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Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children Version 3.0, Approved January 25, 2003

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Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children Version 3.0, Approved January 25, 2003 Society of Nuclear Medicine Procedure Guideline for Radionuclide Cystography in Children version 3.0, approved January 25, 2003 Authors: Gerald A. Mandell, MD (DuPont Hospital for Children, Wilmington, DE); Douglas F. Eggli, MD (Pennsylvania State University/Milton S. Hershey Medical Center, Hershey, PA); David L. Gilday, MD (Hospital for Sick Children, Toronto, Ontario, Canada); Sydney Heyman, MD (Children’s Hospital of Philadelphia, Philadelphia, PA); Joe C. Leonard, MD (Oklahoma Children’s Memorial Hospital, Oklahoma City, OK); John H. Miller, MD (Children’s Hospital Los Angeles, Los Angeles, CA); Helen R. Nadel, MD (Children’s Hospital, British Columbia, Vancouver, Canada); Amy Piepsz, MD (CHU St. Pierre, Department of Radioisotopes, Brussels, Belgium); and S. Ted Treves, MD (Children’s Hos- pital, Boston, MA). I. Purpose III. Common Indications The purpose of this guideline is to assist nuclear A. Initial evaluation of females with urinary tract medicine practitioners in recommending, perform- infection for reflux. ing, interpreting, and reporting the results of ra- B. Diagnosis of familial reflux. dionuclide cystography (RNC) in children. C. Evaluation of vesicoureteral reflux after medical management. D. Assessment of the results of antireflux surgery. II. Background Information and Definitions E. Serial evaluation of bladder dysfunction (e.g., neurogenic bladder) for reflux. Urinary tract infection is a common problem in the pediatric population. The signs and symptoms are nonspecific, particularly in the younger child. The IV. Procedure role of vesicoureteral reflux in the pathogenesis of A. Direct Radionuclide Cystography pyelonephritis is incompletely understood. Approx- 1. Patient preparation imately 40% of patients with upper urinary tract in- a. Preparation before arrival in the depart- fection have vesicoureteral reflux. Urinary tract in- ment fection, unrecognized and inadequately treated, can There is usually no preparation necessary. lead to hypertension and chronic renal failure. b. Preparation before catheterization of the bladder A. RNC is a method to evaluate for vesicoureteral i. The study is explained to parents and reflux, which results in significantly less gonadal all children old enough to understand. radiation when compared with conventional ra- ii. Continual communication and reassur- diographic technique (VCUG). In addition, RNC ance with explanation of each step is has a sensitivity for detection of vesicoureteral essential for success. reflux equal to that of VCUG. RNC does not pro- iii. A calming effect can be produced by a vide the same anatomic detail as VCUG. quiet, dimly lit room, the watching of B. Direct radionuclide cystography (DRC) requires television, or even the reading of a catheterization of the bladder and instillation of story, making sedation rarely neces- radionuclide and fluid for maximum distension sary. iv. The child may be instructed to void im- of the bladder, allowing imaging during filling, mediately before catheterization if voiding, and after voiding. residual volume (RV) is measured by C. Indirect radionuclide cystography (IRC) does catheterization rather than by com- not require bladder catheterization but does re- puter analysis of bladder activity. quire the intravenous injection of the radiophar- 2. Information pertinent to performing the pro- maceutical for evaluation of renal function, urine cedure drainage, and detection of vesicoureteral reflux. a. No latex materials should be used in pa- • 180 RADIONUCLIDE CYSTOGRAPHY IN CHILDREN tients prone to latex allergy (e.g., congeni- f . The Foley balloon is inflated only after tal spinal defects and chronic urethral the catheter and its balloon are confirmed catheterization). Urethral anesthesia with to be in the bladder. For infants, inflating xylocaine should not be used in patients the balloon with 1 cc allows voiding with an allergic history. around catheter without impairing blad- b. Histories of previous urinary tract infec- der capacity. tions, prior surgery to the urinary tract, an- i. Urine return can be appreciated even timicrobial prophylaxis, and congenital with the balloon still positioned in the urinary abnormalities (duplex systems, posterior urethra. etc.) are important. ii. The balloon must be deflated for void- c. Review of available past radiographic, ul- ing portion of the study. trasound, and radionuclide studies adds to g. There is a small risk of catheter-induced in- the accuracy of interpretation of the cur- fection. rent study. 4. Radiopharmaceutical d. The bladder volume for the individual pa- a. 99mTc-pertechnetate is usually used as the tient can be approximated in milliliters ac- instillate. cording to the formula: b. 99mTc-sulfur colloid and 99mTc-diethylene- (age in years + 2) x 30 cc = bladder vol- triaminepentaacetic acid (9 9 mTc-DTPA) is u m e . nonabsorbable through bladder and bowel There is a nonlinear relationship be- mucosa and should be used in the evalua- tween functional bladder capacity and pa- tion of augmented bladders. tient’s age. c. The radiopharmaceutical can be mixed in a Example for 6-mo-old: 0.5 y + 2 = 2.5 x fixed volume of saline or irrigating solu- 30 = 75 cc. tion (250–500 mL). e. The end of filling is usually achieved by the i. The container of solution is hung 100 patient spontaneously voiding, by reach- cm above the table. ing the appropriate volume for the pa- ii. The container of saline solution is sur- tient’s age, or when there is cessation of rounded by lead shielding and at- flow from the bottle of solution (back-pres- tached to the urethral catheter by ve- sure effect) in a nonvoiding patient. nous tubing. f. Cyclic voiding (multiple fills) results in d. Another method introduces the radiophar- greater detection of vesicoureteral reflux in maceutical by injection directly into the infants and young children. catheter. Saline (10–20 cc) may be intro- 3. Precautions duced first to reduce exposure to bladder a. The examination table is covered with mucosa. plastic-lined absorbent paper to contain i. The subsequent instillation of saline so- spilled radiopharmaceutical and reduce lution advances the radiopharmaceuti- contamination of the table during DRC. cal into the bladder. b. Gentle catheterization by a qualified indi- ii. Increments of infusion can be recorded vidual can prevent an overly traumatic and by the addition of a volume chamber to painful experience and results in better co- the intravenous setup. operation during follow-up examinations. iii. At times of reflux, approximate blad- c. Slow, deep breathing and a gentle forward der volumes can be recorded. motion of the catheter should be used to re- 5. Image acquisition lax the spastic external sphincter. a. For the filling phase, the patient is supine d. An application of urethral anesthesia (3–5 with the head of the camera positioned mL lidocaine jelly) in the male urethra 2–5 posteriorly under the table. Cooperative min before catheterization helps decrease children (older than 3 y) can sit on a table, the patient’s discomfort. the collimator being placed vertically e. Sterile urethral catheterization should be against the back of the child. performed with the largest size Foley or b. The digital camera is equipped with a gen- feeding catheter that will comfortably pass eral-purpose collimator. the meatus (a 2.6-mm diameter catheter c. Computer images are obtained at a rate of [French #8] for most patients and 1.8-mm 5 s per frame (128 x 128 matrix suggested). diameter [French #6] for infants). d. High-intensity analogue images may be • SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL MARCH 2003 181 Radiation Dosimetry for Children1 (5 years old) Radiopharmaceutical Administered Activity Organ Receiving the Effective Dose3 La r g e s t Radiation Dose2, 3 MB q Mg y / M B q MSv/MBq (m C i ) (r a d / m C i ) (rem/mCi) 99mTc-pertechnetate 18.5–37 0.028 0.0024 bladder (0.5–1.0) (0.10) (0.0089) 99mTc-sulfur colloid 18.5–37 0.028 0.0024 bladder (0.5–1.0) (0.10) (0.0089) 99mTc-DTPA 18.5–37 0.028 0.0024 bladder (0.5–1.0) (0.10) (0.0089) 1Treves ST. Pediatric Nuclear Medicine. 2nd ed. New York, NY: Springer-Verlag; 1995:569. 2Assumed activity in bladder for 15 min. 3Per MBq (per mCi). taken every 30–60 s. c. Quantitation of postvoid RV requires re- e. Voiding images are obtained with the cam- gions of interest (ROIs) to be drawn over era positioned posteriorly, with the infant, the bladder on pre- and postvoid images. toddler, or uncooperative child in the i. The first method requires recording of supine position and with the cooperative volume of voided urine: child sitting upright on a bedpan. voided volume (mL) x f. The computer images (128 x 128 matrix postvoid bladder counts (ROI) suggested) of voiding are obtained every RV (mL) = 2–10 s and analogue images may be taken initial bladder counts (ROI) – every 30–60 s. postvoid bladder counts (ROI) g. A 30-s anterior pre- and postvoid image can be obtained for calculation of residual ii. The second method requires an empty bladder volume. bladder for accurate calculation of RV: 6. Interventions postvoid bladder counts (ROI) x a . A urine specimen may be obtained for volume infused c u l t u r e . RV (mL) = b. Slowing the filling rate (particularly in in- initial bladder counts (ROI) fants) decreases bladder irritation and 8. Interpretation criteria spasm and may permit satisfactory filling The radionuclide classification of reflux is less volumes. exacting and differs from the radiographic c. Maintenance of the catheter in place until classification. the end of the study avoids additional a. RNC grade 1, with activity limited to the catheterizations and permits recycling if ureter. (Radiographic grade I) the initial fill consists of an inappropriate b. RNC Grade 2, with activity reaching the col- volume to assess reflux. lecting system with none or minimal activity 7. Processing in ureter.
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