Nuclear Medicine Applications in

the Genitourinary System

Lecture 1
By
Saima Munir

1
 Synthesis
Renin, erythropoietin, & calcitriol

Regulation
• Electrolytes (Cations & Anions).
• Water volume.
• Plasma Osmolality (Osmolarity).
Blood • Blood pressure.
• Acid base.
Urine
Excretes
Urea, Uric acid, Creatinine, Acids & Bases
Hormones (and their metabolites)
Any excess of Intake
Drugs & foreign substances.
2
Indications – Renal Radionuclide Studies
• Renal perfusion and function

• Obstruction (Lasix renal scan)

• Renovascular HTN (Captopril renal scan)

• Infection (renal morphology scan)

• Pre-surgical quantitation (nephrectomy)

• Renal transplant

• Congenital anomalies, masses

3
 Renal Radiotracers

GF TS TF
Tc-99m DTPA >95%
Tc-99m MAG3 <5% 95%
I-131 OIH 20% 80%
Tc-99m GHA 40%-60% 20%
Tc-99m DMSA some 60%

DMSA = Dimercaptosuccinic Acid

OIH = Orthoidohippurate
MAG3 = Mercaptoacetyltriglycine
DTPA = Diethylenetriamine Pentaacetic Acid
GH = Glucoheptonate
4
Semin NM Apr.92
 Renal Radionuclide Studies
Dynamic Studies
Flow + Function + Drainage

– 99mTc DTPA (filtered)

– 99mTc MAG3 (secreted, better quality images than DTPA)

Static studies ( Renal Cortex)

- 99mTc DMSA (fixed in the tubules)

Combine (Dy & Stat)

– 99mTc Glucoheptonate (filtered and fixed)
5
 Dynamic Renal Studies
Indications
• Urinary outflow obstruction

• Work up of renovascular hypertension

• Acute renal failure after surgery, trauma, shock

• Abnormality on ultrasound or CT especially in

pediatrics

• Evaluation of the renal transplant

6
 Patient Preparation
• Hydration
 5-10 ml/kg water (2-4 cups) 30-60 min. pre-
injection

• Catheterize (reflux, urgency etc)

• IV line & saline drip if Captopril renogram

• Void before injection and at end of study

Int’l Consens. Comm. Semin NM ‘99:146-159

7
 Procedure
• RP: MAG3, DTPA

• Dose: 2 - 5 mCi adult, peads: Webster rule or

minimum 0.5 mCi

• Supine position, Include bladder, heart

• LEAP Collimator

• RPh injected as iv bolus

Int’l Consens. Comm. Semin NM ‘99:146-159

8
 Acquisition

• Flow : 2-3 sec / fr x 1 min

• Dynamic: 15-30 sec / frame x 20-30 min

• Post-void: 2-5 min static image

• Image over injection site

9
 The Renogram

• The computer adds up

the radioactivity in
each kidney

• This can be shown as

a graph of activity
versus time –
“Time Activity curve”
 T1/2
• Time required for 50% tracer to leave
the dilated unit i.e. time required for activity
to fall to 50% of peak

11
 Relative uptake
Contribution of each kidney to the total
function

net cts in Lt ROI

% Lt kid =-----------------------------x 100%
net cts Lt + net cts Rt ROI

Normal 50/50 - 55/45

Abnormal > 60/40

Taylor, SeminNM Apr 99
12
Nuclear Medicine Applications in
the Genitourinary System

Lecture 2
By
Saima Munir

13
 Renal Dynamic Studies
Interventions
The Diuretic renogram
(with Lasix)

The Captopril renogram

(ACE inhibitor)

14
 The Diuretic Renogram
 To evaluate drainage in a dilated
collecting system and to exclude urinary
obstruction

 increase urinary output and pressure in

the collecting system by a diuretic
(furosemide)

 images and curves indicating stasis or

obstruction
15
 Technique

 Initial computer set-up to include diuretic

study

 Inject 40 mg (0.5 mg /kg ,Peads 1 mg/kg)

Lasix (Furosemide) iv and continue slow
dynamic for 30 min in the same position

 F - 0, F -15, F +15

 Post-void image may be useful

16
F +15

17
 T1/2 Washout
cts•
100% • T1/2 of clearance:
– < 10 min: Nl
– > 10 min but < 20 min
equivocal
50% – > 20 min obstructed

T1/2 min
•
The captopril renogram

(ACE inhibitor)

20
 Renal Artery Stenosis
• Captopril study is indicated for evaluation of renal
artery stenosis

• RAS is the narrowing of the renal artery --impede

blood flow to the target kidney

• Most often caused by atherosclerosis or

fibromuscular dysplasia

• Mediated by renin - Angiotensi - aldosterone

system

• Potentially curable by renal revascularization

21
 Clinical Findings- RAS

• <1% unselected population with HTN

• 20-30% develop RVH
• Abrupt onset HTN in child, adult < 30 or > 50y
• Severe HTN resistant to medical Rx
• Unexplained or post-ACEI impairment in renal function
22
23
25
 ACEI (Captopril) Renography
 It is a safe and noninvasive way to evaluate renal
blood flow and excretory function

 Sensitivity of this test is about 85-90% and

specificity of 93-98%

 Angiotensin-converting-enzyme inhibitor) is
a pharmaceutical drug used

 Tc99-DTPA, Tc99-MAG or I131-hippurate

 Either a slowing of the excretion of Tc99-DTPA or

a reduction of the uptake of the Tc99-MAG 3
Effect of ACEI(Captopril) on Renin-
Angiotensin System
RAS
Angiotensinogen (Liver)
Renin (kidney)
Angiotensin I Captopril
Lung ACE
Angiotensin II (vasoactive)

Aldosterone Vasoconstriction

HTN Maintain GFR

27
 ACEI (Captopril) Renography
Patient Preparation
• off ACEI & Angiotensin II receptor blockers x 3-7
days
• Off Calcium channel blockers
• Off diuretics x 5-7d
• No solid food x 4 hrs, Patient well hydrated
• ACEI
– Captopril 25-50 mg po (crushed), 1 hr pre-scan
– Enalaprilat 40 µg/kg iv (2.5 mg max), 15 min pre-scan
– Monitor BP every 15 min

28
 Procedure
• 1 day vs. 2 day test
• Flow & dynamic x 20-30 min.

 1 day test:
Baseline scan (1-2 mCi), followed by post-
Captopril scan (5-10 mCi)

 2 day test:
(3-5 mCi) post-Captopril scan, only if abnormal
then perform baseline

*Flow & dynamic x 20-30 min. 29

Nuclear Medicine Applications in the
Genitourinary System

Lecture 3
By
Dr. Naureen Nizar
SIUT
30
 Renal Transplant

• Is associated with as survival benefit for patients

with end stage renal disease (ESRD) when
compared to dialysis
• The preferred therapy for most of the Pts with
ESRD
• More cost- effective; Better survival; Better life
quality

31
 Complications
 Early complications
 Surgical complications—Lymphocele, Urinary leak, arterial
stenosis, vascular occlusion,ureteral obstruction
 Delayed or slow graft function

 Vasomoter Nephropathy
 Hyperacute rejection
 Accelerated acute rejection
 Acute rejection
 Infectious complications
 Malignancy
 Chronic allograft dysfunction

32
 Renal Scan in Transplanted Kidney
• Both qualitative and quantitative

• Baseline scan Should be done in 1-2 days of

transplant for accurate assessment of problems

• Standard protocol for renal scan

• Camera positioned anteriorly over the pelvis

including renal transplant and bladder in the field of
view
33
 Renogram Evaluation
Immediate (first week) complications:
Acute tubular necrosis (ATN):
• Preserved or only mildly reduced perfusion
• Marked parenchymal retention

Accelerated acute rejection:

• Presents within a few days to a few weeks following
transplantation.

Renal vein thrombosis / Renal artery thrombosis

• Decreased or absent perfusion 34
 Renogram Evaluation…
Early (1-4 weeks) complications:
Acute rejection:
• There is decreased perfusion
• Decrease in function on serial radionuclide
imaging studies

Urine leak or fistula:

• May see excreted radiotracer adjacent to
transplanted kidney

Ureteral obstruction: 35
 Renogram Evaluation…
Late (> 4 weeks) complications:
Renal artery stenosis:
• Decreased perfusion, normal parenchymal
transit, and absent or minimal cortical retention
Lymphocele:
• A large photopenic region may be seen exerting
mass effect on the transplanted kidney.

Chronic rejection:
• Thin cortex and mild hydronephrosis
• Diminished uptake of tracer and normal
parenchymal transit.
36
• Renal Cortical Scintigraphy

(DMSA Scan)

37
 Indications
• Detection of focal renal parenchymal abnormalities

• Assessment of the kidney in the acute phase of a Urinary

Tract Infection (UTI) (Acute pyelonephritis)

• Assessment of the kidney for detection of scarring in the

late phase, 4 to 6 months following a UTI

• Differential renal function estimation – particularly when

kidneys may be lying at different depths eg a low-lying or
malrotated kidney.

38
 Indications…

• Assessment of renal function in the presence of an

abdominal mass

• Detection of residual functioning renal tissue following

direct trauma

• Congenital Anomalies---Agenesis, Ectopy, Fusion

(horseshoe, crossed fused ectopia), Polycystic
kidney, Multicystic dysplastic kidney

39
 99mTc DMSA Scan

• 99mTc DMSA is injected intravenously, it slowly

concentrates in the kidney where it mostly becomes
bound to the proximal tubular cells

• There is a low extraction efficiency by the kidneys,

but 2 or 3 hours following injection there is sufficient
uptake to obtain good images of the functioning renal
cortex with low background

40
 Procedure
Patient preparation
• No specific preparation is required
• If relevant, the date of last UTI should be recorded
and whether the patient is on prophylactic antibiotics

Injection Technique
• Simple intravenous injection

Radiopharmaceutical
• 99m Tc DMSA (dimercaptosuccinic acid). 1-5 mCi iv
(peads 0.04 -0.05 mCi/Kg

41
 Procedure…

Camera

Single or double headed gamma camera

Collimator

• A low energy high resolution (LEHR) collimator is

recommended
• For children an ultra-high resolution (LEUHR) may be
used

42
 Procedure…
Patient Position

• Adults may be imaged supine. The seated or standing

position is also acceptable as long as the patient can
remain still

• Children should be imaged supine with suitable support to

keep movement to a minimum. Very small children may
be placed directly on the collimator surface if the camera
allows this and there is no danger of them falling off

• It is important that the patient should be as close to the

collimator face as possible in order to obtain the best
resolution
43
 Procedure…
Views

• The minimum data set is a posterior view and both

left and right posterior oblique views.

• The anterior view should always be acquired when

there is an ectopic kidney, spinal abnormalities with a
scoliosis or when tumours and / or an abdominal
mass is present

• The anterior view is also useful for calculating relative

function when the kidneys may lie at different depths.
44
 Procedure…
Computer Acquisition
• Static imaging of abdomen & pelvis 2-4 hr Post Injection
(matrix 128*128, 256*256)

• Multiple views: anterior , posterior, oblique (300-500

kcounts)

• SPECT (matrix 128*128, 60-120 frames, 20-40sec/fram)

• Delayed 24hr imaging in severe obstruction

Interventions
• Nil
45
 Procedure…
Data Analysis
• Percent differential renal function (DRF) should be
calculated from the posterior view by drawing regions of
interest (ROI) around each kidney.

• A background ROI should also be drawn in any nearby

non-renal area.

• Counts in the background region are used to subtract

background counts from each kidney ROI

• DRF of each kidney should then be calculated from the

percentage of background subtracted counts in each
kidney
46
 Procedure…
• If an anterior view has also been obtained, background
subtracted kidney counts should also be calculated from this
image

• The geometric mean of the posterior and anterior background

subtracted counts in each kidney should then be calculated.

Geometric Mean Count = √Posterior Count x Anterior Count

• This gives an approximate correction for the fact that kidneys
may lie at different depths, particularly important for ectopic or
malrotated kidneys.

• Displayed results should include all acquired images. Each

image must be labelled to show the projection and with left and
right sides marked.
47
Radionuclide Cystography

48
 Radionuclide Cystogram
• Cystography is a procedure used to visualize the urinary
bladder

• A special imaging test that involves placing radioactive

material into the bladder

• A scanner then detects radioactivity to check bladder and

urinary tract functions

49
 Indications
• Evaluation of children with recurrent UTI
– 30-50% have VUR

• Diagnosis of familial reflux

• Evaluation of vesicoureteral reflux after medical

management and antireflux surgery

• Serial evaluation of bladder dysfunction (e.g.,

neurogenic bladder) for reflux
50
 Vesicoureteral Reflux…
• Primary VUR--Insufficient submucosal length of the
ureter relative to its diameter

• Secondary VUR– distortion of ureterovesical

junction due to raised vesicular pressures

– Anatomical: Posterior urethral valves; urethral or meatal

stenosis.

– Functional: Bladder instability, neurogenic bladder and

non-neurogenic,neurogenic bladder, Urinary tract
infections may cause reflux due to the elevated pressures
associated with inflammation 51
International Classification of Vesicoureteral Reflux

52
 Diagnosis
The following procedures may be used to diagnose
VUR:
– Nuclear cystogram (RNC)
– Fluoroscopic Voiding
– Cystourthrogram (VCUG)
– Ultrasonic Cystography
– Abdominal ultrasound

• VCUG is the method of choice for grading and initial

workup, while RNC is preferred for subsequent
evaluations as there is less exposure to radiation
53
 Radionuclide Cystography
Direct
Catheterization of the
bladder
Instillation of radionuclide
and fluid for maximum
distension of the bladder
Imaging during
filling,voiding, after
voiding
Indirect
I/V injection of the
radiopharmaceutical for
evaluation of renal
function, urine drainage,
and detection of
vesicoureteral reflux
54
 Direct Radionuclide Cystogram

• The examination table is covered with plastic-lined

absorbent paper to contain spilled
radiopharmaceutical and reduce contamination

• Gentle & sterile catheterization by a qualified

individual with application of urethral anesthesia

55
 Direct Radionuclide Cystogram…
 99m Tc-pertechnetate, DTPA, 99m Tc-sulfur colloid
(0.5 -1 mCi)

 The RP can be mixed in a fixed volume of saline or

irrigating solution (250–500 mL)

 The container should be surrounded by lead

shielding and is hung 100 cm above the table

 RP can be injection directly into the catheter, Saline

(10–20 cc) may be introduced first to reduce
exposure to bladder
56
 Direct Radionuclide Cystogram…
Bladder volume=(age in years + 2) x 30 cc

• The end of filling is usually achieved by reaching

the appropriate volume for the patient’s age

• When there is cessation of flow from the bottle of

solution (back-pressure effect) in a nonvoiding
patient

• Patient sitting or semi recumbent, supine

57
 Direct Radionuclide Cystogram…

 Patient spontaneously void

 Dynamic imaging posterior pelvis 30 s/fr

 Imaging: filling phase, void, post-void

 A 30-s anterior pre- and postvoid image can be

obtained for calculation of residual bladder volume.

58
 Indirect Radionuclide Cystogram
• MAG-3, DTPA

• At the end of the renogram

• Camera is vertical, Posterior

• Patient Position: Sitting or standing

• Dynamic Frame rate: Max of 5 sec./frame.

60
 Indirect Radionuclide Cystogram…
• The dynamic acquisition should begin before the
child starts to micturate and be continued until
micturition is complete

• Cematic display with contrast enhancement assists in

the detection of vesicoureteral reflux.

• Curve analysis may demonstrate a sudden increase in

activity in the collecting system and ureter indicative
of vesicoureteral reflux

• The voided volume of urine can be measured

61
 Direct vs Indirect Cystogram
Direct Indirect
• Tc-99m S.C, DTPA • Tc-99m DTPA or Tc-
1mci in 500 ml saline 99m MAG3
• via Foley • i.v.
Advant.
• Done at any age • No catheter
• VUR during filling • info on kidneys

Disadv.
• Catheterization • Need pt cooperation
• Need good renal fct
63
Glomerular Filtration Rate

65
 Glomerular Filtration Rate
• Glomerular filtration rate (GFR) is the clearance, by
the kidney, of a marker in plasma, expressed as the
volume of plasma completely cleared of the marker per
unit time

• Patient’s remain asymptomatic until there has been a

significant decline in GFR

• Can be very accurately measured using “goldstandard”

technique

66
 Glomerular Filtration Rate…
• Fundamental to:
diagnosis of kidney disease

• Monitoring the progression of kidney disease

prognosis
efficacy of treatment
facilitate timing of therapeutic interventions

• Drug dosage
elimination of drugs/drug metabolites by the
kidney
67
The ideal substance to measure GFR would
…
• Be freely filtered at the glomeruli
• Not be bound to plasma proteins
• Not be metabolized
• Be non-toxic
• Be excreted only by the kidneys
• Be neither reabsorbed nor secreted by the renal
tubules
• Be stable in blood and urine
• Be easily measured
68
 Concept of clearance
• Volume of plasma that would have to be filtered
by the glomeruli in one minute to account for
the amount of that substance appearing in the
urine each minute under steady state conditions

• Volume of plasma that contains the amount of

the substance excreted in the urine in one minute
under steady state conditions

69
 Clearance = UxV/Px
• Where,
– Ux = urine concentration of x (mg/dL)
– Px = plasma concentration of x (mg/dL)
– V = urine output (mL/min)

• In a steady state, for a substance handled only be the

kidneys that is neither reabsorbed nor secreted:
Amount filtered = amount excreted

• Thus, the clearance of a substance that is neither

reabsorbed nor secreted is equal to GFR
70
 Methods of GFR Estimation

24 hrs Creatinine
Clearance
Biochemical

Radiopharmaceutical
Plasma Sampling

Renogram

71
 Candidate markers for GFR
Insulin
• Filtered only
• Not made by body; continuous infusion
Creatinine
• An endogenous product of muscle metabolism; near-
constant production
• Filtered, but a bit secreted
Urea
• An endogenous product of protein intake
• Filtered and absorbed; synthesis varies with diet
72
 Radioisotopes
• Used to determine glomerular filtration, renal plasma
flow, and filtration fraction in domestic animals

• Advantages
– Do not require collection of urine
– Not time consuming

• Disadvantages
– Use of radioactivity
– Require special equipment and expertise

73
 Radioisotopes
• Glomerular filtration rate
– 125I-iothalamate

– 51Cr-ethylenediaminetetraaceticacid (EDTA)
– 99mTc-diethylenetriaminepentaacetic acid (DTPA)

• Renal plasma flow

– 131I-iodohippurate
– 3H-tetraethylammonium bromide

74
Introduction

Renogram (Gates method)

The gamma camera uptake method with Tc-99m-
DTPA is simple and less time consuming for the
determination of the GFR

However, its diagnostic accuracy is debated

75
Introduction

Plasma Sample Clearance Method of GFR

Estimation
Single- or two-plasma sample clearance method
( PSC1 or PSC2) chosen as a reference

Proved accurate for quantification of renal

function

 This method, however, is not routinely performed

76
Materials and Methods

Adopted Methodology of the Study

Plasma Sample
24 Hr CC
Clearance method

Tc-99m At 60 min At 180 min

DTPA (I/v)
Pre and
post
CDDP Gates
cycle × 6 method

PSC 1
PSC 2
method

MDRD
CG’s method

Biodex
uptake
system
79
 Data acquisition
• Patient preparation
• RP choice
• Injecting and blood sampling
• Slandered preparation
• Measuring plasma samples and slandered

*Measuring the left over activity

80