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Radiologic Management of Urinary Tract Obstruction

Variant: 1   Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
Procedure Appropriateness Category
PCN (includes PCNU) Usually Appropriate
PCN (includes PCNU) followed by delayed surgery Usually Appropriate
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) May Be Appropriate
Retrograde ureteral stenting May Be Appropriate
Medical management without decompression Usually Not Appropriate

Variant: 2   Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
Procedure Appropriateness Category
Retrograde ureteral stenting Usually Appropriate
PCN (includes PCNU) May Be Appropriate
PCN (includes PCNU) followed by delayed surgery May Be Appropriate
Medical management without decompression Usually Not Appropriate
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually Not Appropriate

Variant: 3   Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
Procedure Appropriateness Category
Retrograde ureteral stenting Usually Appropriate
PCN Usually Appropriate
Medical management without decompression Usually Not Appropriate
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually Not Appropriate
PCN followed by delayed surgery Usually Not Appropriate

Variant: 4   Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
Procedure Appropriateness Category
PCN (includes PCNU) Usually Appropriate
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually Appropriate
Retrograde ureteral stenting Usually Appropriate
PCN (includes PCNU) followed by delayed surgery May Be Appropriate
Medical therapy without decompression Usually Not Appropriate

Variant: 5   Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
Procedure Appropriateness Category
PCN (includes PCNU) Usually Appropriate
Retrograde ureteral stenting May Be Appropriate
PCN (includes PCNU) followed by delayed surgery May Be Appropriate
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually Not Appropriate
Medical therapy without decompression Usually Not Appropriate

Variant: 6   Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
Procedure Appropriateness Category
PCN (includes PCNU) Usually Appropriate
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually Appropriate
PCN (includes PCNU) followed by delayed surgery Usually Appropriate
Retrograde ureteral stenting Usually Appropriate
Medical therapy without decompression Usually Not Appropriate

Panel Members
Matthew J. Scheidt, MDa; Eric J. Hohenwalter, MDb; Jason W. Pinchot, MDc; Osmanuddin Ahmed, MDd; Marc A. Bjurlin, DO, MSce; Aaron R. Braun, MDf; Charles Y. Kim, MDg; Erica M. Knavel Koepsel, MDh; Kristofer Schramm, MDi; David M. Sella, MDj; Clifford R. Weiss, MDk; Jonathan M. Lorenz, MDl.
Summary of Literature Review
Introduction/Background
Special Treatment Considerations
Discussion of Procedures by Variant
Variant 1: Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
Variant 1: Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
A. Medical management without decompression
Variant 1: Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
B. PCN (includes PCNU)
Variant 1: Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
C. PCN (includes PCNU) followed by delayed surgery
Variant 1: Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
D. Percutaneous antegrade ureteral stenting (with or without safety nephrostomy)
Variant 1: Urinary diversion after remote history of cystectomy for cancer. No fever, normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. CT shows new moderate bilateral hydronephrosis.
E. Retrograde ureteral stenting
Variant 2: Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
Variant 2: Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
A. Medical management without decompression
Variant 2: Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
B. PCN (includes PCNU)
Variant 2: Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
C. PCN (includes PCNU) followed by delayed surgery
Variant 2: Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
D. Percutaneous antegrade ureteral stenting (with or without safety nephrostomy)
Variant 2: Seven-day history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. CT scan shows a 10 mm calculus in the mid right ureter without hydronephrosis.
E. Retrograde ureteral stenting
Variant 3: Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
Variant 3: Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
A. Medical management without decompression
Variant 3: Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
B. PCN
Variant 3: Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
C. PCN followed by delayed surgery
Variant 3: Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
D. Percutaneous antegrade ureteral stenting (with or without safety nephrostomy)
Variant 3: Pregnant patient (20+ weeks) with 3-day history of left flank pain, fever, and leukocytosis. Urinalysis positive for infection. Ultrasound shows new, moderate left hydronephrosis.
E. Retrograde ureteral stenting
Variant 4: Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
Variant 4: Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
A. Medical therapy without decompression
Variant 4: Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
B. PCN (includes PCNU)
Variant 4: Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
C. PCN (includes PCNU) followed by delayed surgery
Variant 4: Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
D. Percutaneous antegrade ureteral stenting (with or without safety nephrostomy)
Variant 4: Advanced cervical carcinoma with decreased estimated glomerular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter that is due to local invasion by a pelvic mass.
E. Retrograde ureteral stenting
Variant 5: Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
Variant 5: Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
A. Medical therapy without decompression
Variant 5: Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
B. PCN (includes PCNU)
Variant 5: Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
C. PCN (includes PCNU) followed by delayed surgery
Variant 5: Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
D. Percutaneous antegrade ureteral stenting (with or without safety nephrostomy)
Variant 5: Prolonged history of right flank pain, fever, and leukocytosis. Urinalysis positive for blood and infection. Patient appears septic and is hypotensive. CT scan shows dilated right ureter and renal pelvis with perinephric stranding. No etiology for ureteral obstruction identified with current imaging.
E. Retrograde ureteral stenting
Variant 6: Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
Variant 6: Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
A. Medical therapy without decompression
Variant 6: Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
B. PCN (includes PCNU)
Variant 6: Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
C. PCN (includes PCNU) followed by delayed surgery
Variant 6: Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
D. Percutaneous antegrade ureteral stenting (with or without safety nephrostomy)
Variant 6: Urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen or creatinine, moderate abdominal pain, and no peritoneal signs. CT urogram reveals contrast leak from left pelvic ureteral injury. Current therapy consists of Foley catheter in the bladder.
E. Retrograde ureteral stenting
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

·        ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

·        ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

·        ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

·        ACR Manual on Contrast Media

·        ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
References
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.