American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Urinary Tract Obstruction

Variant 1: Adult patient with urinary diversion after remote history of cystectomy for cancer. Patient has no fever. Patient has normal white blood cell (WBC) count and urine output. Loopogram shows no reflux into distal ureters. Computed tomography (CT) scan 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
Medical management without decompression Usually not appropriate N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Retrograde ureteral stenting May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy followed by delayed surgery Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Adult patient with a 7-day history of right flank pain, fever, and leukocytosis. Urinalysis is 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
Medical management without decompression Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Retrograde ureteral stenting Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy followed by delayed surgery May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Adult pregnant (20+ weeks) patient with a 3-day history of left flank pain, fever, and leukocytosis. Urinalysis is positive for infection. Ultrasound scan 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
Medical management without decompression Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Retrograde ureteral stenting Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy followed by delayed surgery Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Adult patient with advanced cervical carcinoma presenting with decreased estimated globular filtration rate <15. Normal WBC, positive pelvic pressure, no flank pain. CT scan reveals new bilateral hydronephrosis and hydroureter 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
Medical therapy without decompression Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Retrograde ureteral stenting Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy followed by delayed surgery May be appropriate N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Adult patient with a prolonged history of right flank pain, fever, and leukocytosis. Urinalysis is 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
Medical therapy without decompression Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Retrograde ureteral stenting May be appropriate N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually not appropriate N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy followed by delayed surgery May be appropriate N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Variant 6: Adult patient with urinary ascites after recent abdominal surgery. Elevated blood urea nitrogen/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
Medical therapy without decompression Usually not appropriate N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Retrograde ureteral stenting Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy Usually appropriate N/A N/A 9 n/a 0 0 0 0 0 0 0 0 0
Percutaneous antegrade ureteral stenting (with or without safety nephrostomy) Usually appropriate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
Percutaneous nephrostomy followed by delayed surgery Usually appropriate N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.