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Appropriateness Criteria

Variant 1: Antenatal diagnosis of hydronephrosis. Initial neonatal imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 0 2 16
References Study Quality
25 (23474928) 4
3 (25435247) 4
6 (20951094) 3
20 (16427220) 4
12 (18071685) 4
22 (16716789) 4
23 (22506510) 2
24 (24413717) 2
27 (19484160) 4
26 (16025288) 2
28 (15197477) 4
29 (22836304) 4
30 (19663038) 4
21 (17653772) 2
Voiding urosonography Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 1 12 0 0 1 0 0 0
References Study Quality
41 (16086170) 4
42 (17520246) 1
43 (20686902) 3
44 (24659313) 2
45 (26597418) 3
Fluoroscopy voiding cystourethrography Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 5 3 3 1 6 1 0 0 0
References Study Quality
2 (18278521) 3
20 (16427220) 4
12 (18071685) 4
27 (19484160) 4
29 (22836304) 4
32 (18520762) 4
33 (8957961) 3
34 (22797098) 3
35 (16967282) 3
31 (20650494) 4
36 (22857837) 4
40 (10458467) 3
39 (27919407) 4
37 (25722643) 4
38 (28612058) 4
Nuclear medicine cystography Usually not appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 1 1 12 2 1 2 2 0 0 0 0
References Study Quality
46 (6462809) 3
47 (11122000) 3
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 1 0 0 0 0 0 0
DTPA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
MAG3 renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 17 1 0 1 0 0 0 0 0
Variant 2: Antenatal diagnosis of hydronephrosis with normal neonatal ultrasound.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder follow-up in 1-6 months Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 1 0 0 4 7 5
References Study Quality
3 (25435247) 4
4 (20399145) 4
5 () 4
26 (16025288) 2
30 (19663038) 4
48 (22426549) 1
49 (22350369) 3
50 (24927968) 4
Voiding urosonography Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 3 5 2 5 0 0 0 0
References Study Quality
41 (16086170) 4
42 (17520246) 1
43 (20686902) 3
44 (24659313) 2
45 (26597418) 3
Fluoroscopy voiding cystourethrography Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 5 3 3 2 6 0 0 0 0
References Study Quality
2 (18278521) 3
20 (16427220) 4
12 (18071685) 4
27 (19484160) 4
29 (22836304) 4
32 (18520762) 4
33 (8957961) 3
34 (22797098) 3
35 (16967282) 3
31 (20650494) 4
36 (22857837) 4
40 (10458467) 3
39 (27919407) 4
Nuclear medicine cystography Usually not appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 1 1 12 2 2 1 2 0 0 0 0
References Study Quality
46 (6462809) 3
47 (11122000) 3
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 1 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 0 0 1 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 0 0 0 0 0 0 0
DTPA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
MAG3 renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
Variant 3: Antenatal diagnosis of hydronephrosis with isolated mild (SFU grade 1 and 2 or APRPD less than 15 mm) hydronephrosis on initial neonatal ultrasound.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder follow-up in 1-6 months Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 2 1 3 5 6
References Study Quality
4 (20399145) 4
5 () 4
8 (15653195) 3
10 (16362721) M
49 (22350369) 3
50 (24927968) 4
Voiding urosonography May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 2 0 7 3 6 0 0 0 1
References Study Quality
41 (16086170) 4
42 (17520246) 1
43 (20686902) 3
44 (24659313) 2
45 (26597418) 3
Fluoroscopy voiding cystourethrography May be appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 3 1 4 3 8 0 0 0 0
References Study Quality
2 (18278521) 3
20 (16427220) 4
12 (18071685) 4
27 (19484160) 4
29 (22836304) 4
32 (18520762) 4
33 (8957961) 3
34 (22797098) 3
35 (16967282) 3
31 (20650494) 4
36 (22857837) 4
40 (10458467) 3
39 (27919407) 4
Nuclear medicine cystography Usually not appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 2 2 8 4 4 1 2 0 0 0 0
References Study Quality
48 (22426549) 1
47 (11122000) 3
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 1 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 1 0 1 0 0 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 1 0 0 0
DTPA renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
MAG3 renal scan Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 4 0 0 0 0 0 0 0
Variant 4: Male. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening, or posterior urethral dilation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder follow-up in 1-6 months Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 1 0 1 3 12
References Study Quality
1 (21683656) 3
23 (22506510) 2
50 (24927968) 4
34 (22797098) 3
21 (17653772) 2
51 (16882811) M
52 (17619702) 4
53 (19484161) 4
55 (20713223) 2
54 (16945650) 3
Fluoroscopy voiding cystourethrography Usually appropriate Moderate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 0 0 0 0 1 3 14
References Study Quality
3 (25435247) 4
20 (16427220) 4
12 (18071685) 4
26 (16025288) 2
28 (15197477) 4
29 (22836304) 4
50 (24927968) 4
31 (20650494) 4
57 (19239817) 4
51 (16882811) M
60 (25813560) 3
56 (20524012) 3
58 (7717237) 3
59 (10588268) 4
MAG3 renal scan Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 1 0 1 0 2 9 5 0
References Study Quality
20 (16427220) 4
29 (22836304) 4
62 (21830021) 2
52 (17619702) 4
53 (19484161) 4
63 (15148596) 2
73 (22570256) 3
55 (20713223) 2
72 (24206785) 4
70 (23500640) 3
71 (26165191) 2
68 () 2
66 (18631923) 3
67 (15758800) 2
61 (24549283) 4
Voiding urosonography Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 5 6 4 2 1 0 0 0 0
References Study Quality
41 (16086170) 4
42 (17520246) 1
43 (20686902) 3
44 (24659313) 2
45 (26597418) 3
Nuclear medicine cystography Usually not appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 2 2 8 4 3 0 1 0 1 1 0
References Study Quality
46 (6462809) 3
MRI abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 4 6 0 3 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 3 5 7 0 2 0 1 0 0
References Study Quality
74 (24183522) 4
76 (25102294) 2
75 (29702016) 3
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 3 2 3 1 0 1 0 0
DTPA renal scan Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 3 4 8 1 2 0 0 0 0
References Study Quality
20 (16427220) 4
29 (22836304) 4
62 (21830021) 2
53 (19484161) 4
63 (15148596) 2
61 (24549283) 4
Variant 5: Female. Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound, or hydronephrosis associated with parenchymal abnormalities, hydroureter, bladder wall thickening.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder follow-up in 1-6 months Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 0 1 1 14
References Study Quality
1 (21683656) 3
23 (22506510) 2
50 (24927968) 4
34 (22797098) 3
21 (17653772) 2
52 (17619702) 4
53 (19484161) 4
55 (20713223) 2
54 (16945650) 3
Voiding urosonography Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 4 1 7 4 1
References Study Quality
41 (16086170) 4
42 (17520246) 1
43 (20686902) 3
44 (24659313) 2
45 (26597418) 3
Fluoroscopy voiding cystourethrography Usually appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 1 0 0 1 1 3 12
References Study Quality
3 (25435247) 4
20 (16427220) 4
12 (18071685) 4
26 (16025288) 2
28 (15197477) 4
29 (22836304) 4
50 (24927968) 4
31 (20650494) 4
57 (19239817) 4
51 (16882811) M
60 (25813560) 3
56 (20524012) 3
MAG3 renal scan Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 1 0 1 0 1 9 5 1
References Study Quality
4 (20399145) 4
20 (16427220) 4
29 (22836304) 4
62 (21830021) 2
52 (17619702) 4
53 (19484161) 4
63 (15148596) 2
73 (22570256) 3
55 (20713223) 2
72 (24206785) 4
70 (23500640) 3
71 (26165191) 2
69 () 4
68 () 2
66 (18631923) 3
67 (15758800) 2
61 (24549283) 4
Nuclear medicine cystography May be appropriate (Disagreement) Expert Opinion ☢☢ 0.03-0.3 mSv [ped] 5 5 0 1 1 4 8 1 1 1 1
References Study Quality
46 (6462809) 3
47 (11122000) 3
MRI abdomen and pelvis with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 3 7 1 3 0 0 0 0
References Study Quality
74 (24183522) 4
75 (29702016) 3
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 2 6 4 3 0 1 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 3 3 1 1 0 0 0
DTPA renal scan Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 1 7 7 0 2 1 0 0 0
References Study Quality
20 (16427220) 4
29 (22836304) 4
62 (21830021) 2
53 (19484161) 4
63 (15148596) 2
64 (15821462) 4
65 (20823803) 4
61 (24549283) 4
Variant 6: Antenatal diagnosis of hydronephrosis with moderate or severe (SFU grade 3 or 4 or APRPD greater than 15 mm) hydronephrosis on initial neonatal ultrasound and no evidence of reflux on VCUG.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US kidneys and bladder follow-up in 1-6 months Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 1 0 1 0 2 8 5
References Study Quality
1 (21683656) 3
2 (18278521) 3
4 (20399145) 4
6 (20951094) 3
22 (16716789) 4
23 (22506510) 2
29 (22836304) 4
48 (22426549) 1
21 (17653772) 2
51 (16882811) M
53 (19484161) 4
55 (20713223) 2
54 (16945650) 3
77 (23726167) 3
MAG3 renal scan Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 0 1 2 5 2 9
References Study Quality
3 (25435247) 4
20 (16427220) 4
22 (16716789) 4
27 (19484160) 4
28 (15197477) 4
52 (17619702) 4
73 (22570256) 3
55 (20713223) 2
72 (24206785) 4
70 (23500640) 3
71 (26165191) 2
68 () 2
66 (18631923) 3
67 (15758800) 2
61 (24549283) 4
MRI abdomen and pelvis with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 2 2 1 5 3 1 0 0
References Study Quality
74 (24183522) 4
76 (25102294) 2
75 (29702016) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 1 1 2 7 5 0 1 0
DTPA renal scan May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 1 0 1 5 4 6 2 0
References Study Quality
20 (16427220) 4
29 (22836304) 4
62 (21830021) 2
53 (19484161) 4
63 (15148596) 2
64 (15821462) 4
65 (20823803) 4
61 (24549283) 4
MRI abdomen and pelvis without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 4 3 3 4 2 2 0 0 0
References Study Quality
74 (24183522) 4
76 (25102294) 2
75 (29702016) 3
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.