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301
Perspective
Current Status of the Society Thomas
J. Barloon,1
Robert
C. Brown,
and Kevin
The purpose of this survey was to determine tice among radiologists who specialize in adult
Areas of controversy
A Survey
of Adult Uroradiology: of Uroradiology S. Berbaum
current pracuroradiology.
that exist in adult uroradiology
include
the type and amount of IV contrast material for routine excretory urography (EU); whether written permission should be obtained before EU; and the primary responsibility for extracorporeal shock-wave lithotnipsy (ESWL), prostate sonography, and uroradiology intenventional procedures. We believe adult uroradiology as performed by members of the Society of Uroradiology reflects state-of-the-art practice. Their consensus may provide useful guidelines for general radiologists.
of injection and amount of contrast material (with a 70-kg adult with normal renal function as standard). They also were asked to indicate who was primarily responsible for ESWL, transrectal sonography with biopsy, and uroradiology interventional procedures in their institutions.
Results Fifty-eight(65%)of
89 individual
avoid duplication. and
and Methods
Questionnaires
2% (one)
performed
were sent to 89 members
of the Society of Urora-
survey
questionnaires
from
separate programs were returned. Each questionnaire was labeled with the individual respondent’s name and address to Types
of practice
group, 74% (40) academic, Materials
of Members
median
private
monthly
solo.
varies
of 1 00/month,
The
and remained
reported
an increase
number
widely
and
practices
included
20% (1 1) private
4% (two) government-associated,
has
of EU procedures
(range,
i 7-500),
decreased
with
a
in 61 % (34)
of
the same in 39% (22). No respondent
diology in the United States and Canada who were in active practice of adult uroradiology as of March 1 , 1989 (Fig. i). The survey asked uroradiologists the following: type of practice (academic, private group, government-associated, private solo); number of EU proce-
respondents listing each of the indications for adult EU. Written permission is routinely obtained before EU by 30% (17)
dures performed
of respondents.
and whether the number has increased,
decreased,
or remained the same during the past 5 years; and whether written permission is obtained before EU. Additional questions involved the routine use of ionic or nonionic contrast material and, if nonionic
contrast material was not routinely use of nonionic contrast material.
used, the indications
for selective
Uroradiologists were asked to rank their indications for EU. Those uroradiologists who left the indication blank were not tabulated. If the indication
given
was
not
used
zero was noted. The respondents
by
the
responding
uroradiologist,
a
were asked to indicate the method
(0%).
Ionic
Table
contrast
1 shows
material
the percentage
is routinely
of
used
for
EU by 90% (Si) of respondents, whereas nonionic contrast material is routinely used by 1 0% (six). Those uroradiologists who routinely use ionic contrast ten nonionic contrast matenialfon
2). Other included
indications comatose
plant, fluid-electrolyte lack of steroid
material a variety
selectively adminisof indications (Table
listed by two or fewer condition,
solitary
imbalance,
pretreatment,
kidney
unoradiologists or renal
lack of support
pheochnomocytoma,
trans-
personnel, recent
ionic
August 18, 1989; accepted after revision September 28, 1989. 1All authors: Department of Radiology, The University of Iowa College of Medicine, Iowa City, IA 52242. Address reprint requests to 1. J. Barloon, Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Received
AJR i54:301-304,
February
1990 0361 -803X/90/1542-0301
© American
Roentgen Ray Society
302
BARLOON
ET AL.
Downloaded from www.ajronline.org by 205.217.255.184 on 10/04/15 from IP address 205.217.255.184. Copyright ARRS. For personal use only; all rights reserved
ADDRESS:
(please
Private (solo( Private (group( Academic Government (e.g. VA)
check
1990
Before gynecologic surgery Hypertersive evaluation Preoperative evaluation of colorectal disease/hernia Upper urinary tract surveillance of bladder tunors Trauma Azotemia Evaluation of obstructive uropathy Screening potential renal donors Henaturia Palpable renal mass
NAME:
Type of Practice
February
_____ _____ _____ _____ _____
Practice:
Adult
AJR:154,
one( 8.
Are there additional indications uroorams in adult 2.gJ_5.?
not listed
for which
you perform
encretory
9.
When using intravenous contrast (whether ionic or nonionic(, approximately much contrast is routinely administered adult aith normal renal function weighing 70 kg). )please check jy one)
-
1.
Approximate number of excretory urograms (IVPs( performed Ld.t.tDD.t!(e.g. 10/day x 20 work days - 200 studies/mxnth(. ____________________month
2.
Number check
of excretxry urograms (EU) perfxrmed ome(. Increai Decreased Approximately same number performed written
permission adult
over
each month
in adult
the past 5 or 6 years
3.
Dx you routinely obtain for excretory orography Yes No
4.
When performing excretory (please check tsJi 2!it(? Ionic contrast Nonionic contrast
5.
If nonionic contrast medium is not routinely used in your department, do you ever use nonlonic contrast for tE following T1cations? Relative renal insufficiency History of previous Df.,t2.!: contrast reaction (e.g. difficulty breathing. anaphyloid reaction) History of previous minor contrast reaction (e.g. uticaria( Requested by patient or Other indications for using nonionic contrast in your practice jpjgf
urograns,
which
before
injecting
contrast
medium
intravenxus
(please
is routinely
Total Total Total Total
contrast
used
of of of of
20 g 40 g 60 g more
of iodine of iodine of iodine than 60 g
contrast contrast contrast of iodine
contrast
10.
Is eotracorporeal shock wave lithotripsy (ESWL) in your department direction of radiologists? Yes No ESWL is not performed in our department or hospital.
11.
Are you or other radiologists in transrectal ultrasound including Yes, transrectal ultrasound radiologist(s). No. transreccal ultrasound by radiologist(s). Transrectal ultrasound and radiologists and urologists. Tramsrectal ultrasound and department or hospital.
urn.
how
under
the
your department primarily responsible for prostate biopsy? and prostate biopsy are primarily performed and prostate
biopsy
d!!
52!
primarily
prostate
biopsy
are performed
prostate
biopsy
are not performed
by
performed
by both in our
(1( 12.
Are you or other radiologists primarily responsible for interventional uroradiologic procedures (e.g. percutaneous antegrade pyleogram, stone extractions, urethral or ureter stricture dilatation. etc(? Yes, uroradiologists or other radiologists in our department are primarily responsible for uroradiologic interventional procedures. No. uroradiologists or other radiologists in our department are not primarily responsible for uroradiologic interventional procedures. Both radiologists and urologists in our department perform interventional uroradiologic procedures.
13 .
Please
(21
(3( 6.
7.
Which method of injecting intravenous contrast for excretory urography is most commonly used in your department (please check ]j one)? Bolus injection (by hand-held syringe; performeWb staff or resident physician) Bolus injection (by hand-held syringe; performed by trained technologist or nurse) Automatic injector (e.g. pre-programed injector) Drip infusion method Combination of bolus injection followed by drip infusion Other (please explain other method)
Indications for performing excretory urograms in your adult atients (in terms of frequency: 1 - nost comon indication, 2 - second most conanon in ication, etc.). If a listed indication is not used. please use (0) to indicate. _____ Urinary tract infection in female or ma1e patient Before prostatectomy
Fig. 1.-Survey
sent to 89 members
list
Thank
of the Society of Uroradiology
contrast material administration, pulmonary disease, and patient’s anxiety. The most common methods of injecting IV contrast material for EU included bolus injection by hand-held syringe performed by staff or resident physician (65%, 37 respondents); bolus injection by hand-held syringe performed by a trained technologist on nurse (26%, 1 5 respondents); drip infusion (4%, two respondents); and a combination of bolus injection followed by drip infusion (5%, three respondents). No respondent (0%) used an automatic preprogrammed injector. The amount of IV contrast material routinely administered was 20 g of iodine contrast material (43%, 23 respondents), 40 g (47%, 25 respondents), and 60 g (10%, five respon-
addi ti ona 1 coments.
you for completing
who practice
this survey.
adult uroradiology.
dents). Of the five responding unoradiologists who use 60 g of contrast material, four use bolus injection technique and one uses drip infusion. The majority of respondents (62%, 35) said ESWL is not performed primarily under the direction of radiologists, 4% (two) indicated the procedure is performed by radiologists, and 34% (19) do not have ESWL in their department on hospital. Among the 1 9 unoradiologists who do not have ESWL available, five are in private practice, 1 2 are in academic programs, and two are in government-associated practice. Transnectal sonognaphy and prostate biopsy are performed primarily by unoradiologists (39%, 22 respondents) on by both unonadiologists and nonnadiologists (39%, 22); 1 6% (nine)
AJR:154,
February
TABLE
1: Indications
SURVEY
1990
for Adult
Excretory
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Urinary tract infection Obstructive uropathy Hematuria Upper urinary tract surveillance patients with bladder tumors Trauma Before prostatectomy Before gynecologic surgery Palpable renal mass Screening renal donors Preoperative colorectal disease Hypertensive evaluation Azotemic evaluation
TABLE Material
2:
Indications
Percentage Not Indicated
96 90 89
4 10 11
88 85 84 82 70 52 51 39 16
12 15 16 18 30 48 49 61 84
of
for Selective
Use
of Nonionic
Indications
History of major contrast reaction History of minor contrast reaction Relative renal insufficiency Requested by referring physician or patient
5.
Cardiac
failure
7.
Advanced
and/or
of allergy
Contrast
Percentage
1. 2. 3. 4.
6. History
URORADIOLOGY
Urography
Percentage Indicated
Indications
OF
96 40 51 52 26 22
arrhythmia
or asthma
age
21
8. Diabetes mellitus 9. Blood dyscrasia (myeloma,
14 7
sickle cell anemia)
indicated prostate sonognaphy and biopsy are not performed by radiologists and 7% (four) stated that this procedure is not performed in their department or hospital. Of the four unonadiologists who do not have prostate sonognaphy available, three are in private practice and one is in an academic radiology program. Most respondents (82%, 47) stated that uroradiology interventional procedures are performed pnimarily by unonadiologists on interventional radiologists in their department or hospital, 1 4% (eight) stated that interventional studies are performed by both uronadiologists and nonradiologists, and 4% (two) stated that nonnadiologists have primary responsibility for uroradiology interventional procedures.
Discussion
Our survey reflects agreement and controversy in uronadiology practice. The number of EU procedures performed over the past 5 years has decreased in 61 % of uroradiology practices, which probably reflects the primary use of sonography, CT, and occasionally MR (noted by several uronadiologists)
to evaluate
suspected
renal
lesions
(e.g.,
hematunia,
renal obstruction, azotemia). Our survey shows that certain responding uroradiologists believe that EU is not indicated in their practice for evaluation of urinary tract infection (4%), obstructive uropathy (1 0%), and hematunia (1 1 %). For example, Goldman et al. [1] and Hillman et al. [2] advocate CT as the only study necessary to evaluate gynecologic malignancies for possible urinary tract involvement. Ellenbogen et
PRACTICE
303
al. [3] advocate sonognaphy primarily to detect urinary tract obstruction. Most respondents agree that there is little mdication for EU in the azotemic patient on for hypertensive evaluation. Evidence has accumulated from clinical expenience and prospective studies that hypertensive unognams are not satisfactory for differentiating hypertension due to renal artery stenosis from essential hypertension [4]. There was disagreement on the value of EU in screening renal donors and in preoperative evaluation before colorectal surgery. Fifty-two percent of respondents stated EU was appropriate for screening renal donors, whereas 48% said EU was not indicated. Fifty-one percent of respondents stated EU was indicated for preoperative evaluation of colorectal disease, whereas 49% said EU was not indicated. Conversely, several respondents noted the number of EU procedures performed has remained the same because of the increased number performed before and after ESWL while the other indications have decreased. Written informed consent before injecting IV contrast matenial has been advocated by radiologists [5, 6]; however, the majority in our survey do not obtain written permission. Spring et al. [5] surveyed 902 patients regarding their opinion of informed written consent before contrast procedures. They found 90% would rather receive this information than not receive it; conversely, 1 0% preferred not to receive the infonmation. Limitations in obtaining informed consent were common and included medical emergencies and patients with limited understanding of the risk disclosure. Interestingly, two respondents routinely obtained written permission because of state law requirements. There is disagreement concerning the routine use of nonionic contrast material during EU on CT [7-i 2]. Nonionic contrast material has been advocated for routine use because of probable decrease in adverse reactions; however, only 1 0% (six respondents) routinely use nonionic contrast matenial for EU, whereas 90% (51) do not do so. Earlier studies [1 2-1 4] were conflicting and provided no clean guidance. However, recent studies from Japan and Australia [1 5, 16] have indicated nonionic contrast material provided a safety margin of 6:1 when compared with ionic contrast material. We did not survey unoradiologists regarding their reasons for routine use of ionic contrast material as opposed to nonionic contrast material. Most current literature suggests the routine use of nonionic contrast material may be financially prohibitive [5, 1 3, 1 4, 1 7, 1 8]. Indications for selective use of nonionic contrast material (by those uronadiologists who routinely use ionic contrast material) included history of major and minor reactions to contrast materials, relative renal insufficiency, and request by physician on patient (Table 2). Recent studies were unable to show a difference in the incidence of nephrotoxicity between patients receiving a nonionic contrast agent and those receiving an ionic contrast agent [1 9, 20]. The majority of radiologists use a bolus injection with a hand-held syringe, which is performed by either a physician or trained technologist. Only a small percentage routinely use drip infusion or bolus followed by drip infusion. Investigations also have supported bolus injection for EU [20, 21]. Two respondents use bolus injection in patients less than 40 years old and drip infusion in those more than 40 years old.
BARLOON
Downloaded from www.ajronline.org by 205.217.255.184 on 10/04/15 from IP address 205.217.255.184. Copyright ARRS. For personal use only; all rights reserved
304
There is general agreement on the amount of radiographic contrast material for IV injection. Davidson [22] has noted that the diagnostic quality of EU depends on the level of contrast agent present in the plasma and available to the kidney for excretion. Of the responding uronadiologists, 90% used 20-40 g of iodine for IV injection. These amounts are supported by studies showing maximal benefit at these 1evels in adults of standard weight and normal renal function
[22, 23]. The survey suggests that primary responsibility for renal stone lithotnipsy is under the guidance of nonnadiologists. This parallels our experience and that of others [24, 25]. However, most uroradiologists in our survey continue to perform interventional unonadiology procedures. The number and complexity of interventional procedures probably have increased with the advent of ESWL [26, 27]. Although several reviews [28, 29] have been published on tnansrectal sonography with biopsy in prostate cancer screening and staging, its exact role remains to be clarified. Among responding uroradiologists, 39% (22) perform tnansnectal sonognaphy with biopsy and 39% (22) perform the procedure in cooperation with unologists. Ten respondents stated that tnansnectal sonography with biopsy is performed by nonnadiologists in their institutions, whereas four respondents stated that the procedure is not performed in their institutions. In summary, our survey of uronadiologists reflects areas of agreement and controversy. Sixty-one percent of responding unonadiologists noted a decreased use of EU, probably because of an increased use of sonography and CT. Ninety percent of our sample routinely use ionic contrast material and selectively use nonionic contrast material for limited mdications. Reports from Japan and Australia will probably reverse this trend in the next 2-3 years. The most common method of IV contrast material injection is the hand-held bolus technique performed by a physician on trained technologist. Most respondents use 20-40 g of contrast material for IV injection. Interventional uroradiology procedures mostly remain the primary responsibility of radiologists. Prostate sonognaphy with biopsy also is performed either by the uroradiologist or together with the urologist. However, at those institutions with ESWL available, the nonradiologist has the primary nesponsibility.
ACKNOWLEDGMENTS
The authors their
Phyllis
participation,
Bergman
thank
the members Patricia
for editorial
Osborn
of The Society for
secretarial
of Uroradiology assistance,
for and
assistance.
REFERENCES 1 . Goldman SM, Fishman EK, Rosenshein NB, et al. Excretory urography and computed tomography in the initial evaluation of patients with cervical cancer: are both examinations necessary? AJR 1984;143: 991-996
2. Hillman BJ, Clark AL, Babbitt G. Efficacy of the excretory urogram in the staging of gynecologic malignancies. AJR 1984;143:997-999
ET AL.
AJR:154,
3. Ellenbogen
PH, Scheible
scale ultrasound
FW, Talner
in detecting
LE, Leopold
urinary
tract
February
GA. Sensitivity
obstruction.
AJR
1990
of gray 1978;1 30:
731 -733 4. Thornbury JR, Stanley JC, Fryback DG. Hypertensive urogram: a nondiscriminatory test for renovascular hypertension. AJR 1982;138:43-47 5. Spring DB, Winfield AC, Friedland GW, Shuman WP, Preger L. Written informed consent for IV contrast-enhanced radiography: patients’ attitudes and common limitations. AJR 1988;151 :1243-1 245 6. Winfield AC, Ford cv, James AE, Heller AM, Lamballe AK. Response of patients to informed consent for excretory urography. Urol Radiol 1986;8:35-39 7. Evens AG. Economic impact of low-osmolality contrast agents on radiology procedures and departments. Radiology 1987;162:267-268
8. White Al Jr, Halden WJ Jr. Liquid gold: low osmolality
contrast
media.
Radiology 1986;159:559-560 9. McClennan BL. Low-osmolality contrast media: premises and promises. Radiology 1986;1 62:1-8 1 0. Wolf GL. Safer, more expensive iodinated contrast agents: how do we decide? Radiology 1986;1 59:557-558 1 1 . Bagg MNJ, Horwitz TA, Bester L. Comparison of patient responses to high- and low-osmolality contrast agents injected intravenously. AJR 1986;147: 185-1 87 12. Wolf GL, Arenson AL, Cross AP. A prospective trial of ionic vs nonionic contrast agents in routine clinical practice: comparison of adverse effects. AJR 1989;1 52:939-944 13. Kinnison ML, Powe NA, Steinberg EP. Results of randomized controlled trials of low- versus high-osmolality contrast media. Radiology 1989;1 70:
381 -389 14. Evens AG. Low-osmolality contrast media: good news or bad? Radiology 1988;1 69:277-278 1 5. Palmer FJ. The RACR survey of intravenous contrast media reactions: final report. Australas Radio! 1988;32:426-428 1 6. Katayama H. Report of the Japanese Committee on the Safety of Contrast Media. Scientific Poster, Radiological Society of North America Meeting, Chicago, 1988 1 7. Lasser EC, Berry CC. Nonionic vs ionic contrast media: what do the data tell us?AJR 1989;152:945-946 1 8. Powe NA, Steinberg EP, Erickson JE, et al. Contrast medium-induced adverse reactions: economic outcome. Radiology 1989;1 69:163-168 19. Schwab SJ, Hlatky MA, Pieper MS, et al. Contrast nephrotoxicity: a
randomized controlled trial of a nonionic and an ionic radiographic agent.
N Eng! J Med
1989;320:
contrast
149-153
20. Parfrey PS, Gnffiths SM, Barrett BJ, et al. Contrast material-induced
renal
failure in patients with diabetes mellitus, renal insufficiency, or both: a prospective controlled study. N EngI J Med 1989;320: 143-149 21 . Cattell WA Excretory pathways for contrast media. Invest Radio! 1970;5:473-486 22. Davidson AJ. Radiology of the kidney, chapter 1 . Philadelphia: Saunders, 1985: 3-31 23. van Waes PFGM. High-dose urography in oliguric and anuric patients: excretion of urographic contrast media in advanced renal failure. Amster-
dam: Excerpta Medico, 1972:63-99 24. Barth KH, Pahira JJ, Elliott LP. Extracorporeal shockwave lithotripsy: role of the radiologist. Radiology 1985;1 55:835-836 25. Bush WH, Gibbons RP. Extracorporeal shock wave lithotripsy: role of the radiologist (letter). Radiology 1981;1 58:855 26. Cochran ST, Barbaric ZL, Mindell HJ, Chaussy CD, Fuchs GJ, Lupu AN. Extracorporeal shock wave lithotripsy: impact on the radiology department of a stone treatment center. Radiology 1987;163:655-659 27. Tegtmeyer CJ, Kellum CD, Jenkins A, et al. Extracorporeal shock wave lithotripsy: interventional radiologic solutions to associated problems. Radiology 1986;161 :587-592 28. Lee F, Littrup PJ, Kumasaka GH, Borlaza GS, McLeary AD. The use of transrectal ultrasound in the diagnosis, guided biopsy, staging and screening of prostate cancer. RadioGraphics 1987;7:627-644
29. Dahnert WF, Hamper UM, Eggleston JC, Walsh PC, Sanders AC. Prostatic evaluation echopenic
by transrectal sonography with appearance of early carcinoma.
histopathologic correlation: Radiology 1986;1 58:97-102
the
301
Perspective
Current Status of the Society Thomas
J. Barloon,1
Robert
C. Brown,
and Kevin
The purpose of this survey was to determine tice among radiologists who specialize in adult
Areas of controversy
A Survey
of Adult Uroradiology: of Uroradiology S. Berbaum
current pracuroradiology.
that exist in adult uroradiology
include
the type and amount of IV contrast material for routine excretory urography (EU); whether written permission should be obtained before EU; and the primary responsibility for extracorporeal shock-wave lithotnipsy (ESWL), prostate sonography, and uroradiology intenventional procedures. We believe adult uroradiology as performed by members of the Society of Uroradiology reflects state-of-the-art practice. Their consensus may provide useful guidelines for general radiologists.
of injection and amount of contrast material (with a 70-kg adult with normal renal function as standard). They also were asked to indicate who was primarily responsible for ESWL, transrectal sonography with biopsy, and uroradiology interventional procedures in their institutions.
Results Fifty-eight(65%)of
89 individual
avoid duplication. and
and Methods
Questionnaires
2% (one)
performed
were sent to 89 members
of the Society of Urora-
survey
questionnaires
from
separate programs were returned. Each questionnaire was labeled with the individual respondent’s name and address to Types
of practice
group, 74% (40) academic, Materials
of Members
median
private
monthly
solo.
varies
of 1 00/month,
The
and remained
reported
an increase
number
widely
and
practices
included
20% (1 1) private
4% (two) government-associated,
has
of EU procedures
(range,
i 7-500),
decreased
with
a
in 61 % (34)
of
the same in 39% (22). No respondent
diology in the United States and Canada who were in active practice of adult uroradiology as of March 1 , 1989 (Fig. i). The survey asked uroradiologists the following: type of practice (academic, private group, government-associated, private solo); number of EU proce-
respondents listing each of the indications for adult EU. Written permission is routinely obtained before EU by 30% (17)
dures performed
of respondents.
and whether the number has increased,
decreased,
or remained the same during the past 5 years; and whether written permission is obtained before EU. Additional questions involved the routine use of ionic or nonionic contrast material and, if nonionic
contrast material was not routinely use of nonionic contrast material.
used, the indications
for selective
Uroradiologists were asked to rank their indications for EU. Those uroradiologists who left the indication blank were not tabulated. If the indication
given
was
not
used
zero was noted. The respondents
by
the
responding
uroradiologist,
a
were asked to indicate the method
(0%).
Ionic
Table
contrast
1 shows
material
the percentage
is routinely
of
used
for
EU by 90% (Si) of respondents, whereas nonionic contrast material is routinely used by 1 0% (six). Those uroradiologists who routinely use ionic contrast ten nonionic contrast matenialfon
2). Other included
indications comatose
plant, fluid-electrolyte lack of steroid
material a variety
selectively adminisof indications (Table
listed by two or fewer condition,
solitary
imbalance,
pretreatment,
kidney
unoradiologists or renal
lack of support
pheochnomocytoma,
trans-
personnel, recent
ionic
August 18, 1989; accepted after revision September 28, 1989. 1All authors: Department of Radiology, The University of Iowa College of Medicine, Iowa City, IA 52242. Address reprint requests to 1. J. Barloon, Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242. Received
AJR i54:301-304,
February
1990 0361 -803X/90/1542-0301
© American
Roentgen Ray Society
302
BARLOON
ET AL.
Downloaded from www.ajronline.org by 205.217.255.184 on 10/04/15 from IP address 205.217.255.184. Copyright ARRS. For personal use only; all rights reserved
ADDRESS:
(please
Private (solo( Private (group( Academic Government (e.g. VA)
check
1990
Before gynecologic surgery Hypertersive evaluation Preoperative evaluation of colorectal disease/hernia Upper urinary tract surveillance of bladder tunors Trauma Azotemia Evaluation of obstructive uropathy Screening potential renal donors Henaturia Palpable renal mass
NAME:
Type of Practice
February
_____ _____ _____ _____ _____
Practice:
Adult
AJR:154,
one( 8.
Are there additional indications uroorams in adult 2.gJ_5.?
not listed
for which
you perform
encretory
9.
When using intravenous contrast (whether ionic or nonionic(, approximately much contrast is routinely administered adult aith normal renal function weighing 70 kg). )please check jy one)
-
1.
Approximate number of excretory urograms (IVPs( performed Ld.t.tDD.t!(e.g. 10/day x 20 work days - 200 studies/mxnth(. ____________________month
2.
Number check
of excretxry urograms (EU) perfxrmed ome(. Increai Decreased Approximately same number performed written
permission adult
over
each month
in adult
the past 5 or 6 years
3.
Dx you routinely obtain for excretory orography Yes No
4.
When performing excretory (please check tsJi 2!it(? Ionic contrast Nonionic contrast
5.
If nonionic contrast medium is not routinely used in your department, do you ever use nonlonic contrast for tE following T1cations? Relative renal insufficiency History of previous Df.,t2.!: contrast reaction (e.g. difficulty breathing. anaphyloid reaction) History of previous minor contrast reaction (e.g. uticaria( Requested by patient or Other indications for using nonionic contrast in your practice jpjgf
urograns,
which
before
injecting
contrast
medium
intravenxus
(please
is routinely
Total Total Total Total
contrast
used
of of of of
20 g 40 g 60 g more
of iodine of iodine of iodine than 60 g
contrast contrast contrast of iodine
contrast
10.
Is eotracorporeal shock wave lithotripsy (ESWL) in your department direction of radiologists? Yes No ESWL is not performed in our department or hospital.
11.
Are you or other radiologists in transrectal ultrasound including Yes, transrectal ultrasound radiologist(s). No. transreccal ultrasound by radiologist(s). Transrectal ultrasound and radiologists and urologists. Tramsrectal ultrasound and department or hospital.
urn.
how
under
the
your department primarily responsible for prostate biopsy? and prostate biopsy are primarily performed and prostate
biopsy
d!!
52!
primarily
prostate
biopsy
are performed
prostate
biopsy
are not performed
by
performed
by both in our
(1( 12.
Are you or other radiologists primarily responsible for interventional uroradiologic procedures (e.g. percutaneous antegrade pyleogram, stone extractions, urethral or ureter stricture dilatation. etc(? Yes, uroradiologists or other radiologists in our department are primarily responsible for uroradiologic interventional procedures. No. uroradiologists or other radiologists in our department are not primarily responsible for uroradiologic interventional procedures. Both radiologists and urologists in our department perform interventional uroradiologic procedures.
13 .
Please
(21
(3( 6.
7.
Which method of injecting intravenous contrast for excretory urography is most commonly used in your department (please check ]j one)? Bolus injection (by hand-held syringe; performeWb staff or resident physician) Bolus injection (by hand-held syringe; performed by trained technologist or nurse) Automatic injector (e.g. pre-programed injector) Drip infusion method Combination of bolus injection followed by drip infusion Other (please explain other method)
Indications for performing excretory urograms in your adult atients (in terms of frequency: 1 - nost comon indication, 2 - second most conanon in ication, etc.). If a listed indication is not used. please use (0) to indicate. _____ Urinary tract infection in female or ma1e patient Before prostatectomy
Fig. 1.-Survey
sent to 89 members
list
Thank
of the Society of Uroradiology
contrast material administration, pulmonary disease, and patient’s anxiety. The most common methods of injecting IV contrast material for EU included bolus injection by hand-held syringe performed by staff or resident physician (65%, 37 respondents); bolus injection by hand-held syringe performed by a trained technologist on nurse (26%, 1 5 respondents); drip infusion (4%, two respondents); and a combination of bolus injection followed by drip infusion (5%, three respondents). No respondent (0%) used an automatic preprogrammed injector. The amount of IV contrast material routinely administered was 20 g of iodine contrast material (43%, 23 respondents), 40 g (47%, 25 respondents), and 60 g (10%, five respon-
addi ti ona 1 coments.
you for completing
who practice
this survey.
adult uroradiology.
dents). Of the five responding unoradiologists who use 60 g of contrast material, four use bolus injection technique and one uses drip infusion. The majority of respondents (62%, 35) said ESWL is not performed primarily under the direction of radiologists, 4% (two) indicated the procedure is performed by radiologists, and 34% (19) do not have ESWL in their department on hospital. Among the 1 9 unoradiologists who do not have ESWL available, five are in private practice, 1 2 are in academic programs, and two are in government-associated practice. Transnectal sonognaphy and prostate biopsy are performed primarily by unoradiologists (39%, 22 respondents) on by both unonadiologists and nonnadiologists (39%, 22); 1 6% (nine)
AJR:154,
February
TABLE
1: Indications
SURVEY
1990
for Adult
Excretory
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Urinary tract infection Obstructive uropathy Hematuria Upper urinary tract surveillance patients with bladder tumors Trauma Before prostatectomy Before gynecologic surgery Palpable renal mass Screening renal donors Preoperative colorectal disease Hypertensive evaluation Azotemic evaluation
TABLE Material
2:
Indications
Percentage Not Indicated
96 90 89
4 10 11
88 85 84 82 70 52 51 39 16
12 15 16 18 30 48 49 61 84
of
for Selective
Use
of Nonionic
Indications
History of major contrast reaction History of minor contrast reaction Relative renal insufficiency Requested by referring physician or patient
5.
Cardiac
failure
7.
Advanced
and/or
of allergy
Contrast
Percentage
1. 2. 3. 4.
6. History
URORADIOLOGY
Urography
Percentage Indicated
Indications
OF
96 40 51 52 26 22
arrhythmia
or asthma
age
21
8. Diabetes mellitus 9. Blood dyscrasia (myeloma,
14 7
sickle cell anemia)
indicated prostate sonognaphy and biopsy are not performed by radiologists and 7% (four) stated that this procedure is not performed in their department or hospital. Of the four unonadiologists who do not have prostate sonognaphy available, three are in private practice and one is in an academic radiology program. Most respondents (82%, 47) stated that uroradiology interventional procedures are performed pnimarily by unonadiologists on interventional radiologists in their department or hospital, 1 4% (eight) stated that interventional studies are performed by both uronadiologists and nonradiologists, and 4% (two) stated that nonnadiologists have primary responsibility for uroradiology interventional procedures.
Discussion
Our survey reflects agreement and controversy in uronadiology practice. The number of EU procedures performed over the past 5 years has decreased in 61 % of uroradiology practices, which probably reflects the primary use of sonography, CT, and occasionally MR (noted by several uronadiologists)
to evaluate
suspected
renal
lesions
(e.g.,
hematunia,
renal obstruction, azotemia). Our survey shows that certain responding uroradiologists believe that EU is not indicated in their practice for evaluation of urinary tract infection (4%), obstructive uropathy (1 0%), and hematunia (1 1 %). For example, Goldman et al. [1] and Hillman et al. [2] advocate CT as the only study necessary to evaluate gynecologic malignancies for possible urinary tract involvement. Ellenbogen et
PRACTICE
303
al. [3] advocate sonognaphy primarily to detect urinary tract obstruction. Most respondents agree that there is little mdication for EU in the azotemic patient on for hypertensive evaluation. Evidence has accumulated from clinical expenience and prospective studies that hypertensive unognams are not satisfactory for differentiating hypertension due to renal artery stenosis from essential hypertension [4]. There was disagreement on the value of EU in screening renal donors and in preoperative evaluation before colorectal surgery. Fifty-two percent of respondents stated EU was appropriate for screening renal donors, whereas 48% said EU was not indicated. Fifty-one percent of respondents stated EU was indicated for preoperative evaluation of colorectal disease, whereas 49% said EU was not indicated. Conversely, several respondents noted the number of EU procedures performed has remained the same because of the increased number performed before and after ESWL while the other indications have decreased. Written informed consent before injecting IV contrast matenial has been advocated by radiologists [5, 6]; however, the majority in our survey do not obtain written permission. Spring et al. [5] surveyed 902 patients regarding their opinion of informed written consent before contrast procedures. They found 90% would rather receive this information than not receive it; conversely, 1 0% preferred not to receive the infonmation. Limitations in obtaining informed consent were common and included medical emergencies and patients with limited understanding of the risk disclosure. Interestingly, two respondents routinely obtained written permission because of state law requirements. There is disagreement concerning the routine use of nonionic contrast material during EU on CT [7-i 2]. Nonionic contrast material has been advocated for routine use because of probable decrease in adverse reactions; however, only 1 0% (six respondents) routinely use nonionic contrast matenial for EU, whereas 90% (51) do not do so. Earlier studies [1 2-1 4] were conflicting and provided no clean guidance. However, recent studies from Japan and Australia [1 5, 16] have indicated nonionic contrast material provided a safety margin of 6:1 when compared with ionic contrast material. We did not survey unoradiologists regarding their reasons for routine use of ionic contrast material as opposed to nonionic contrast material. Most current literature suggests the routine use of nonionic contrast material may be financially prohibitive [5, 1 3, 1 4, 1 7, 1 8]. Indications for selective use of nonionic contrast material (by those uronadiologists who routinely use ionic contrast material) included history of major and minor reactions to contrast materials, relative renal insufficiency, and request by physician on patient (Table 2). Recent studies were unable to show a difference in the incidence of nephrotoxicity between patients receiving a nonionic contrast agent and those receiving an ionic contrast agent [1 9, 20]. The majority of radiologists use a bolus injection with a hand-held syringe, which is performed by either a physician or trained technologist. Only a small percentage routinely use drip infusion or bolus followed by drip infusion. Investigations also have supported bolus injection for EU [20, 21]. Two respondents use bolus injection in patients less than 40 years old and drip infusion in those more than 40 years old.
BARLOON
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304
There is general agreement on the amount of radiographic contrast material for IV injection. Davidson [22] has noted that the diagnostic quality of EU depends on the level of contrast agent present in the plasma and available to the kidney for excretion. Of the responding uronadiologists, 90% used 20-40 g of iodine for IV injection. These amounts are supported by studies showing maximal benefit at these 1evels in adults of standard weight and normal renal function
[22, 23]. The survey suggests that primary responsibility for renal stone lithotnipsy is under the guidance of nonnadiologists. This parallels our experience and that of others [24, 25]. However, most uroradiologists in our survey continue to perform interventional unonadiology procedures. The number and complexity of interventional procedures probably have increased with the advent of ESWL [26, 27]. Although several reviews [28, 29] have been published on tnansrectal sonography with biopsy in prostate cancer screening and staging, its exact role remains to be clarified. Among responding uroradiologists, 39% (22) perform tnansnectal sonognaphy with biopsy and 39% (22) perform the procedure in cooperation with unologists. Ten respondents stated that tnansnectal sonography with biopsy is performed by nonnadiologists in their institutions, whereas four respondents stated that the procedure is not performed in their institutions. In summary, our survey of uronadiologists reflects areas of agreement and controversy. Sixty-one percent of responding unonadiologists noted a decreased use of EU, probably because of an increased use of sonography and CT. Ninety percent of our sample routinely use ionic contrast material and selectively use nonionic contrast material for limited mdications. Reports from Japan and Australia will probably reverse this trend in the next 2-3 years. The most common method of IV contrast material injection is the hand-held bolus technique performed by a physician on trained technologist. Most respondents use 20-40 g of contrast material for IV injection. Interventional uroradiology procedures mostly remain the primary responsibility of radiologists. Prostate sonognaphy with biopsy also is performed either by the uroradiologist or together with the urologist. However, at those institutions with ESWL available, the nonradiologist has the primary nesponsibility.
ACKNOWLEDGMENTS
The authors their
Phyllis
participation,
Bergman
thank
the members Patricia
for editorial
Osborn
of The Society for
secretarial
of Uroradiology assistance,
for and
assistance.
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the
