How concerned are you about radiation exposure?

Urology Times reached out to four urologists (selected randomly) and asked them each the following question: How concerned are you about radiation exposure?

“Everybody’s worried about radiation overexposure. It’s unfortunate the CT scan provides the best information. For kidney stones, we’ll do ultrasounds and KUBs. X-rays often don’t give us enough information, so we get the CT scan anyway.

I order ultrasounds and x-rays whenever possible, but I follow a lot of patients for microhematuria and abnormal urine cytologies, and they require CAT scans. You need to weigh the pros and cons. CT scans give you in-depth information, but you have to ensure it’s appropriate.

In my practice, we often get IVPs for kidney stones, and a lot of radiologists snicker because it’s a relatively antiquated study and they don’t do them anymore. But it still gives us the information we need without risking that extra radiation.

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If you can get away with doing an upper or lower abdominal scan, it’s a good way to limit radiation, especially for chronic issues. You don’t want to continue those sorts of studies on patients if you know it’s something that needs to be followed for the rest of their life.

I hate to say this, but I come from a family of attorneys and this is a very litigious society. I feel like we’re somewhat painted into a corner in terms of ordering tests because that give us better information. Heaven forbid you miss something and then you’re asked, “Why didn’t you get a CT scan?”

Meredith Perry, DO

Somers Point, NJ

Next: "We have protocols designed to specify what kind of imaging we prefer."

“I’m absolutely concerned. Within our organization, we have protocols designed to specify what kind of imaging we prefer. This is nice because the urologists come together and agree on a protocol. Then we are confident our providers will adhere to it, including our primary care colleagues.

For example, for the workup for asymptomatic microscopic hematuria, we use renal ultrasound to avoid the CT. If there is an abnormality, a CT probably follows the ultrasound. But overall, many of the CT scans can be avoided. A study that originated at Kaiser in Southern California and was presented at the AUA showed that patients with asymptomatic microscopic hematuria can likely avoid CT scan as a primary study for upper tract evaluation. This has drastically changed the number of CT scans we do.

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We also use low-dose radiation protocols for people who have had recent CT scans. If we’re doing scans for specific indications like kidney stones and they’ve recently had a full CT scan for other reasons, we will do low-dose just so we can identify the stone. Radiologists worry they could miss incidental findings so they don’t perform low-dose if the patient has not had another imaging recently. Nowadays we’ll see ultrasounds that are really good, plus with the use of MRI, I think we’ve got a lot of other options so that CT can be avoided in many scenarios.”

Joseph E. Dall'Era, MD

Denver

Next: "[Urologists] have been good stewards for several years on radiation exposure."

We’ve been good stewards for several years on radiation exposure. In urology, the CT scan is our primary diagnostic radiologic tool, but it’s not being overused. Quite the opposite. The best example is stone disease. If somebody has an acute stone episode, we tend to get a CT scan. Otherwise we try to manage our patients with ultrasounds and KUBs, which have little or no radiation exposure.

Another important factor is cooperation between radiologists and urologists like we have in our institution. So when we do a CT urogram, we do a three-phase study: without contrast, a cortical phase honing in on kidneys, and the excretory phase-another full scan from diaphragm to pubis. But now we’re able to do reconstructions with computer programs that have become marvelously sophisticated, without additional radiation.

The second example is cancer. They just rewrote the whole bladder cancer protocol and it’s much more practical. If patients have a low-grade tumor, the chance of having an upper tract tumor or one anywhere else is so low, it’s not worth doing a follow-up CT.

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We used to be very indiscriminate in our use of CTs for fear we were going to miss cancers. We’re now more confident in our ability to decide when we need to get studies.

As urologists, we’re doing many fewer CT scans and being much more judicious about using them. So I say kudos to us because this is a dramatic change.”

Nina Davis, MD

Portland, OR

Next: "People have gotten so worried about using radiation...that they sacrifice diagnostic accuracy."

The short answer is yes. However, put it this way, patients who are most worried are usually those at lowest risk for problems. From a provider standpoint, it’s important to be mindful, but any single study is highly unlikely to be a problem in anyone who is not pregnant and not a child. If you’re looking at a single study, the risk is essentially zero.

The real issue is, the information we have on carcinogenicity from medical radiation exposure is extrapolated from atomic bomb survivors. The biggest takeaway is that over the age of 30, the risk of exposure is substantially less than if you’re under 30. In my practice, I’m very mindful of radiation exposure in younger people. In older people, especially those in their 50s, 60s, and 70s, I honestly don’t pay attention to it.

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The pendulum has swung so far away from CT scans, particularly for kidney stones, people will sacrifice 30% diagnostic accuracy in the name of reducing radiation. Frankly, that does patients a disservice.

The big point I would hammer home is that people have gotten so worried about using radiation when it’s appropriate and of almost no risk to the patients, that they sacrifice diagnostic accuracy. It’s good to be cognizant, but to sacrifice helping diagnose and treat the patient is where it becomes a problem.”

Peter Steinberg, MD

Boston

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