From Source Reduction to Risk-Based Discharge: An End-to-End Sustainable Management Framework for Medical Radioactive Wastewater in China—A Narrative Review

With the rapid development of nuclear medicine, the safe and sustainable management of medical radioactive wastewater has become an increasingly critical challenge at the interface of radiation protection and environmental engineering in China. Current management practices primarily focus on end-of-pipe treatment, whereas systematic frameworks integrating wastewater generation, collection, treatment, monitoring, and risk-informed discharge remain insufficient. In this narrative review, we systematically examine the complete management chain of medical radioactive wastewater, from generation to discharge, by evaluating source reduction strategies, available treatment technologies, and international regulatory frameworks, while also summarizing the requirements for whole-process monitoring and occupational radiation protection. We characterize the pollution profiles and discharge loads associated with major medical radionuclides, assess the applicability of different treatment technologies under various operational scenarios, and analyze key differences between Chinese and international regulatory approaches. Based on these analyses, we first establish a hierarchical decision matrix for treatment process selection considering hospital classification and site-specific constraints, and subsequently propose a six-tier end-to-end management framework integrating source reduction, source characterization, multi-constraint process selection, tiered treatment intensification, multi-level quality monitoring, and risk-informed discharge. This framework promotes a paradigm shift in medical radioactive wastewater management from conventional end-of-pipe treatment toward integrated full-chain governance, providing theoretical insights and practical guidance for the standardized, refined, and sustainable management of medical radioactive wastewater in China.