UROLOGY

1. NUCLEAR MEDICINE IN UROLOGY
Dr. Anupam Anand
Urology Dept. NRSMCH

2. Radioisotope
• The terms Radionuclide, Radioisotope, Radio Tracer or
Nuclear Imaging agent all refer to the radioactive
material that is used to make the nuclear medicine
images.
• These substances are molecules that contain radioactive
atoms.
• When those atoms decay, they emit energy in the form
of gamma rays or alpha or beta particles & they are
detected by the nuclear medicine camera

3. History
• Cyclotron invention in 1931 by Lawrence and
Sloan.
• It accelerates charged particles outwards from
the center of a flat cylindrical vacuum chamber
along a spiral path.

4. cyclotron

5. History
• Discovery of fission reaction in 1938 with production of
Iodine-131.
• First used for evaluation of thyroid function with I131.
• Diodrast studied for GU tract in 1950s but disadvantage
was significant hepatic uptake.
• Development of various radiotracers such as 99mTc
labeled to DTPA, DMSA, GHA, MAG3 have further
developed the field.
• Development of SPECT and PET scans are latest in the
field.

6. Scintigraphy
• Scintigraphy (Latin scintilla, spark) is a
diagnostic test used in nuclear medicine,
wherein radioisotopes are taken internally and
the emitted radiation.
• This raditaion activity is captured by external
detector gamma camera to form two-
dimensional images.
• It is not like a X-ray/CT scan where external
radiation is passed through the body to form
an image.
6

7. Emission Imaging
7

8. RADIATION
GENERATOR
DOSE CALIBRATOR
GAMMA CAMERA / SPECT
PETCT
PHARMACEUTICALS

9. Why Radiotracer studies
• Provides useful and often valuable functional information
that is not easily available from other methods.
• Associated with lower absorbed radiation dose and
significantly lower morbidity than with contrast assisted
procedures.
• Scintigraphy does not damage the kidney, has no lingering
toxicity and is free from allergic reactions.
• It is noninvasive, has minimal risk, minimal discomfort, and
allows determination of the function of the kidney.
9

10. Radio isotopes
• They are helpful in diagnostic & management
purpose.
• MC used in urology - compounds labeled with
Tc99m
Ideal agent
• Should contain no particulate radiation.
• Shortest possible half life.
• Should emit a photon in the range of 100-300 keV,
so can be detected by gamma camera..
• Inexpensive.
• Easy to store.
10

11. PHARMACEUTICALS
DTPA :
MAG3 :
EC:
MDP:
DMSA:
FDG:
PSMA :
EDTMP:
MIBG:
DIETHYLENE TRIAMINE PENTAACETIC ACID
MERCAPTOACETYLTRIGLYCINE
ETHYLENE DICYSTINE
METHYLENE DIPHOSPHONATE
DIMERCAPTO SUCCINIC ACID
FLUORODEOXY GLUCOSE
PROSTATE SPECIFIC MEMBRANEANTIGEN
ETHYLENE DIAMINE TETRAMETHYLENE PHOSPHONIC ACID
METAIODO BENZY GUANIDINE
RADIONUCLIDES
99mTc: metastable Tecnetium
18f : radioactive fluorine
177Lu: Lutitium
68 Ga: Gallium
153Sm : Samarium
99mTc generator produced, t1/2 - 6 hrs , E (g)- 143Kev
18f
cyclotron produced, positron t1/2-110min
, energy 511 Kev
177Lu
reactor produced, t1/2 6.7days
Ebeta: 497Kev, Eg- 113, 208 kev.
68 Ga Generator, t/1-68 min, positron E- 630Kev.
153Sm
Reactor produced, t1/2-1.9d, Eb- 810Kev,
Eg- 103Kev

12. Radioisotopes…
12

13. KIDNEY AND URINARY TRACT IMAGING
ADRENAL IMAGING AND TREATMENT
PROSTATE IMAGING AND TREATMENT
SCROTAL, TESTIS , PENIS IMAGING

14. OIH (Orthoiodo Hippurate)
• First described in 1960s.
• Structurally related to PAH (para-amino-
hippurate).
• Tubular secretion – 80%
• Glomerular filtration – 20%.
• Low rate of extra-renal handling (<2%)
• Dose: 0.002-0.004mCi/kg.
• Thyroid uptake can be blocked by Lugol’s
iodine.
• Expensive when compared to other
radiotracers.
14

15. 99mTc-DTPA
• Technetium 99m-diethylene triamine pentaacetic
acid (99mTc-DTPA) is primarily a glomerular
filtration agent .
• It is most useful for evaluation of obstruction and
renal function because it is excreted through the
kidney and dependent on glomerular filtration rate
(GFR).
• It is less useful in patients with renal failure because
impaired GFR may limit adequate evaluation
of the collecting system and ureters.
• T1/2 = <12 min
• It is readily available and relatively inexpensive.
15

16. 99mTc-MAG3
• Technetium 99m-mercaptoacetyl triglycine (99mTc-
MAG3) cleared mainly by tubular secretion.
• A small amount, approximately 10%, of MAG3 is
excreted by extrarenal , mostly by hepatobiliary
excretion.
• T1/2 = 6 hrs
• Because it is extensively bound to protein in plasma,
it is limited in its ability to measure GFR but is
an excellent choice for patients with renal
insufficiency and urinary obstruction.
16

17. 99mTc-Ethylene dicysteine
• Similar to MAG property (tubular secretion)
• Can be labeled at room temp
17

18. 99mTc-DMSA
• Technetium 99m-dimercaptosuccinic acid (99mTc-
DMSA) is cleared by both filtration and
secretion.
• 99mTc-DMSA localizes to the renal cortex with
little accumulation in the renal papilla and medulla.
• Therefore it is most useful for identifying cortical
defects and ectopic or aberrant kidneys.
• 99mTc-DMSA can distinguish a benign functioning
abnormality in the kidney from a space-occupying
malignant lesion, which would not have normal
renal function.
18

19. Radionuclides
• Three basic classes of radionuclide for kidney
function & structure:
▫ Filtered agents : DTPA and MAG3
▫ Excreted agents : MAG3 and Hippuran,EC2
▫ Cortical imaging agents : DMSA and
Glucoheptonate
19

20. Filtered Radionuclides
• DTPA ,MAG3 are filtered through the glomerulus.
This is useful in evaluating:
▫ Perfusion
 Vascular supply
▫ Filtration
 Measuring renal function (GFR)
▫ Drainage
 Detects obstruction
20

21. Excreted Radionuclides
• MAG3 and Hippuran, EC2 are excreted by the renal
tubules. These radionuclides are helpful in
evaluating patients with:
▫ Diminished renal function
▫ Kidney transplants
21

22. Cortical Imaging Radionuclides
• DMSA and Glucoheptonate are accumulated in the
cortex so they are helpful in evaluating:
▫ Renal scarring from chronic
infection
▫ Infarction
▫ Renal mass
▫ Differential renal mass
22

23. KIDNEY AND URINARY TRACT IMAGING
ONLY KIDNEY IMAGING
DMSA RENAL SCAN .
UPPER URINARY TRACT IMAGING :
(RENAL ARTERY, KIDNEY AND URETER)
DTPA / EC / MAG3 RENOGRAM .
LOWER URINARY TRACT IMAGING:
(URETER AND BLADDER- REFLUX)
DRCG .

24. 99mTc DMSA SCAN PARAMETERS
1) SIZE, SHAPE, POSITION
2) DIFFERENTIAL FUNCTION
3) CORTICAL DEFECTS
CORTICAL BINDING TRACER
TIME GAP B/W INJECTION
AND SCANING- 3 HRS
DIFFERENTIAL FUNCTION
ESTIMATION IS MORE
ACCURATE.
GFR AND DRAINAGE CANNOT
BE ESTIMATED .

25. 99m Tc DMSA
25
99mTc-DMSA scan
shows a focal wedge-shaped abnormality in
the
upper pole of the left kidney consistent with
Acute
Pyelonephritis

26. HYDRONEPHROTIC KIDNEY PYELONEPHRITIC KIDNEYS
SCARRED KIDNEYS NONFUNCTIONING LEFT KIDNEY

27. RENOGRAM:
1)PERFUSION (MORE
IMPORTANT IN
RAS/RHTN,
TRANSPLANT KIDNEY)
2)SPLIT FUNCTION,
3) GFR
4)DRAINAGE CURVE.
PERFUSION
SPLIT RENAL FUNCTION
CURVE

29. MAG 3 EC DTPA
FUNCTION TUBULAR
GLOMERULAR
1)VISUALIZE KIDNEY WHEN LESS / NO
GLOMERULAR FILTRATION
(ATN, TOTAL OB, RENAL TOXICITY)
+++ --
2) VISUALIZE FOCAL LESIONS +++ +
3) NEONATES / INFANTS STRONGLY +++ +
4) EXTRACTION EFFICIENCY
5) BACKGROUND CLEARNCE
60%
FAST
(70 %)
FAST
20 %
SLOW
6) PARENCHYMAL EVALUATION ++++ ++
7) DRAINAGE ESTIMATION
8) CURVE
9) RADIATION EXPOSURE(TARGET
ORGANS AND PELVIC ORGANS)
10) EARLY POST OP ASSESSMENT
++ +
STEEP BLUNT
LESS MORE
++ (tubular recovery
early
+/-

30. DTPA scan
• FLOW PHASE
 2 sec images for 2 mins then 1 sec images foer 60 sec
 Shows renal uptake, background clearance and vascular
anomalies(active bleeding, Avm)
• RENAL PHASE- 2-4 mins
 1 min images for 30 mins. Most sensitive of renal dysfunction.
• EXCRETORY PHASE-
 1 min images for 30 mins
 A diuretic(furosemide- 0.5mg/kg) given when max collecting system
activity visualised. Highly technician dependant.

31. DTPA scan
• T ½- ( collecting system activity decreased by 50%)
 Less than 10 mins- unobstructed
 10 to 20 min- mild to mod delay, may be mechanical obs
 More than20 min- high grade obstruction.
 if DJ stenting is in situ, then tests must be done with an unclamped
catheter.
 Hepatobiliary images should be exluded while analysis.

32. RCC HYDRONEPHROTIC OBSTRUCTED

33. HN NONOBSTRUCTED
NONFUNCTIONING

34. ECTOPIC KIDNEY

36. 1, 3a - NO
SURGEY
REQUIRED
REST ALL
REQUIRE
SUREGRY

37. DTPA EC /MAG3 DMSA
1) RENAL PERFUSION +++ +++ -------
2) SPLIT RENAL FUNCTION +++ ++++ +++++++
3) INTRA RENAL TRANSIT TIME +++ ++++ -----------
4) PELVICALYCEAL DRAINAGE +++ +++ ------------
5) BLADDER +/- +/- --------
6) PYELONEPHRITIS ------ +/- +++++++
7) SCARRING +/- +/- +++++++++
8) OTHER CORTICAL DEFECTS +/- ++/- ++++++++++
9) EARLY POST OPERATIVE +++ +++++++ +++
(TUBULAR RECOVERY)
10) LATE POST OPERATIVE
(GFR ESTIMATION)
+++++++++ ++++ +++/-
11) NEONATES AND INFANTS +++ +++++++++++ ++++++
12) RENAL TRANSPLANT ++++++ ++++ ++/-
13) RAS / R HTN (GLOMERULUS) ++++++ +/- +/-
14) ECTOPIC KIDNEYS +++ +++ +++
15) RENAL CALCULI ++ ++ +++++++
16) RENAL TUMOURS +++(GFR ) +/- +++(FUNC)

38. DRCG (DIRECT RADIONUCLIDE
CYSTOGRAM
TO DETECT REFLUX.
MCUG IS MOSTLY PREFERRED THAN DRCG IN
REGULAR PRACTICE.
FILLING BLADDER WITH DTPA AND ACQUIRING
THE SCAN.
GRADING DONE DEPENDING ON THE
VISUALIZATION OF URINARYTRACT.

40. ADRENAL
123 /131 I- MIBG SCAN :
1)FOR HYPERSECRETING PHEOCHROMOCYTOMS > ADENOMAS.
2) NOREPINEPHRINE ANALOG
3) DOSE - 0.5-1 mCi I.V., SCAN AT 24,48/72 HRS.
131 I NORCHOLESTEROL: FOR ADENOMAS (NOT ROUTINELY USED).
18F FDG PETCT
CARCINOMA >> ADENOMA. ADRENAL METASTASES EVALUATION.
CORTISOL SECRETING ADENOMAS >> NONFUNCTIONING ADENOMS.
PHEOCHROMOCYTOMAS VS ADENOMAS RELATIVELY DIFFICULT.
BETTER THAN CECT.
123 /131 I- MIBG THERAPY:
100-150mCi DOSE AS MANY TIMES NOT EXCEEDING 1 Ci IN LIFE TIME.

41. MIBG
• Metaiodobenzylguanidine (MIBG)
scintigraphy
• Using 123I or 131I
• Detection of ectopic
pheochromocytomas- gold standard
• Metastatic or locally recurrent disease
• Focal areas of increased MIBG activity
• Sensitivity less than 90%
• Specificity exceeds 90% if correlated
with CT or MRI
41

42. PROSTATE:
SCINTIGRA
PHY
PETCT THERAPY
99mTcMDP BONE 18F FDG 177Lu PSMA
SCAN 68Ga PSMA 177Lu EDTMP
11C CHOLINE
18f CHOLINE
153 Sm EDTMP
18f FLUCICLOVINE
18f Na f BONE SCAN

43. Radiotracers for Prostate cancer imaging
43

44. BONE SCAN
1)99mtc MDP injected iv and scan done after 3 hrs.(MDP
gets adsorbed to bone surface)
2) To detect osteoblastic lesions.
3) Sensitivity ~99%, specificity ~65%.
4) False positive lesions:
Infections,
degenerative,
Lytic lesions cannot be detected, fractures
metabolic lesions etc.
5)18f fluorine bone scan : improves specificity, lytic are
better visualized, not routinely done.

46. 68 Ga PSMA < PET-CT > 18f FDG
1) PRE RADICAL PROSTATECTOMY
2) BEFORE BIOPSY
3) PROSTITIS /BPH /CA
4)BIOCHEMICAL RECURRENCE
(LOW PSA 1-2 ng /ml)
5) METASTASES EVALUATION
1) AGGRESSIVE TUMOURS
GLEASON >7
2) CASTRATION RESISTANT
EXTENSIVE DISEASE
3) NOT USED FOR
INDOLENT TUMOURS
4) METASTASES
EV
ALUATION
5) MONITORING RESPONSE
PSMA EXPRESSION GLUT RECEPTOR

47. CT PET PETCT CT PET BONE SCAN
FDG FDG FDG

48. Palliation of bone pain in cancer patients
• Radiopharmaceutics - available for reduction of
metastatic bone pain
• Duration of response - few weeks to a few months
Radiopharmaceutics are commercially available (beta
emitters)
• Sodium phosphate (32P)
• Strontium-89 chloride (89sr)
• Samarium-153 (153sm).
Now alpha emitters – radium 223 improve bone pain with
improve overall survival
48

49. Sodium phosphate (32P)
• Since the 1950s
• Radioactive phosphate is incorporated into
hydroxyapatite
• Good response rates, 60% to 85%
• Advantages of 32P
1. Oral
2. Does not have to be sterile or completely free of
pyrogens
3. Low expense
49

50. Strontium-89 chloride
• Silberstein and colleagues
• Overall response rate of 25-65%
• Half life 4-5 days
• Beta emitter
• Retention is longer , lead to myelotoxicity
• Amount of response directly proportional to the
administered dose
• Use: castration resistent prostate cancer bone
pain
50

51. Samarium-153-
ethylenediaminetetramethylenephosphon
ate
• Binds hydroxyapatite
• Response rates of 55% to 80%
• Half life 2 days
• No additional effects demonstrated at higher doses
• Primary adverse reaction - myelotoxicity
• Fatalities if using both 89sr and 153sm
• Result of severe thrombocytopenia
• Initial 48 to 72 hour increase in pain- ‘‘flare
phenomenon,’’
• Associated with a therapeutic palliative response.
51

52. TREATMENT FOR PROSTATE CA
177Lu PSMA:
1)Castration resistation prostate cancers.
2)68Ga PSMApet avid cancers are eligible.
3)beta therapy (peptide therapy).
4)Treats primary and metastatic prostatic cancer
5)Good treatment response noted till now.
6)177Lu is used as better energy and short tissue penetration.
7) 150-200mci given i.V. in a cycle, max 5-6 cycles not
exceeding 1 ci.

53. 177Lu EDTMP AND 153 SM EDTMP
BONE PAIN PALLIATION THERAPY
Edtmp gets adsorbed in bone metastases.
Beta therapy. High energy , short tissue
Penetration. Given i.V.
Bone metastases well distinguised on MDP bone scan are
eligible for therapy.

54. PROSTATE CANCER TREATMENT ELIGIBILITY
FOR LU PSMA THERAPY
NOT ELIGIBLE
ELIGIBLE

55. URO-ONCO OTHER THAN PROSTATE:
RCC:
BLADDER CANCER:
TESTICULAR
TUMOURS:
PENIS CANCERS:
MDP BONE SCAN
SKELETAL
METASTASES
DTPA
FUNCTION AND
DRAINAGE
DMSA SPLIT FUNCTION
FDG PETCT
STAGING ,
METASTASES
EVALUATION,
RECURRENCE

56. RCC
1) DTPA FOR SPLIT FUNCTION AND DRAINAGE.
2) DMSA FOR SPLIT FUNCTION
3) BONE SCAN (18F Na F > 99mTcMDP) LYTIC >BLASTIC.
4) 18f FDG PETCT- RESTAGING > STAGING,
(HIGHEST SENSITIVITY FOR PAPILARY II RCC)
ROUTINELY USED FOR EXTRA RENAL METASTATIC
WORK UP ALONG WITH BONE SCAN, TKI EFFICACY.
BLADDER CANCER
1)DTPA /DMSA (FOR RENAL FUNCTION IF CAUSING
SECONDARY HN).
2) MDP / 18F BONE SCAN FOR METASTASES WORK UP.
3)MRI >> FDG PET IN STAGING AND RECURRENCE
(PHYSIOLOGICAL UPTAKE)
TESTICULAR TUMOURS
1)FDG PET : SEMINOMAS . STAGING AND RESTAGING.
(NOT INDICATED IN NONSEMINOMAS, <1 CM SEMINOMA)
DETECTION OF VIABLE RESIDUAL TISSUE.
DIFFERENTIATES FIBROSIS FROM VIABLE RESIDUAL
MASS. (BEST BEFORE 6 WEEKS POST CTx)
2) BONE SCAN: FOR SKELETAL METASTASES.
CARCINOMA PENIS 1)FDG PETCT : STAGING (SCC), METASTASES WORK UP.
2)BONE SCAN: SKELETAL METASTASES EVALUATION.

57. Kidney cancer
• 18F- FDG PET
Highest sensitivity for papillary RCC type II
with metastasis.
• 124I – girentuximab
target Carbonic anhydrase IX (CAIX)
CAIX universally expressed by clear cell RCC
• 99mTc – sestamibi
Bind with high mitochondrial content
Bening oncocytoma, parathyroid adenoma
57

58. 58
Differentiation of a localized clear cell RCC (A to C) from a benign renal
oncocytoma (D to F) using 99mTc-sestamibi SPECT/CT.
(A) CECT -heterogeneous mass in the left kidney . (B)Axial 99mTc-sestamibi
SPECT (C) axial 99mTc-sestamibi SPECT/ CT - NO radiotracer uptake. On HPE
resected mass - clear cell RCC.
(D) CECT - left-sided heterogeneous renal mass (E)Axial 99mTc-sestamibi SPECT
.(F) axial 99mTc-sestamibi SPECT/CT - show intrinsic/highest radiotracer uptake,
in those parts of the mass (red arrowheads). On HPE resected renal mass biopsy

60. IMAGING EARLY
TORSION
LATE
TORSION
TORSION
OF
APPENDAGES
ABSCESS EPIDYDIMITIS EPIDYDIMO-
ORCHITIS
FLOW COLD HOT COLD HOT HOT HOT
DELAYED COLD COLD COLD COLD CRESENT
HOT
HOT

61. EPIDIDYMOORCHITIS TESTICULAR TORSION

62. Male infertility
• Penile scintigraphy
• By using RBC labeled Tc99m.
• To evaluation of penile blood flow for erectile
dysfunction
• Radiological evaluation of priapism
62

63. THANK YOU