Pediatric Radiation Exposure and Effective Dose Reduction during Voiding Cystourethrography

Purpose: To compare radiation exposure and effective dose in children who underwent voiding cystourethrography (VCUG) performed with grid-controlled variable-rate pulsed fluoroscopy (GCPFL) with radiation exposure and effective dose in children who underwent VCUG performed with continuous fluoroscopy (CFL) and to compare these effective doses with those estimated with radionuclide cystography (RNC).

Materials and Methods: Institutional review board approval was obtained, and the informed consent requirement was waived for this HIPAA-compliant retrospective study. Radiation exposure and fluoroscopy time during VCUG were reviewed in 145 children (75 girls, 70 boys; age range, 3 days to 8 years) who underwent GCPFL or CFL between 2001 and 2002. Children were grouped on the basis of the fluoroscopy unit used and their supine anteroposterior abdominal diameter (group 1, 8.0–8.5-cm diameter; group 2, 10–11-cm diameter; group 3, 12–13-cm diameter). Analysis of variance was used to compare radiation exposure and fluoroscopy time between fluoroscopy units and patient diameter groups. Effective doses were calculated and compared for both fluoroscopes and for estimated RNC dose values.

Results: GCPFL resulted in a significant reduction in total radiation exposure, which was at least eight times lower than that with CFL in all three groups (P < .001 for all). There was no significant difference in fluoroscopy time (P > .50). Effective radiation doses from GCPFL were approximately one order of magnitude lower than those from CFL but one order of magnitude higher than those from RNC.

Conclusion: In children, VCUG can be performed with a GCPFL unit that delivers radiation exposures that are at least eight times lower than those delivered by a conventional CFL unit.

Supplemental material:

© RSNA, 2008


  • 1 Siegel MJ, Schmidt B, Bradley D, Suess C, Hildebolt C. Radiation dose and image quality in pediatric CT: effect of technical factors and phantom size and shape. Radiology 2004; 233: 515–522. LinkGoogle Scholar
  • 2 Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001; 176: 289–296. Crossref, MedlineGoogle Scholar
  • 3 Boone JM, Geraghty EM, Seibert JA, Wootton-Gorges SL. Dose reduction in pediatric CT: a rational approach. Radiology 2003; 228: 352–360. LinkGoogle Scholar
  • 4 Frush DP. Strategies of dose reduction. Pediatr Radiol 2002; 32: 293–297. Crossref, MedlineGoogle Scholar
  • 5 Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 2003; 112: 951–957. Crossref, MedlineGoogle Scholar
  • 6 Donnelly LF, Emery KH, Brody AS, et al. Minimizing radiation dose for pediatric body applications of single-detector helical CT: strategies at a large children's hospital. AJR Am J Roentgenol 2001; 176: 303–306. Crossref, MedlineGoogle Scholar
  • 7 Pages J, Buls N, Osteaux M. CT doses in children: a multicentre study. Br J Radiol 2003; 76: 803–811. Crossref, MedlineGoogle Scholar
  • 8 Paterson A, Frush DP, Donnelly LF. Helical CT of the body: are settings adjusted for pediatric patients? AJR Am J Roentgenol 2001; 176: 297–301. Crossref, MedlineGoogle Scholar
  • 9 Archer BR. Radiation management and credentialing of fluoroscopy users. Pediatr Radiol 2006; 36(suppl 14): 182–184. Crossref, MedlineGoogle Scholar
  • 10 Connolly B, Racadio J, Towbin R. Practice of ALARA in the pediatric interventional suite. Pediatr Radiol 2006; 36(suppl 14): 163–167. Crossref, MedlineGoogle Scholar
  • 11 Justino H. The ALARA concept in pediatric cardiac catheterization: techniques and tactics for managing radiation dose. Pediatr Radiol 2006; 36: 146–153. Crossref, MedlineGoogle Scholar
  • 12 Strauss KJ, Kaste SC. The ALARA (as low as reasonably achievable) concept in pediatric interventional and fluoroscopic imaging: striving to keep radiation doses as low as possible during fluoroscopy of pediatric patients—a white paper executive summary. Pediatr Radiol 2006; 36: 110–112. Crossref, MedlineGoogle Scholar
  • 13 Strauss KJ. Pediatric interventional radiography equipment: safety considerations. Pediatr Radiol 2006; 36: 126–135. CrossrefGoogle Scholar
  • 14 Wagner LK. Minimizing radiation injury and neoplastic effects during pediatric fluoroscopy: what should we know? Pediatr Radiol 2006; 36(suppl 14): 141–145. Crossref, MedlineGoogle Scholar
  • 15 Ward VL. Patient dose reduction during voiding cystourethrography. Pediatr Radiol 2006; 36: 168–172. CrossrefGoogle Scholar
  • 16 Diamond DA, Kleinman PK, Spevak M, Nimkin K, Belanger P, Karellas A. The tailored low dose fluoroscopic voiding cystogram for familial reflux screening. J Urol 1996; 155: 681–682. Crossref, MedlineGoogle Scholar
  • 17 Kleinman PK, Diamond DA, Karellas A, Spevak MR, Nimkin K, Belanger P. Tailored low-dose fluoroscopic voiding cystourethrography for the reevaluation of vesicoureteral reflux in girls. AJR Am J Roentgenol 1994; 162: 1151–1154. Crossref, MedlineGoogle Scholar
  • 18 Lebovic S, Lebowitz R. Reducing patient dose in voiding cystourethrography. Urol Radiol 1980; 2: 103–107. Google Scholar
  • 19 O'Connor SJ, Wirt MD, Ruess L, Sutherland RS, Anderson ML, Patel MG. Image capture vs spot radiographic exposures for the detection and grading of vesicoureteral reflux in children with digital fluoroscopy. In: The Society for Pediatr Radiol 47th Annual Meeting Scientific Session. Savannah, Ga: Springer-Verlag, 2004; S50. Google Scholar
  • 20 Cleveland RH, Constantinou C, Blickman JG, Jaramillo D, Webster E. Voiding cystourethrography in children: value of digital fluoroscopy in reducing radiation dose. AJR Am J Roentgenol 1992; 158: 137–142. Crossref, MedlineGoogle Scholar
  • 21 Persliden J, Helmrot E, Hjort P, Resjo M. Dose and image quality in the comparison of analogue and digital techniques in paediatric urology examinations. Eur Radiol 2004; 14: 638–644. Crossref, MedlineGoogle Scholar
  • 22 Lederman HM, Khademian ZP, Felice M, Hurh PJ. Dose reduction in pediatrics. Pediatr Radiol 2002; 32: 844–848. Crossref, MedlineGoogle Scholar
  • 23 Ward VL, Barnewolt CE, Strauss KJ, et al. Radiation exposure reduction during voiding cystourethrography in a pediatric porcine model of vesicoureteral reflux. Radiology 2006; 238: 96–106. LinkGoogle Scholar
  • 24 Varchena V. Pediatric phantoms. Pediatr Radiol 2002; 32: 280–284. Crossref, MedlineGoogle Scholar
  • 25 Lebowitz RL. The detection and characterization of vesicoureteral reflux in the child. J Urol 1992; 148: 1640–1642. Crossref, MedlineGoogle Scholar
  • 26 American College of Radiology. ACR standard for the performance of voiding cystourethrography in children. In: ACR standards 1999–2000. Reston, Va: American College of Radiology, 1999; 101–104. Google Scholar
  • 27 Paltiel HJ, Rupich RC, Kiruluta HG. Enhanced detection of vesicoureteral reflux in infants and children with use of cyclic voiding cystourethrography. Radiology 1992; 184: 753–755. LinkGoogle Scholar
  • 28 Strauss KJ. Clinical radiation dose monitoring. In: Balter S, Shope T, eds. Syllabus: categorical course in physics—physical and technical aspects of angiography and interventional radiology. Oak Brook, Ill: Radiological Society of North America, 1995; 171–187. Google Scholar
  • 29 Gkanatsios NA, Huda W, Peters KR, Freeman JA. Evaluation of an on-line patient exposure meter in neuroradiology. Radiology 1997; 203: 837–842. LinkGoogle Scholar
  • 30 Li S, O'Dea TJ, Geise RA. Establishing a quality control program for an automated dosimetry system. Med Phys 1999; 26: 1732–1737. Crossref, MedlineGoogle Scholar
  • 31 ManRay: effective dose software. BioMed Software Web site. Google Scholar
  • 32 Briesmeister J. MCNP: a general Monte Carlo N-particle transport code, version 5. LA-UR-03–1987, 2003. Google Scholar
  • 33 Cristy M, Eckerman KF. Specific absorbed fractions of energy at various ages from internal photon sources. Report ORNL/TM-8381. Oak Ridge, Tenn: Oak Ridge National Laboratory, 1980. Google Scholar
  • 34 Loevinger R, Budinger TF, Watson EE. MIRD primer for absorbed dose calculations. New York, NY: Society of Nuclear Medicine, 1988. Google Scholar
  • 35 Motulsky H. Intuitive biostatistics. New York, NY: Oxford University Press, 1995; 255–267. Google Scholar
  • 36 Browner WS, Newman TB, Cummings SR, Hulley SB. Estimating sample size and power: the nitty gritty. In: Hulley SB, Cummings SR, Browner WS, Grady D, Hearst N, Newman TB, eds. Designing clinical research. Philadelphia, Pa: Lippincott Williams & Wilkins, 2001; 65–91. Google Scholar
  • 37 Hernandez RJ, Goodsitt MM. Reduction of radiation dose in pediatric patients using pulsed fluoroscopy. AJR Am J Roentgenol 1996; 167: 1247–1253. Crossref, MedlineGoogle Scholar
  • 38 Mantovani A, Giroletti E. Evaluation of the dose to pediatric patients undergoing micturating cystourethrography examination and optimization of the examination. Radiol Med (Torino) 2004; 108: 283–291. MedlineGoogle Scholar
  • 39 Fotakis M, Molyvda Athanasopoulou E, Psarrakos K, Economou I. Radiation doses to paediatric patients up to 5 years of age undergoing micturating cystourethrography examinations and its dependence on patient age: a Monte Carlo study. Br J Radiol 2003; 76: 812–817. Crossref, MedlineGoogle Scholar
  • 40 Perisinakis K, Raissaki M, Damilakis J, Stratakis J, Neratzoulakis J, Gourtsoyiannis N. Fluoroscopy-controlled voiding cystourethrography in infants and children: are the radiation risks trivial? Eur Radiol 2006; 16: 846–851. Crossref, MedlineGoogle Scholar
  • 41 National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States: recommendations of the National Council on Radiation Protection and Measurements. In: NCRP report no. 93. Bethesda, Md: National Council on Radiation Protection and Measurements, 1987. Google Scholar
  • 42 Treves ST, Gelfand M, Willi UV. Vesicouretic reflux and radionuclide cystography. In: Treves ST, ed. Pediatric nuclear medicine. 2nd ed. New York, NY: Springer-Verlag, 1995; 411–429. Google Scholar
  • 43 Mandell GA, Eggli DF, Gilday DL, et al. Procedure guideline for radionuclide cystography in children. J Nucl Med 1997; 38: 1650–1654. MedlineGoogle Scholar

Article History

Published in print: 2008