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Radionuclide Cystography 138 The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized. Revised 2010 (Res. 25)* ACR–SPR–SNM PRACTICE GUIDELINE FOR THE PERFORMANCE OF ADULT AND PEDIATRIC RADIONUCLIDE CYSTOGRAPHY PREAMBLE These guidelines are an educational tool designed to assist Therefore, it should be recognized that adherence to these practitioners in providing appropriate radiologic care for guidelines will not assure an accurate diagnosis or a patients. They are not inflexible rules or requirements of successful outcome. All that should be expected is that the practice and are not intended, nor should they be used, to practitioner will follow a reasonable course of action establish a legal standard of care. For these reasons and based on current knowledge, available resources, and the those set forth below, the American College of Radiology needs of the patient to deliver effective and safe medical cautions against the use of these guidelines in litigation in care. The sole purpose of these guidelines is to assist which the clinical decisions of a practitioner are called practitioners in achieving this objective. into question. I. INTRODUCTION The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by This guideline was revised collaboratively by the the physician or medical physicist in light of all the American College of Radiology (ACR), the Society for circumstances presented. Thus, an approach that differs Pediatric Radiology (SPR), and the Society of Nuclear from the guidelines, standing alone, does not necessarily Medicine (SNM). imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may This guideline is intended to guide interpreting physicians responsibly adopt a course of action different from that in performing radionuclide cystography (RNC) in adult set forth in the guidelines when, in the reasonable and pediatric patients. Properly performed imaging of the judgment of the practitioner, such course of action is bladder with radiopharmaceuticals provides a sensitive indicated by the condition of the patient, limitations of means of detecting, following, and evaluating certain available resources, or advances in knowledge or conditions of the bladder and ureters. As with all technology subsequent to publication of the guidelines. scintigraphic studies, correlation of findings with the However, a practitioner who employs an approach results of other imaging and nonimaging procedures, as substantially different from these guidelines is advised to well as clinical information, is necessary for maximum document in the patient record information sufficient to diagnostic yield. explain the approach taken. Application of this guideline should be in accordance with The practice of medicine involves not only the science, the ACR Technical Standard for Diagnostic Procedures but also the art of dealing with the prevention, diagnosis, Using Radiopharmaceuticals. alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to (For pediatric considerations see sections VI and VII.) always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. PRACTICE GUIDELINE Radionuclide Cystography / 1 II. DEFINITION catheterization if residual volume is measured by catheterization rather than by computer analysis of RNC involves filling the urinary bladder with a bladder activity [3]. Latex materials should not be used in radiopharmaceutical, either by direct retrograde patients known or prone to have latex allergy (e.g., administration via catheter or by indirect, antegrade patients with congenital spinal dysraphism). drainage of an intravenously administered radio- pharmaceutical that is excreted by the kidneys, and If the indirect (antegrade) technique (see below) is subsequent imaging with a gamma camera. employed, either technetium-99m DTPA or mercapto- acetyltriglycine (MAG-3®) must be used; technetium- III. GOAL 99m MAG-3® is preferred. This test usually is performed as the final part of a conventional renal scan. The goal of RNC is to enable the interpreting physician to Administered activity is the same as for renal scintigraphy detect and quantify physiologic and anatomic (see the ACR–SPR Practice Guideline for the abnormalities of the genitourinary system by producing Performance of Adult and Pediatric Renal Scintigraphy), images of diagnostic quality. with which this technique can be combined. The advantages of the indirect technique are that it is IV. INDICATIONS noninvasive and it provides information about renal function. A disadvantage is a lower sensitivity than direct Clinical indications [1-3] for RNC include, but are not cystography, because a) the bladder may only be partially limited to: filled, b) reflux can be detected only during the voiding 1. Initial diagnosis of vesicoureteral reflux in phase, and c) it may be difficult to differentiate between female patients with urinary tract infection. reflux and residual antegrade excretion [4-6]. Another 2. Diagnosis of familial reflux. disadvantage of indirect cystography is that it imparts a 3. Follow-up of previously diagnosed higher radiation dose to the patient than direct vesicoureteral reflux to assess for spontaneous cystography. Indirect cystography should not be used if resolution. the patient is not toilet trained or has compromised renal 4. Evaluation of vesicoureteral reflux after medical function [4-7]. or surgical management. 5. Serial evaluation of bladder dysfunction for Administered activity in children should be determined reflux. based on body weight and should be as low as reasonably 6. Quantification of postvoid residual urine in the achievable for diagnostic image quality. bladder. 7. Hydronephrosis. VII. SPECIFICATIONS OF THE EXAMINATION For the pregnant or potentially pregnant patient, see the ACR Practice Guideline for Imaging Pregnant or The written or electronic request for radionuclide Potentially Pregnant Adolescents and Women with cystography should provide sufficient information to Ionizing Radiation. demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. V. QUALIFICATIONS AND RESPONSIBLITITIES OF PERSONNEL Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including See the ACR Technical Standard for Diagnostic known diagnoses). Additional information regarding the Procedures Using Radiopharmaceuticals. specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to VI. RADIOPHARMACEUTICALS allow for the proper performance and interpretation of the examination. If the direct (retrograde) technique (see below) is employed, technetium-99m as sodium pertechnetate, The request for the examination must be originated by a sulfur colloid, or stannous diethylenetriamine pentaacetic physician or other appropriately licensed health care acid (DTPA) may be used. Sodium pertechnetate should provider. The accompanying clinical information should not be used in individuals who have undergone bladder be provided by a physician or other appropriately licensed augmentation with gastric or intestinal tissue. An health care provider familiar with the patient’s clinical administered activity of 18.5 to 37 MBq (0.5 to 1.0 mCi) problem or question and consistent with the state’s scope is introduced aseptically into the urinary bladder via a of practice requirements. (ACR Resolution 35, adopted in urethral catheter. Administered activities of 9.25 to 18.5 2006) MBq (0.25 to 0.5 mCi) may be considered for infants and toddlers. The patient should void immediately before 2 / Radionuclide Cystography PRACTICE GUIDELINE A. Vesicoureteral Reflux radionuclide cystography for detecting vesicoureteral reflux. For infants and children refer also to the
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