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Investigation of Bladder Tumors with CT Urography in Patients Presenting with Gross Hematuria
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Radiology, Oncology and Radiation Science, Radiology.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Bladder tumor is the most common tumor detected in patients presenting with gross hematuria. Early detection and treatment is crucial for good prognosis, however, delay in diagnosis and treatment is common. Routine work-up of gross hematuria includes cystoscopy and Computed Tomography Urography (CTU). If CTU has a high detection rate of bladder tumor, it can be used to direct further investigation of the patient, hopefully reducing delay to diagnosis and treatment. There is no consensus on which phase the bladder should be assessed at CTU. Assessment of the bladder in an early contrast-enhancing phase requires contrast material enhancement in bladder tumors and a bladder that is properly distended with urine. For patients younger than 50 years, the routine CTU protocol used for examining gross hematuria patients included unenhanced (UE), corticomedullary phase (CMP), and excretory phase (EP), with the start of the scan being enhancement triggered: patients aged 50 years or older followed the same protocol plus a nephrographic phase (NP).

The CTU protocol was compared with flexible cystoscopy for detecting bladder tumors. Sensitivity for bladder cancer detection was equal for CTU and cystoscopy (0.87).

Patients diagnosed with bladder cancer (n=50) were examined during UE, CMP, and EP, and 21 patients were additionally examined in NP. The highest mean tumor contrast enhancement was seen in CMP (37 HU).

The CMP, NP, and EP in 106 patients were randomized into an evaluation order (n=318 different phases) and blindly reviewed by two uroradiologists. In CMP, sensitivity (0.95) and negative predictive value (0.99) were higher than in NP and EP.

Four different preparation protocols for achieving bladder distension were compared. The protocol that included drinking 1 l of fluid during a two-hour period prior to examination without voiding during that period, gave satisfactory bladder distension without causing unacceptable patient discomfort and having the lowest compliance.

 

Gross hematuria patients should be primarily examined with CTU including UE, CMP and EP to direct further investigation of the patients. The patients should follow a preparation protocol including drinking 1 l of fluid during a two-hour period before examination and not voiding during that period.

 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. , 81 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 991
Keyword [en]
CT Urography, Bladder tumor, Gross hematuria, Tissue charactarization, Bladder distension, Tumor detection
National Category
Radiology, Nuclear Medicine and Medical Imaging
Research subject
Radiology
Identifiers
URN: urn:nbn:se:uu:diva-219390ISBN: 978-91-554-8933-5 (print)OAI: oai:DiVA.org:uu-219390DiVA: diva2:708335
Public defence
2014-05-16, Rosénsalen, Akademiska sjukhuset, ing 95/96, NBV, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2014-04-25 Created: 2014-02-28 Last updated: 2014-04-29
List of papers
1. Bladder cancer detection in patients with gross haematuria: Computed tomography urography with enhancement triggered scan versus flexible cystoscopy
Open this publication in new window or tab >>Bladder cancer detection in patients with gross haematuria: Computed tomography urography with enhancement triggered scan versus flexible cystoscopy
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2015 (English)In: Scandinavian journal of urology, ISSN 2168-1805, E-ISSN 2168-1813, Vol. 49, no 5, 377-381 p.Article in journal (Refereed) Published
Abstract [en]

Objective

Computed tomography urography (CTU) can be used to direct further investigation of patients if the bladder tumour detection rate is high. The aim of this study was to compare a CTU protocol including an enhancement-triggered scan and flexible cystoscopy for detecting bladder tumours.

Materials and methods

Patients with gross haematuria undergoing CTU during 2005–2008 were included. For patients younger than 50 years the CTU protocol included unenhanced, enhancement-triggered corticomedullary, and excretory phases. Patients older than 50 years followed the same protocol plus a nephrographic phase. The entire urinary tract was examined in all phases.

Results

Of 435 patients, 55 patients were diagnosed with bladder tumour. CTU detected bladder tumour in 48 patients (87%). Five CTU examination reports were false positive. With CTU, sensitivity for finding bladder tumour was 0.87, specificity 0.99, positive predictive value (PPV) 0.91 and negative predictive value (NPV) 0.98. Cystoscopy detected bladder tumour in 48 patients (87%) and had one false-positive finding, resulting in sensitivity of 0.87, specificity 1.0, PPV 0.98 and NPV 0.98.

Conclusions

The detection rate of bladder tumours for the CTU protocol including an enhancement-triggered scan was high and comparable to flexible cystoscopy. Hence, this protocol could be used to assess the bladder as the primary investigation and direct further investigation of the patient.

National Category
Radiology, Nuclear Medicine and Medical Imaging
Research subject
Radiology
Identifiers
urn:nbn:se:uu:diva-221283 (URN)10.3109/21681805.2015.1026937 (DOI)000364428800006 ()
Available from: 2014-03-27 Created: 2014-03-27 Last updated: 2017-12-05Bibliographically approved
2. Contrast enhancement in bladder tumors examined with CT urography using traditional scan phases
Open this publication in new window or tab >>Contrast enhancement in bladder tumors examined with CT urography using traditional scan phases
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2014 (English)In: Acta Radiologica, ISSN 0284-1851, E-ISSN 1600-0455, Vol. 55, no 9, 1129-1136 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Bladder assessment in an early contrast-enhancing computed tomography urography (CTU) phase requires that bladder tumors be enhanced using contrast material.

PURPOSE:

To investigate the enhancement pattern in bladder tumors using a CTU protocol where the scan is enhancement triggered.

MATERIAL AND METHODS:

Fifty patients diagnosed with bladder cancer were examined during the unenhanced (UP), corticomedullary (CMP), and excretory phases (EP). Twenty-one patients, all aged 50 years or older, were also examined during the nephrographic phase (NP). A ROI placed in the aorta was used to start the scan during the CMP when the attenuation reached 200 Hounsfield units (HU). The NP and EP were started with a 40 s and 300 s delay, respectively, after the CMP was finished. Attenuation and size measurements were made in the axial plane.

RESULTS:

Mean contrast enhancement of bladder tumors was 37, 25, and 17 HU in the CMP, NP, and EP, respectively. The differences in contrast enhancement were significant across all three phases. Eighty-eight percent of patients showed the highest contrast enhancement in the CMP. In 96% of the cases, contrast enhancement >20 HU was seen. The mean value of the shortest dimension of the bladder tumors was 22 ± 12 mm.

CONCLUSION:

The contrast enhancement is significantly higher in the CMP than in the NP and EP, suggesting that the CMP is preferable when assessing the bladder in the early contrast enhancing phase.

National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:uu:diva-212552 (URN)10.1177/0284185113513762 (DOI)000343887800015 ()24277884 (PubMedID)
Available from: 2013-12-11 Created: 2013-12-11 Last updated: 2017-12-06Bibliographically approved
3. Comparison of post contrast CT urography phases in bladder cancer detection
Open this publication in new window or tab >>Comparison of post contrast CT urography phases in bladder cancer detection
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2016 (English)In: European Radiology, ISSN 0938-7994, E-ISSN 1432-1084, Vol. 26, no 2, 585-591 p.Article in journal (Refereed) Published
Abstract [en]

Objectives The aim of this study was to investigate which post-contrast phase(s) in a four-phase CT urography protocol is (are) most suitable for bladder cancer detection. Methods The medical records of 106 patients with visible haematuria who underwent a CT urography examination, including unenhanced, enhancement-triggered corticomedullary (CMP), nephrographic (NP) and excretory (EP) phases, were reviewed. The post-contrast phases (n = 318 different phases) were randomized into an evaluation order and blindly reviewed by two uroradiologists. Results Twenty-one patients were diagnosed with bladder cancer. Sensitivity for bladder cancer detection was 0.95 in CMP, 0.83 in NP and 0.81 in EP. Negative predictive value (NPV) was 0.99 in CMP, 0.96 in NP and 0.95 in EP. The sensitivity was higher in CMP than in both NP (p-value 0.016) and EP (p-value 0.0003). NPV was higher in CMP than in NP (p-value 0.024) and EP (p-value 0.002). Conclusion In the CT urography protocol with enhancement-triggered scan, sensitivity and NPV were highest in the corticomedullary phase, and this phase should be used for bladder assessment.

Keyword
Multidetector computed tomography; Urography; Urinary bladder neoplasms; Haematuria; Early detection of cancer
National Category
Radiology, Nuclear Medicine and Medical Imaging
Research subject
Radiology
Identifiers
urn:nbn:se:uu:diva-221282 (URN)10.1007/s00330-015-3844-7 (DOI)000368639200034 ()26002135 (PubMedID)
Available from: 2014-03-27 Created: 2014-03-27 Last updated: 2017-12-05Bibliographically approved
4. Comparison of four different preparation protocols to achieve bladder distension in patients with gross haematuria undergoing a CT urography
Open this publication in new window or tab >>Comparison of four different preparation protocols to achieve bladder distension in patients with gross haematuria undergoing a CT urography
2012 (English)In: Radiography, ISSN 1078-8174, E-ISSN 1532-2831, Vol. 18, no 3, 206-211 p.Article in journal (Refereed) Published
Abstract [en]

Introduction

CT examination has been shown to be effective in detecting bladder cancer. Proper evaluation of the bladder requires it to be well distended. The purpose of the present study was to establish a preparation protocol to achieve satisfactory bladder distension without causing unacceptable patient discomfort.

Material and method

We used four different preparation protocols (1: 0.5 L of fluid intake during a 1-h period, 2: Same as 1 with the addition of IV diuretics when the patient was examined, 3: 1 L of fluid intake during a 2-h period, 4: Same as 3 with the additional instruction to empty the bladder after 1 h. In protocols 1–3, the patients were asked not to empty their bladder during the preparation time). Bladder volume was calculated and bladder distension was judged as satisfactory or not by the radiologist. The patients answered questions about their ability to follow the preparation protocol and were requested to rate their need to empty the bladder pre-, during and post-examination.

Results

Protocol 1 had the lowest bladder volume. Protocols 2, 3 and 4 were similar in bladder volume. However, Protocol 2 caused unacceptable patient discomfort, and the compliance was lowest in Protocol 4.

Conclusion

Protocol 3, drinking 1 L of fluid during a 2-h period, gave satisfactory bladder distension, did not cause unacceptable discomfort in patients and did not have the lowest compliance.

Keyword
Bladder cancer, CT, Haematuria, Urography, Distension
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:uu:diva-183661 (URN)10.1016/j.radi.2012.02.004 (DOI)
Available from: 2012-10-31 Created: 2012-10-31 Last updated: 2017-12-07Bibliographically approved

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