). The patients were studied in a supine position, and the time activity curve was acquired for at least 20–30 min. If the pelvis or ureter remains incompletely drained at the end of the diuretic renogram phase, the patient should be repositioned prone to assess whether postural changes facilitate additional drainage.

Interpretation of the test relies on visual pattern analysis and the percent Differential Renal Function (DRF), also known as split renal function, which quantifies the relative contribution of each kidney to total renal function. This index is calculated using the total counts from the renogram curve for each kidney, after subtracting background activity, during the 60-s interval following the appearance of radioactivity in the calyces. A DRF of 45%–55%, with a total of 100% for both kidneys, is considered within normal ranges. This protocol allows the examination to be completed without interruption for voiding, thereby reducing the risk of false positive interpretations related to bladder fullness.

However, many authors disagree with the well-tempered method, arguing that nuclear medicine techniques should imitate physiological settings, such as maintaining oral hydration and avoiding fluid overload by intravenous volume expansion. In addition, the use of routine bladder catheterization may necessitate antibiotic therapy. Furthermore, the diuretic effect lasts for 1–2 h due to the high dose of furosemide.[18]

F0 Method

In 1993, Rossleigh et al.[27] highlighted the importance of gravity-assisted drainage in diuretic renography for patients with a history of urinary tract surgery, noting that diminished tissue tonicity can lead to radiotracer stasis. Regardless of the timing of furosemide administration or the use of high-extraction-rate tracers, Rossleigh et al.[27] recommended that patients be positioned upright for approximately 5 min at the end of the diuretic phase to facilitate gravity-assisted drainage. In the absence of an indwelling catheter, this was done after voiding, followed by acquisition of a 5-min static image.

To simplify the investigation of hydronephrosis with diuretic renography, Wong et al.[28] proposed in 2000, the F0 protocol based on the simultaneous administration of Tc-99 m MAG3 and 1 mg/kg furosemide. The test was performed in a supine position, without the need for bladder catheterization. At the end of the 20-min diuretic phase, a 5-min gravity-assisted drainage image after voiding was recommended.[27]

DRF was calculated using the total counts of the renogram curve for each kidney minus background in the 1.5– 2.5-min interval after the radiopharmaceutical injection. The percentage of residual activity was calculated by comparing with the last 5 min of the diuretic phase.

The advantages of the F0 method are as follows. It is timesaving and less invasive compared to other protocols, resulting in better patient compliance and in a lower number of tests disrupted because of voiding. However, the simultaneous administration of furosemide with tracer induces an early acceleration of renal transit.

The main drawbacks of early furosemide injections are loss of information about the baseline state and the influence of diuretics on DRF measurement.[29]

F+2 Method

DRF is usually calculated by dividing the radioactive tracer accumulation on each side in the first 2 min by the total accumulation in both kidneys over the same time.[30,31] If employing the Patlak-Rutland slope method to calculate DRF, some physicians propose infusing furosemide 2 min after tracer injection (F+2) to avoid furosemide’s influence on index measurement.[32]

The relative function is expressed as a percentage of the overall function (normal range: 45%–55%). It evaluates relative function in the hydronephrotic kidney, and this value is dependent on effective tracer extraction and may reflect changes in function in the opposite kidney.[33,34]

Diagnostic criteria for diuretic renography in supine position

When patients are examined in the supine position, physiological urine stasis in the dilated urinary tract causes urinary flow indices such as diuretic excretion rate and T1/2 to be unreliable.[25] Consequently, the visual interpretation of the renogram curve results in subjective and scarcely reproducible results.

DRF has its limits. First, it does not show urine drainage, as it evaluates tracer input rather than outflow, comparing radioactive tracer accumulation on both sides in the first 2 min following tracer injection. A drop in DRF below 40% is commonly considered a criterion for pyeloplasty in hydronephrosis because it is a marker of kidney injury.[35] However, this does not always lead to reduced renal function or obstruction.[36] DRF measurement can be influenced by kidney depth,[37] and caution should be exercised when analyzing DRF in the setting of hydronephrosis because the kidney with hydroureteronephrosis paradoxically may have a higher differential function than the contralateral normal.[38] Some authors have confirmed that DRF can be an indirect and late indicator of obstruction, but that it could also be normal, even when there is aberrant drainage.[39]

Other specialists have suggested calculating the Normalized Residual Activity (NORA) to standardize the test’s interpretation. The NORA index is measured by acquiring images after voiding and walking for a few minutes near the end of the dynamic period, which is 40–50 min after tracer injection. This indicator can quantify renal output. It is nearly independent of renal function and can be used regardless of the timing of the furosemide administration.[40] In most cases, the NORA index might contradict the results of the dynamic phase.[41] However, methodological variance makes it impossible to decide the optimal period to calculate the NORA index. As a result, test comparisons betweeninstitutions are difficult, and diagnosis is still subjective.

Comparison between the Methods in Supine Position

In synthesis, several approaches such as F+20, F-15, well-tempered F+20, F0, and F+2 were reported, giving different furosemide dosages with changed administration timing and diagnostic criteria. However, the European Association of Nuclear Medicine (EANM) guidelines (2001) do not provide evidence that one method is preferable to the others.[32]

Some researchers who compared various methods in the same patient concluded that F+20 provides information about the baseline state and can be performed without repeating the test; F-15 is thought to be the most specific, but F0 is more practical than others, resulting in fewer interrupted studies to void.[42,43] The downside of early furosemide tests (F0 and F-15) is that they do not provide information about baseline conditions and the influence of diuretics on renal transit time. This should be taken into consideration when calculating DRF, such as by using the integral technique. Some studies using the Patlak-Rutland slope approach have proposed infusing furosemide 2 min after the tracer injection (F+2),[44] but this strategy has not gained traction.

A 2008 study[12] to assess interobserver consistency in reporting on renal drainage collected during Tc-99 m MAG3 diuretic renography, when already processed data were made available to observers, revealed that nuclear physicians made a wide variety of drainage interpretations. The authors concluded that there is a critical need for improved standardization when evaluating drainage quality.

F+10 Seated Position Method

In cases of obstructive renal pathology, imaging in the erect position may be preferable due to the effects of hydrostatic pressure and gravity on urine drainage.[45]

Another important aspect of diuretic renography is the dosage of diuretic administered. In recent years, the recommended furosemide dose has gradually decreased from 0.5–1 mg/kg (40–80 mg) to 0.25 mg/kg (20 mg)[46] [Table 1].

Table 1: Comparison of various procedures for diuretic renography in use
Method Hydration Position Timing (min) Furosemide dose
F+20 500 mL of oral water at 20 min Sitting/supine +20 0.50 mg/kg (max 40 mg)
F-15 500 mL of oral water Sitting/supine -15 0.50 mg/kg (max 40 mg)
Well-tempered 15 mL/kg/minute saline solution intravenous in 30’ + bladder catheter Supine/prone +20 1 mg/kg (up to 80 mg)
F0 Oral water Supine 0 1 mg/kg (max 40 mg)
F+10 (sp) 500 mL of oral water at 5 min Sitting + 10 0.25 mg/kg (10-20 mg)

sp: seated position

Taylor wrote an interesting report in the April 2014 issue of the Journal of Nuclear Medicine for Continuing Education,[47] in which he emphasized the importance of gravity-assisted drainage and post-void imaging. Furthermore, in a more recent study, he reported that the F+10 (seated position [sp]) method, performed with the patient seated, yields results that are comparable to or better than those of the F-15 method.[48,49] The F+10 (sp) method assesses patients in a seated position, under normal physiological hydration and pharmacological washout conditions, using a reduced dose of furosemide with optimized timing. It avoids catheterization and reduces the typical side effects associated with the test.[50]

Using the F+10 (sp) method, the patient is seated in an imaging chair that provides adequate support to minimize movement during the study. A gamma camera with a large-view detector is positioned vertically at a 90° posterior angle. After placement of an intravenous catheter with an injection valve, a bolus of 150–200 MBq of Tc-99 m MAG3 is administered at time zero. A 20-min dynamic acquisition begins acquisition when the tracer reaches the mediastinum. At the 5th min of the scan, the patient drinks 400–500 mL of water. Ten minutes after tracer injection, a furosemide dose of 0.25 mg/kg (typically 20 mg) is administered intravenously [Fig 1]. In underweight patients, or in those with systolic blood pressure below 105 mmHg, the furosemide dose should be gradually reduced to a minimum of 10 mg.[51] Post-void static scans are then acquired in both the seated and supine positions at 20 min and 60 min after tracer injection, respectively, to complete the study.

Diuretic renography in a 65-year-old female with bilateral hydronephrosis caused by pyeloureteral joint disease. F+10(sp) diuretic renography revealed that the left kidney was obstructed: (a) Summed image of the perfusion interval (0-30 s); (b, c) summed image of the uptake interval, overlaid by kidney, cortex, background, and bladder ROIs; (d) time activity curves of the perfusion phase; (e) time activity curves for the kidneys; (f) one-minute frames of the diuretic image; (g) summed image.
Fig 1:
Diuretic renography in a 65-year-old female with bilateral hydronephrosis caused by pyeloureteral joint disease. F+10(sp) diuretic renography revealed that the left kidney was obstructed: (a) Summed image of the perfusion interval (0-30 s); (b, c) summed image of the uptake interval, overlaid by kidney, cortex, background, and bladder ROIs; (d) time activity curves of the perfusion phase; (e) time activity curves for the kidneys; (f) one-minute frames of the diuretic image; (g) summed image.

The diagnosis of obstruction is based on the evaluation of the 20-min/peak ratio, time to peak, and diuretic half-time. When assessed under favorable gravity conditions, the 20 min/peak ratio can effectively distinguish between obstructed and normal kidneys by comparing the average activity of the renogram curves between minutes 19 and 20 to the peak activity (normal value <0.25). This parameter is independent of DRF and reproducible over time[51] [Fig 2 and 3].

A 69-year-old man, 171 cm, 68 kg, with serum creatinine of 0.87 mg/dL and right hydronephrosis. DRF (Differential Renal Function) left/right is 49/51. Time to peak for the left kidney is 5.7 minutes, with a 20-minute/peak ratio of 0.22. The Time to peak for the right kidney is 19.4 minutes, with a 20-minute/peak ratio of 0.90. F+10(sp) diuretic renography revealed that the right kidney was obstructed. (a) Summed image of the perfusion interval (0-30 s); (b, c) summed image of the uptake interval, overlaid by kidney, cortex, background, and bladder ROIs; (d) time activity curves of the perfusion phase; (e) time activity curves for the kidneys; (f) one-minute frames of the diuretic image; (g) summed image.
Fig 2:
A 69-year-old man, 171 cm, 68 kg, with serum creatinine of 0.87 mg/dL and right hydronephrosis. DRF (Differential Renal Function) left/right is 49/51. Time to peak for the left kidney is 5.7 minutes, with a 20-minute/peak ratio of 0.22. The Time to peak for the right kidney is 19.4 minutes, with a 20-minute/peak ratio of 0.90. F+10(sp) diuretic renography revealed that the right kidney was obstructed. (a) Summed image of the perfusion interval (0-30 s); (b, c) summed image of the uptake interval, overlaid by kidney, cortex, background, and bladder ROIs; (d) time activity curves of the perfusion phase; (e) time activity curves for the kidneys; (f) one-minute frames of the diuretic image; (g) summed image.
A 46-year-old man, 178 cm, 72 kg, with a blood creatinine level of 0.83 mg/dL and a right megaureter. DRF (Differential Renal Function) left/right is 71/29. The Time to peak for the left kidney is 3.6 minutes, with a 20-minute/peak ratio of 0.09. The Time to peak for the right kidney is 9.1 minutes, with a 20-minute/peak ratio of 0.02. F+10(sp) diuretic renography revealed no blockages. (a) Summed image of the perfusion interval (0-30 s); (b, c) summed image of the uptake interval, overlaid by kidney, cortex, background, and bladder ROIs; (d) time activity curves of the perfusion phase; (e) time activity curves for the kidneys; (f) one-minute frames of the diuretic image; (g) summed image.
Fig 3:
A 46-year-old man, 178 cm, 72 kg, with a blood creatinine level of 0.83 mg/dL and a right megaureter. DRF (Differential Renal Function) left/right is 71/29. The Time to peak for the left kidney is 3.6 minutes, with a 20-minute/peak ratio of 0.09. The Time to peak for the right kidney is 9.1 minutes, with a 20-minute/peak ratio of 0.02. F+10(sp) diuretic renography revealed no blockages. (a) Summed image of the perfusion interval (0-30 s); (b, c) summed image of the uptake interval, overlaid by kidney, cortex, background, and bladder ROIs; (d) time activity curves of the perfusion phase; (e) time activity curves for the kidneys; (f) one-minute frames of the diuretic image; (g) summed image.

The F+10 (sp) method offers several advantages. It is well tolerated, owing to the optimized timing between tracer injection (time 0’), oral hydration (time 5’), and intravenous administration of a reduced furosemide dose (0.25 mg/kg, range: 10–20 mg; time 10’). Additional benefits include a lower volume of water intake (400 mL) and a shorter overall test duration (20 min).[52]

This method reduces diuretic-related side effects, such as hypotension and test interruptions due to voiding, without requiring urinary catheterization, thereby enhancing patient compliance. It gives baseline information while avoiding the delayed urine outflow seen in the supine posture. It prevents false positives related to bladder fullness. It enables more reliable and reproducible quantification of renal output, providing more clinical reliability to renogram parameters such as 20-min /peak ratio (normal value <0.25), time to peak (normal value <7 min), and diuretic half-time (normal value <8 min). It can differentiate between normal renal output (time to peak 2-7 min, 20-min/peak ratio <0.25), dilated (time to peak >7 min, 20-min/peak ratio <0.25), and obstructed (20-min /peak ratio >0.25). It may reveal the true impact of renal ptosis on urine discharge. It is used in the post-emergency management of patients with temporary urinary diversion.[53] Percutaneous nephrostomies may be clamped during the dynamic phase to evaluate urine outflow in gravity-favorable conditions. The clamp may be removed at the end of the dynamic phase or during the test without disruption if symptoms of obstruction arise[54] [Fig 4]. This approach is recommended for patients with permanent urinary diversion, allowing for a more accurate assessment of urine output. It describes renal function and physiological urine outflow in bladder cancer patients treated with an orthotopic neobladder, minimizing the uncertainty of retrograde pyelogram or CT-urography responses in cases of suspected uretero-ileal anastomosis stricture.[55]

A 33-year-old female, 156 cm, 40 kg, with a blood serum creatinine of 1.5 mg/dL, had bilateral nephrostomy for mould kidney stones. DRF (Differential Renal Function) left/right is 51/49. The Time to peak for the left kidney is 10.4 minutes, with a 20-minute/peak ratio of 0.13. The Time to peak for the right kidney is 10.9 minutes, with a 20-minute/peak ratio of 0.23. F+10(sp) diuretic renography was performed with clamped nephrostomies and indicated no obstructions. (a) Time activity curves for the kidneys; (b) time activity curves for the cortex; (c) time activity curves for the collecting system and bladder; (d) static scan at the end of the dynamic phase; (e) post-voiding scan of reopened nephrostomies.
Fig 4:
A 33-year-old female, 156 cm, 40 kg, with a blood serum creatinine of 1.5 mg/dL, had bilateral nephrostomy for mould kidney stones. DRF (Differential Renal Function) left/right is 51/49. The Time to peak for the left kidney is 10.4 minutes, with a 20-minute/peak ratio of 0.13. The Time to peak for the right kidney is 10.9 minutes, with a 20-minute/peak ratio of 0.23. F+10(sp) diuretic renography was performed with clamped nephrostomies and indicated no obstructions. (a) Time activity curves for the kidneys; (b) time activity curves for the cortex; (c) time activity curves for the collecting system and bladder; (d) static scan at the end of the dynamic phase; (e) post-voiding scan of reopened nephrostomies.

The 20-min /peak ratio measured by diuretic renography in a sitting position may improve the sensitivity and accuracy of the test for diagnosis and follow-up of obstructive megaureters.[51]

The F+10 (sp) method is suggested in adults with suspected upper urinary tract obstruction by current Society of Nuclear Medicine and Molecular Imaging (known as the SNMMI) procedure standard/EANM guideline v1.0.[46] This approach improves interobserver concordance by giving a more objective and trustworthy semiquantitative evaluation, easing the use of software applications designed for computer-assisted analysis of scintigraphic renal dynamic imaging investigations.[56,57]

CONCLUSION

Diuretic renography using the F+10 (sp) method allows for more consistent and reproducible estimation of kidney output indices in gravity-favorable settings, lowering uncertainty in the diagnosis of obstructive nephropathy and improving interobserver concordance.

A decrease in DRF could be an indirect and later indicator of obstruction, as it evaluates tracer input rather than outflow. The 20-min /peak ratio, when assessed under favorable gravity condition, may provide urologists with early, direct, and reliable monitoring of urine outflow in suspected obstructive nephropathy, allowing for prompt surgical intervention to avoid renal function damage.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

The author certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The author confirms that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using the AI.

Financial support and sponsorship: Nil.

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