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Appropriateness Criteria

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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PCN (includes PCNU) Usually appropriate Strong N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
23 (19853233) 4
18 (8136591) 3
27 (9542016) 4
20 (14514833) 4
30 (9440851) 4
28 (6718717) 4
17 (8186603) 4
16 (9314366) 3
25 (10091780) 2
21 (8539411) 3
22 (8086252) 4
19 (21353753) 4
15 (18625353) 4
29 (2713773) 4
24 (3218915) 4
26 (6332488) 4
PCN (includes PCNU) followed by delayed surgery Usually appropriate Limited N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
14 (20472267) 4
32 (14501730) 2
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) May be appropriate Limited N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
31 (18941097) 4
Retrograde ureteral stenting May be appropriate Limited N/A N/A 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
14 (20472267) 4
12 (10795614) 4
13 (16979745) 3
Medical management without decompression Usually not appropriate Expert Consensus N/A N/A 3 3 0 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Retrograde ureteral stenting Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
33 (26662171) 1
40 (24698195) 1
41 (23795789) 2
38 (12376218) 4
37 (2667249) 4
35 (10468719) 2
36 (8573816) 2
39 (20063999) 4
34 (23017519) 3
PCN (includes PCNU) May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
44 (28128911) 1
43 (6836120) 4
16 (9314366) 3
42 (11257644) 1
PCN (includes PCNU) followed by delayed surgery May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
27 (9542016) 4
28 (6718717) 4
43 (6836120) 4
Medical management without decompression Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Retrograde ureteral stenting Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
46 (11972503) 4
PCN Usually appropriate Limited N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
48 (1490447) 4
50 (1727366) 4
51 (1507334) 4
49 (2036578) 4
47 (1971239) 4
52 (15590807) 4
Medical management without decompression Usually not appropriate Limited N/A N/A 2 2 0 0 0 0 0 0 0 0 0
References Study Quality
46 (11972503) 4
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
PCN followed by delayed surgery Usually not appropriate Expert Consensus N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PCN (includes PCNU) Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
68 (23666587) 2
69 (23164390) 2
64 (2261404) 4
66 (2025771) 4
65 (1916512) 1
25 (10091780) 2
4 (1407920) 2
58 (3721300) 4
6 (2442872) 4
59 (20728326) 4
60 (20419970) 2
61 (21481096) 1
62 (21319508) 2
63 (18042018) 2
67 (8428414) 2
70 (19338533) 2
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
71 (19945660) 4
Retrograde ureteral stenting Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
54 (22315095) 2
55 (19278608) 4
56 (15533473) 2
57 (15851050) 3
PCN (includes PCNU) followed by delayed surgery May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
55 (19278608) 4
56 (15533473) 2
Medical therapy without decompression Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
53 (18554655) 2
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PCN (includes PCNU) Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
77 (26321323) 1
79 (24033464) 2
18 (8136591) 3
75 (1414717) 4
27 (9542016) 4
38 (12376218) 4
76 (10443717) 4
73 (11774760) 4
17 (8186603) 4
37 (2667249) 4
43 (6836120) 4
78 (3398131) 4
74 (20206981) 3
Retrograde ureteral stenting May be appropriate Limited N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
72 (25661913) 4
PCN (includes PCNU) followed by delayed surgery May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
80 (9886587) 2
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually not appropriate Limited N/A N/A 2 2 0 0 0 0 0 0 0 0 0
References Study Quality
79 (24033464) 2
Medical therapy without decompression Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
72 (25661913) 4
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 SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
PCN (includes PCNU) Usually appropriate Limited N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
27 (9542016) 4
43 (6836120) 4
82 (9211774) 4
81 (7563324) 4
83 (9232583) 2
84 (7021877) 4
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
85 (18682673) 4
27 (9542016) 4
43 (6836120) 4
82 (9211774) 4
81 (7563324) 4
PCN (includes PCNU) followed by delayed surgery Usually appropriate Limited N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
86 (8911355) 4
Retrograde ureteral stenting Usually appropriate Expert Consensus N/A N/A 7 7 0 0 0 0 0 0 0 0 0
Medical therapy without decompression Usually not appropriate Expert Consensus N/A N/A 1 1 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.