GENITOURINARY SYSTEM SCINTIGRAPHY

1.

RENAL IMAGING - GENERAL

a. Assessment of 4 renal functions: 1) Blood Flow
2) Glomerular Filtration 3) Tubular Function 4)
Excretory System Function
b. Blood Flow Studies
i. Tc-99 DTPA, Tc-99 MAG, Tc-99 MBq,Tc-99
GH
c. Glomerular Filtration (Passive Process)
i. Passing through glomerular membrane
and into Bowman Space
ii. DTPA small enough to pass and not
reabsorbed
1. Lack of protein binding causes
increase extravascular
distribution and lowers targetto-background noise (MAG and
DMSA has higher)
2. Can accurately measure GFR
3. Pressure changes pre or postglomerulus causes a decreases
GFR and therefore lowers the
amount of radiotracer.
4. Glomerulonephritis disrupt
the permeability and
therefores lowers GFR
iii. GH glucose analog
1. 90% goes into urine
2. 10% retained by PCT allowing
for cortical imaging
d. Tubular Secretion (Active Process)
i. Past I-131 was used, but high rad dose
and inferior spatial resolution
ii. MAG
1. 5% glomerular
2. 55% tubular extraction
3. High protein brinding limits
extravascular distribution and
high target-to-background
ratio
4. Due to high clearance agent
of choice for imaging over
DTPA
e. Cortical Imagaing
i. DMSA
1. Cortical agent of choice due to
high cortical binding
ii. GH can also be used
f.
Collecting System and Ureters
i. DTPA, GH and MAG
1. MAG has highest extraction
ratio and least background
interference
g. Miscellanous
i. Gallium-67 for infectious or neoplastic
processes
ii. Indium-111-WBCs
1. More specific for inflammatory
and acute infectious
processes.
iii. Tc-99m04 scrotal imaging
1. Give K-perchlorate to block
thyroid uptake.
h. Imaging
i. Flow Phase (First minute after injection)
1. DTPA/GH - only 20% seen on
1st pass
2. MAG - 60% on first-pass
extraction
3. areas of HTN and
hypoperfusion are noted and
correlated to delay images
ii. Cortical Phase (3-4 minutes after
injection)

1.

i.

2.

RENAL
a.

b.

c.

d.

e.

ROI are calculated in both

kidneys - check to make sure
only the kidneys are sampled
2. Differential function is
obtained on 4 hour delayed
static images (GH/DMSA)
(normal 45-55%)
iii. Excretory Phase (T 10 min & 2030min in RF pts)
1. Time of radiotracer arrival to
the renal pelvis should be
noted
2. prolonged or diminished
cortical retention should be
noted
3. T 1/2 should be <10min
a. poor renal function
20-30 minutes is
acceptable
4. Residual cortical activity =
ratio of 20minutes to
maximum intensity
a. Normal <0.3
Absolute Function Quantitation
i. DTPA or MAG --> best for assessing rate
of disappearance from the blood and
appearance in cortex or in the urine
IMAGING INTERPRETATION/APPLICATIONS
Mass Lesions
i. Cystic lesion vs hydronephrosis: Hydro
will contain radiotracer and cystic lesion
will NOT
ii. Masses will not accumulate Tc
radiopharmaceuticals
Acute Renal Failure
i. Renal perfusion/flow study: assess
perfusion of kidneys
ii. Renal vein thrombosis: decreased
perfusion with enlarged kidney with
prolonged corticalradiotracer retention
iii. ATN and High Grade Obstruction
1. Arterial flow is maintained
2. GFR drops to ZERO
therefore DTPA will show no
uptake
3. MAG uptake continues as
long as cells are viable
Renal Transplantation
i. Doppler and Bx are first for imaging
ii. Imaging for ATN vs transplant rejection
vs. post-transplant complications
iii. See loss of perfusion and function
iv. Urinomas have tracer, lymphoceles do
not
v. ATN first week
vi. Acute Rejection: 2nd -4th week
vii. Cyclosporine toxicity check history
Renovascular Hypertension
i. Nuclear is not sensitive or specific for
RAS
ii. Increase the sens/specs by using ACE-I
with study
iii. Afferent arteriole is constricted
renin constriction of efferent to
maintain GFR
1. ACE-I to normal pt no change
2. ACE-I to RAS pt prolonged
cortical retention and washout
(MAG)
Urinary Tract Obstruction
i. DTPA and MAG rapidly cleared BEST

ii.

iii.

f.

3.

4.

Obstruction cause post-glomerular

(Bowmans) pressure rises decrease
in GFR
1. Glomerular damaged first then
tubules
MAG/DTPA show delayed drainage BUT
this is seen with RF pts therefore give
LASIX
1. RF pts tracer leaves
2. Obstruction lacks
disappearance of radiotracer
a. T >20 min =
obstruction
b. Normal T <15
minutes

Infection
i. DMSA/GH most sensitive
pyelonephritis
ii. Acute Pyelo: Decreased uptake focal or
diffuse
iii. Chronic Pyelo: scarring results in
contour abnormalities with foci of low
uptake
iv. Ga-67 or In-111 WBC - detect infection
g. Ureteral Reflux
i. Most sensitive over any other method
ii. Slowly fill bladder and report volume
when reflux is seen
TESTICULAR IMAGING
a. Overtaken by US
b. Very good for detection of torsion
i. Central hypovascular defect
ii. Delayed Images: hyper vascular rim
around torsed testi indicated loss of
viability
1. Rim also seen in abscess/
hematoma
c. Epidimyitis and epidisymoorchitis increase
flow
PROSTAT CANCER IMAGING
a. Treatment depends on if pt has local disease or
mets
b. In-111 capromab pendetide (MBq)
i. Monoclonal Ab for cell membrane of
cancer cells
ii. Sens/Specs 75%