Clinical staging of upper urinary tract urothelial carcinoma for T staging: Review and pictorial essay

Upper urinary tract urothelial carcinoma is staged using the TNM classification of malignant tumors. Preoperative TNM is important for treatment planning. Computed tomography urography is now widely used for clinical survey of upper urinary tract carcinoma because of its diagnostic accuracy. Computed tomography urography is recommended as the first‐line imaging procedure in several guidelines. Several reports stated that computed tomography urography is also useful for staging. However, no educational and practical reviews detailing the T staging of upper urinary tract urothelial carcinomas using imaging are available. We discuss the scanning protocol, T staging using computed tomography urography, limitations, magnetic resonance imaging, computed tomography comparison and pitfalls in imaging of upper urinary tract urothelial carcinoma. A recent study reported the high diagnostic accuracy of computed tomography urography with respect to T3 or higher stage tumors. To date, images that show a Tis–T2 stage have not been reported, but various studies are ongoing. Although magnetic resonance imaging has lower spatial resolution than computed tomography urography, magnetic resonance imaging can be carried out without radiation exposure or contrast agents. Magnetic resonance imaging also offers the unique ability of diffusion‐weighted imaging without contrast agent use. Some researchers reported that diffusion‐weighted imaging is useful not only for detecting lesions, but for predicting the T stage and tumor grade. We recommend the appropriate use of computed tomography and magnetic resonance while considering the limitations of each modality and the pitfalls in upper urinary tract urothelial carcinoma imaging.     

Diagnostik von Urothelkarzinomen des oberen Harntrakts

Upper urinary tract transitional cell carcinomas represent 5–6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.     

Computed tomography urography technique, indications and limitations

PURPOSE OF REVIEW: The review discusses the different techniques of computed tomography urography reported in the literature and presents the author's preferred approach. RECENT FINDINGS: Multiphase computed tomography urography offers a comprehensive evaluation of the urinary tract but at the cost of a large dose of contrast medium (100-150 ml), high radiation dose and massive number of images for interpretation. Diuresis induced by frusemide (10 mg) is reported to improve the depiction of ureters in the excretory phase of the examination. The author's preferred approach is a limited computed tomography urography which includes precontrast scanning of the kidneys, followed by an excretory phase 5 min after intravenous injection of 50 ml of contrast medium and 10 mg of frusemide. This limited examination in the author's experience provides a satisfactory evaluation of the urinary tract in the majority of patients, without inflicting a high radiation dose on the patient. SUMMARY: A limited computed tomography urography examination is adequate for the majority of patients requiring excretory urography and a superior replacement of conventional intravenous urography. Information provided by a multiphase computed tomography urography examination is beneficial only in a small number of patients.     

Need for intravenous urography in patients with primary transitional carcinoma of the bladder?

OBJECTIVE: To assess the need for and the efficacy of intravenous urography in the detection of a synchronous upper tract urothelial tumor (UTUT) in patients with primary bladder tumor. MATERIALS: Between 1986 and 1996, 793 patients were diagnosed as having primary tumor of the bladder with pathological confirmation of transitional cell carcinoma. All patients underwent intravenous urography prior to transurethral resection. The mean age of the patients was 66.4 years, and 87.7% of them were male. Of these patients, 72% had superficial tumors, while the remaining 28% had infiltrative tumors. Histological classification of the tumors was: grade I, 10%; grade II, 45%, and grade III, 45%. A chi(2) test was used for statistical analysis. RESULTS: The incidence of upper tract urothelial tumors was 1.1% (9 patients), although intravenous urography only diagnosed 6 cases (0.7%). No differences were seen between patients with or without UTUT with regard to histological grade (p = 0.7), multiple bladder tumors (p = 0.7) and tumor infiltration (p = 0.9). In 5.8% of the patients an unsuspected associated pathology was detected which required treatment in 1.4% of the cases. CONCLUSIONS: Due to the low incidence of UTUT (1.1%) in our series and to the fact that intravenous urography was effective in diagnosing synchronous UTUT in only 66.6% of cases, we do not consider that this procedure should be routinely performed in the diagnostic workup of patients with primary transitional cell tumor of the bladder.     

One year's clinical experience with unenhanced spiral computed tomography for the assessment of acute loin pain suggestive of renal colic

OBJECTIVE: To assess the use of unenhanced spiral computed tomography (CT) as the primary investigation of choice for suspected acute renal colic in clinical urological practice. Patients and Methods Between 1 August 1997 and 31 July 1998, all patients attending a hospital accident and emergency department with acute loin pain suggestive of renal colic underwent a physical examination, urine analysis, plain abdominal radiography (if clinically indicated) and unenhanced spiral CT. The effective radiation dose and financial cost of unenhanced spiral CT and standard three-film emergency intravenous urography (IVU) were calculated. RESULTS: In all, 116 patients were assessed, 63 of whom had calculi and related secondary phenomena of obstruction identified on unenhanced spiral CT. There were two false-positive and one false-negative result. An alternative urinary tract diagnosis was made in four patients, including two with renal cell carcinoma and one ureteric transitional cell carcinoma. Causes other than in the urinary tract were diagnosed in three patients, i.e. two with ovarian cyst and one with sigmoid diverticulitis. The effective radiation dose of unenhanced spiral CT was 4.7 mSv and that for three-film IVU was 1.5 mSv. The costs of both IVU and unenhanced spiral CT were identical. CONCLUSIONS: Unenhanced spiral CT allows a rapid, contrast-medium-free, anatomically accurate diagnosis of urinary tract calculi and in the present series had a sensitivity of 98% and a specificity of 97%. CT provided an alternative diagnosis in 6% of patients. These advantages must be weighed against the threefold greater radiation dose of unenhanced spiral CT than with three-film IVU, and in practice the requirement for a radiologist to interpret routine axial scans.     

Upper urinary tract tumor: differential diagnosis by radiological images

To perform the adequate treatment of upper urinary tract lesions it is very important to have an exact diagnosis. When the suspicion of an upper tract urothelial tumor is established the initial evaluation is carried out by imaging diagnostic tests (intravenous urography, pyelography, and others). The association of radiological tests and urine cytologies allows us to get to a correct diagnosis in most cases. Upper urinary tract endoscopy solves some equivocal cases, but sometimes it is impossible to clarify the nature of the lesion in spite of a comprehensive diagnostic effort. Therapeutic decision should be individualized in these cases. The objective of this article is to describe the various features of upper tract urothelial tumors in a variety of available imaging tests, and to review all conditions that may have similar images, describing the characteristic radiological findings for each of them. We discuss about differential diagnosis and perform a critical evaluation of the diagnostic difficulties that occasionally present upper urinary tract diseases.     

Multidetector computed tomography urography for diagnosing upper urinary tract urothelial tumour

OBJECTIVE: To evaluate multidetector computed tomography urography (MDCTU) for diagnosing upper urinary tract (UUT) urothelial tumour by comparison with retrograde ureteropyelography (RUP). PATIENTS AND METHODS: MDCTU and RUP were used in a selected series of adult patients presenting with haematuria. Entry criteria were based on findings on intravenous urography and were chosen to ensure a high prevalence of UUT urothelial tumour to allow a valid retrospective comparison of the diagnostic techniques. MDCTU and RUP studies were scored for the presence and absence of UUT urothelial tumour by two radiologists, retrospectively and independently, and while unaware of the demographic and clinical information. The reference standards were the histopathology and clinical follow-up. RESULTS: MDCTU and RUP were used in 106 patients over a 24-month period. RUP was attempted in 151 of 212 UUTs; the corresponding MDCTU for each UUT was reviewed. MDCTU was a true-positive (TP) for urothelial tumour in 31, true-negative (TN) in 111, false-positive (FP) in eight and false-negative (FN) in one UUT, giving a sensitivity of 0.97, a specificity of 0.93, a positive predictive value (PPV) of 0.79 and a negative PV (NPV) of 0.99. RUP was technically successful and diagnostic in 96% of the UUTs (143/151). For diagnosing urothelial tumour, RUP was TP in 26, TN in 112, FP in four and FN in one UUT, giving a sensitivity of 0.97, specificity of 0.93, a PPV of 0.79 and NPV of 0.99. CONCLUSION: This study validates quantitatively the use of MDCTU for diagnosing UUT urothelial tumour.     

Computed tomography as an aid in the differential diagnosis of radiolucent stones and tumors of the upper urinary tract

The difficult differential diagnosis of urothelial tumors and nonopaque calculi of the upper urinary tract has been considerably improved by the introduction of computed tomography (CT) in urological diagnosis. Nonopaque calculi although urographically not visible can be determined by CT. Usually urothelial tumors can be traced by CT without invasive methods. In case of doubt in addition to the primary scan a so called flow-study, after application of contrast medium, will furnish additional information. The diagnostic facilities provided by CT are illustrated in 18 cases.     

Does multidetector computed tomographic urography (MDCTU) T staging classification correspond with pathologic T staging in upper tract urothelial carcinoma?

International Urology and Nephrology - Multidetector computed tomographic urography (MDCTU) is not yet sufficient to be used in the clinical staging of upper tract urothelial carcinoma (UTUC). This...     

Computerized tomography for detection and staging of localized and pathologically defined upper tract urothelial tumors

Between 1980 and 1989, 94 patients were evaluated for upper tract urothelial tumors. Preoperative computerized tomography (CT) scans and pathology reports were available in 30 patients who also had nephroureterectomy for treatment of transitional cell carcinoma. Retrospective evaluation of these CT scans was done without knowledge of the final pathological status to determine accuracy of tumor detection and staging. Pathological findings were also reviewed and the pathological staging was compared to that of CT. At pathological evaluation the 30 renal units contained 34 grossly visible, distinct papillary tumors: 7 were ureteral and 27 were in the renal pelvis. Of the renal units 8 also contained carcinoma in situ that was not visible on any study. Conventional excretory urograms and/or retrograde or antegrade pyelograms detected 28 (82%) and CT 17 (50%) of the 34 papillary tumors. Excluding suboptimal scans due to early generation machines, inadequate intravenous contrast medium or too widely spaced slices caused CT sensitivity to increase to 15 of 22 (68%). It was not possible to distinguish stages Ta to T2 lesions on any radiological study. CT sensitivity for parenchymal invasion was 75% with a specificity of 43%. CT sensitivity for fat invasion was 67% with a specificity of 44%. We conclude that CT is limited in usefulness for detection and staging of low stage upper tract urothelial tumors. While CT is the best current imaging modality over-all for staging of upper tract urothelial tumors, results obtained in low stage tumors must be viewed with caution particularly when precise preoperative clinical staging is essential, such as before nephron-sparing procedures.     

Makrohämaturie als Primärsymptom eines extramedullären IgM-Plasmozytoms der Harnblase

Haematuria is the most common clinical symptom of bladder cancer. Besides antibiotic treatment of a probably existing urinary tract infection, ultrasonography of the urinary organs, diagnostic cystoscopy (with biopsy if needed), and radiologic evaluation of the upper urinary tract (intravenous urography, computed tomography or magnetic resonance urography, retrograde pyelography) should be done for further evaluation. Atypical manifestations of systemic diseases with bladder infiltration could feign the clinical appearance of chronic cystitis and hinder determination of the correct diagnosis. The case of a 40-year-old man with recurrent gross haematuria due to extremely rare bladder infiltration through an IgM plasmacytoma is presented.     

Inverted papilloma of the renal pelvis: report of a case

Inverted papilloma of the upper urinary tract is a rare lesion. To our knowledge, we report here the 32nd case of inverted papilloma of the renal pelvis. A 50-year-old man presented with asymptomatic gross hematria. Excretory urography showed a filling defect in the left upper calyx. Computerized tomography showed a poorly enhanced low-density area within the renal pelvis. Since radiographic findings suggested a renal pelvic tumor, the patient underwent total nephroureterectomy. Unexpectedly, a 3 x 2.5 cm polypoid tumor of the renal pelvis was consistent with inverted papilloma. Since this benign lesion is extremely rare within the upper tract and its radiographic characteristics closely resemble those of urothelial carcinoma, the preoperative diagnosis of inverted papilloma of the upper tract cannot be conclusively established even by modern imaging techniques. Therefore treatment consistent with that for urothelial carcinoma should be applied in this disease entity.     

Bildgebende Diagnostik – das Ende des AUG?

For diagnosing patients with acute flank pain, unenhanced helical computed tomography (CT) is the most accurate method. However, conventional diagnosis using sonography and intravenous urography yields comparable results. For proper assessment, the availability, radiation dose, and cost have to be considered as well. Although the availability of CT has increased, radiation dose and cost are in favour of conventional diagnosis. At this time, we recommend sonography as the primary method. Depending on availability, intravenous urography or CT is a possible alternative.     

Role of diffusion‐weighted magnetic resonance imaging as an imaging biomarker of urothelial carcinoma

Diffusion‐weighted magnetic resonance imaging is a type of functional imaging that is increasingly being applied in the management of upper tract urothelial carcinoma and bladder cancer. The image contrast is derived from differences in the Brownian motion of water molecules in tissues. The homogenous high signal intensity of upper tract urothelial carcinoma and bladder cancer on diffusion‐weighted magnetic resonance imaging provides helpful diagnostic information for the presence of cancerous lesions in a non‐invasive manner. Recently, growing evidence has emerged showing that diffusion‐weighted magnetic resonance imaging can serve as an imaging biomarker for characterizing cancer pathophysiology, because the signal reflects biophysical information about the tissues. Quantitative analysis by evaluating the apparent diffusion coefficient values potentially reflects the histological grade and the biological aggressiveness of urothelial carcinoma. The apparent diffusion coefficient value could be a biomarker predicting the clinical course of upper tract urothelial carcinoma and bladder cancer. In addition, in chemoradiotherapy‐based bladder‐sparing approaches against muscle‐invasive bladder cancer, the role of diffusion‐weighted magnetic resonance imaging for predicting the chemoradiosensitivity and for monitoring therapeutic response has been shown. Diffusion‐weighted magnetic resonance imaging is expected to improve the diagnostic accuracy, and this qualitative information might allow individualized treatment strategies for patients with urothelial carcinoma.     

Diagnostic imaging--the end of intravenous urography?

For diagnosing patients with acute flank pain, unenhanced helical computed tomography (CT) is the most accurate method. However, conventional diagnosis using sonography and intravenous urography yields comparable results. For proper assessment, the availability, radiation dose, and cost have to be considered as well. Although the availability of CT has increased, radiation dose and cost are in favour of conventional diagnosis. At this time, we recommend sonography as the primary method. Depending on availability, intravenous urography or CT is a possible alternative.     

Incidentally detected renal carcinoma

The manner of presentation and tumour stage in 52 consecutive patients with renal carcinoma who were treated surgically between 1974 and 1979 (group I) and 112 patients treated similarly between 1980 and 1985 (group II) were reviewed. In group I 16 cases (31%) were discovered incidentally compared to 50 cases (45%) in group II. Before the year 1980 most of the tumours were discovered incidentally at the time of intravenous urography (IVP) or angiography performed for examinations of urinary tract infection or hypertension. After 1980 most incidentally discovered tumours were found at ultrasound or computed tomography (CT) examinations. The tumour stage was lower in the incidentally discovered cases than in cases where the diagnosis was suspected. Routine use of excretory urography, computed tomography, ultrasound, bone scans and other effective diagnostic studies has led to earlier diagnosis, lower stage and possibly better survival in incidentally found cases of renal carcinoma than in cases when the diagnosis was suspected.     

Transitional cell carcinoma of the upper urinary tract following total cystectomy for bladder cancer]

From 1975 to 1990, we treated 118 patients with urinary epithelial cancer, including 100 with primary bladder cancer, 13 with primary upper urinary tract cancer, and 5 with both diseases. Thirty-five patients with primary bladder cancer underwent total cystectomy. Upper urinary tract urothelial cancer developed in 4 patients (4.0%) and was detected only after cystectomy. Three patients had multiple bladder tumors before cystectomy and recurrent tumors under long-term bladder-preserving treatment. The other patient had had cystectomy for the primary bladder lesion. Our present policy is to perform urinary cytology once a month and intravenous urography once a year in patients with bladder cancer for early detection of secondary upper urinary tract cancer.     

Penile-preserving surgery for primary urothelial carcinoma of male urethra

Primary urethral carcinoma is a rare cancer, comprising <1% of all malignancies. The location of this lesion presents a certain dilemma of treatment between efficacy and quality of life. We report an 84-year-old male patient, with a history of chronic hepatitis C, hypertension, and transient ischemic accident, who presented with dysuria and acute urinary retention. The intravenous urography showed mild prostatic enlargement, but no stone or filling defect was noted in the upper urinary tract. On urethrocystoscopy, multiple papillary tumors were found at the pendulous urethra, and the pathology of biopsy confirmed urothelial carcinoma. The patient was admitted, and electroresection with fulguration of urethral tumors was performed owing to the patient's old age and poor performance status. Intraurethral and intravesical chemotherapy with mitomycin C was regularly given at the outpatient clinic. Recurrent urothelial carcinomas were noted twice in the first 2 years of follow up, and repeated transurethral resections were done. Unfortunately, liver cirrhosis with hepatocellular carcinoma was diagnosed last June, for which he received transcatheter arterial chemoembolization. No recurrence of urethral cancer has been found on semiannual cystoscopy in the past 3 years. Penile-preserving surgery is a reasonable surgical option for elderly primary urethral carcinoma patients with acceptable oncological outcome and good quality of life.     

The value of retrograde pyelography for fractionally visualized upper tracts on excretory urography in the evaluation of hematuria

A 5-year retrospective study of 131 hematuria patients (23 with gross and 108 with microscopic hematuria) undergoing retrograde pyelography solely for fractional visualization of the upper tracts on excretory urography revealed no tumors or other significant pathological condition in the 187 renal units (56 bilateral cases) studied. A review of our cases of upper tract urothelial cancer since 1955 revealed 36 patients with complete records of the urological evaluations. None of the cases was diagnosed by retrograde pyelography for fractionally visualized excretory urography and 3 were within 9 months of a previously normal excretory urogram alone or with retrograde pyelography. We believe that retrograde pyelography done solely to evaluate a fractionally visualized upper tract may miss subtle lesions and it should not terminate the evaluation. We recommend that excretory urography, cystoscopy and voided urine cytology studies be performed initially and, if normal, they should be repeated in 6 and 12 months before upper tract urothelial tumors are ruled out.     

Upper tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: incidence and risk factors

OBJECTIVE: To review the incidence, pattern and outcome of upper tract transitional cell carcinoma (TCC) after radical cystectomy for carcinoma of the bladder, and identify risk factors for its development. PATIENTS AND METHODS: The records of 235 consecutive patients who had a radical cystectomy and urinary diversion for TCC at the authors' institution by one surgeon between January 1992 and August 2003 were retrospectively reviewed. RESULTS: Five (2%) of 235 patients developed an upper tract urothelial tumour. The mean follow-up for all patients was 42 months, and was 52.2 months for those with an upper tract tumour. Four of the five patients presented with haematuria and one was diagnosed on routine follow-up intravenous urography. The mean time to the diagnosis of an upper tract tumour was 39.6 months. Of the potential risk factors, only the presence of TCC of the prostatic urethra had a statistically significant association with eventual upper tract tumour (P < 0.01). At the last follow-up, four patients died from urothelial cancer and one was disease-free. CONCLUSIONS: The incidence of upper tract tumour after cystectomy for TCC is low; most patients present with symptoms (haematuria) and have advanced disease at diagnosis. Patients with prostatic urethral involvement at cystectomy are at greater risk of developing upper tract tumour.