Imaging Pearls ❯ Kidney ❯ Bladder
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- “A more serious infectious entity involving the bladder is emphysematous cystitis. While the same gas-producing organisms which cause acute infectious cystitis are involved,9 additional risk factors may cause the infection to advance to this stage. >50% of all patients have diabetes mellitus; other risk factors include bladder outlet obstruction, immunosuppression, and neurogenic bladder. Clinically, emphysematous cystitis is a serious infection with mortality rates as high as 7%. Symptoms are nonspecific and include acute abdominal pain, sepsis, and shock; pneumaturia is highly specific but rare. Treatment includes long-term broad-spectrum antibiotics, bladder drainage, and treatment of predisposing conditions, including strict blood sugar control.”
A pictorial review of genitourinary infections and inflammations
Mark McArthur , Maitraya Patel
Clinical Imaging 104 (2023) 110013 - A final severe complication of genitourinary tract infection/inflammation is the development of various fistulas within the abdomen and pelvis. The two most prevalent types are colovesical and vesicovaginal fistulas. While the most common cause of colovesical fistula is colonic diverticulitis, accounting for 65–79% of cases, neoplasms such as bladder or colon cancer, inflammatory conditions such as Crohn's disease, pelvic radiation, and trauma and iatrogenic causes may also be responsible. Clinical presentation is highly variable and may include pneumaturia, fecaluria, recurrent urinary tract infections, dysuria, urinary frequency, or passage of urine rectally.95 In a study involving 28 years of experience at a United States Department of Veterans Affairs medical center, CT imaging was the most sensitive and specific means for diagnosing colovesical fistula and outlining pertinent anatomy for surgical intervention. Cystography and CT cystography are also commonly used to evaluate fistulas involving the bladder.
A pictorial review of genitourinary infections and inflammations
Mark McArthur , Maitraya Patel
Clinical Imaging 104 (2023) 110013 - A final severe complication of genitourinary tract infection/inflammation is the development of various fistulas within the abdomen and pelvis. The two most prevalent types are colovesical and vesicovaginal fistulas. While the most common cause of colovesical fistula is colonic diverticulitis, accounting for 65–79% of cases, neoplasms such as bladder or colon cancer, inflammatory conditions such as Crohn's disease, pelvic radiation, and trauma and iatrogenic causes may also be responsible. Clinical presentation is highly variable and may include pneumaturia, fecaluria, recurrent urinary tract infections, dysuria, urinary frequency, or passage of urine rectally..
A pictorial review of genitourinary infections and inflammations
Mark McArthur , Maitraya Patel
Clinical Imaging 104 (2023) 110013
- “Early bladder cancer was visualized on CT preceding pathologic diagnosis in more than 2/3 of patients, and the majority of scans were performed for indications other than suspected urinary tract cancer/UTC symptoms. These results suggest that cross-sectional imaging performed for other indications can serve as a resource for opportunistic bladder cancer screening, particularly in high-risk patients.”
Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis
Rubab F. Malik , Renu Berry , Brandyn D. Lau , Kiran R. Busireddy , Prasan Patel , Sunil H. Patel , Elliot K. Fishman , Trinity J. Bivalacqua , Pamela T. Johnson and Farzad Sedaghat
Tomography 2023, 9, 1734–1744. - “Bladder cancer is the sixth most common malignancy in the United States(US). Despite its high prevalence and the significant potential benefits of early detection, no reliable, cost-effective screening algorithm exists for asymptomatic patients at risk. Nonetheless, reports of incidentally identified early bladder cancer on CT/MRI scans performed for other indications are emerging in the literature. This represents a new opportunity for early detection, with over 80 million CT scans performed in the US yearly, 40% of which are abdominopelvic CTs. This investigation aims to define the imaging features of early bladder cancer, with the mission of facilitating early diagnosis.”
Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis
Rubab F. Malik , Renu Berry , Brandyn D. Lau , Kiran R. Busireddy , Prasan Patel , Sunil H. Patel , Elliot K. Fishman , Trinity J. Bivalacqua , Pamela T. Johnson and Farzad Sedaghat
Tomography 2023, 9, 1734–1744. - “A bladder wall mass was visualized in 67% (66/99) of patients and on 35% (78/226) of scans performed before diagnosis. The majority (84%, 67/80) of masses were intraluminal. Mean transverse long- and short-axis measurements were 24 mm and 17 mm, respectively, with long dimension measurements ranging between 5 and 59 mm.”
Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis
Rubab F. Malik , Renu Berry , Brandyn D. Lau , Kiran R. Busireddy , Prasan Patel , Sunil H. Patel , Elliot K. Fishman , Trinity J. Bivalacqua , Pamela T. Johnson and Farzad Sedaghat
Tomography 2023, 9, 1734–1744. - “Given these findings, a routine inspection of the bladder with a high-contrast window and multiplanar reconstructions should be a part of the radiologist’s search pattern, particularly in patients over age 50, like our cohort. Only scrutinizing patients with known exposures, such as smoking, may exclude at-risk patients, as studies have demonstrated that a significant proportion of patients with UTC may have elevated amylamine levels (the leading putative cause of bladder cancer among smokers), despite having no history of tobacco abuse. Also notable is the high proportion of patients undergoing surveillance for malignancies other than UTC within our cohort (48%), suggesting that specific attention should be provided to this patient population.”
Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis
Rubab F. Malik , Renu Berry , Brandyn D. Lau , Kiran R. Busireddy , Prasan Patel , Sunil H. Patel , Elliot K. Fishman , Trinity J. Bivalacqua , Pamela T. Johnson and Farzad Sedaghat
Tomography 2023, 9, 1734–1744. - “As no standardized screening algorithm for bladder cancer detection currently exists, systematic opportunistic screening for bladder abnormalities would represent a paradigm shift among radiologists, potentially facilitating early diagnosis . We believe that during abdominopelvic imaging performed for alternative indications, a concentrated bladder survey could significantly aid in bladder cancer detection, particularly in highriskpatients (those over 50 years of age, especially patients with a history of tobacco abuse and/or industrial chemical exposures). Early asymptomatic detection could, in turn, decrease morbidity and increase cancer survival , improving the quality of life for patients through timely intervention, and the full utilization of minimally invasive treatment options.”
Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis
Rubab F. Malik , Renu Berry , Brandyn D. Lau , Kiran R. Busireddy , Prasan Patel , Sunil H. Patel , Elliot K. Fishman , Trinity J. Bivalacqua , Pamela T. Johnson and Farzad Sedaghat
Tomography 2023, 9, 1734–1744.
- “Bladder PCCs can be functional or nonfunctional, depending on whether catecholamines are oversecreted. Most bladder PCCs (83%) are functional, which means they secrete excess catecholamines that lead to adverse effects, including persistent or paroxysmal hypertension, headaches, palpitations, syncope and sweating. These symptoms often occur during micturition, which leads to increased bladder pressure and contraction, triggering catecholamine release (“micturition attacks”). Other symptoms include gross hematuria or obstructive symptoms such as frequency, urgency, and dysuria. In the case of nonfunctional bladder PCCs, gross hematuria and obstructive issues are often the only symptoms present .”
Magnetic resonance imaging of bladder pheochromocytomas: a review
Yanni Zulia et al.
Abdominal Radiology (2022) 47:4032–4041 - “While the exact mechanism of bleeding and rupture in a pheochromocytoma is unknown, it is believed to be associated with an increase in intracapsular pressure, due to various factors, such as trauma. Additional causes include rapid tumor growth, which can result in the tumor outgrowing its blood supply, leading to central necrosis and hemorrhage. In addition, systemic hypertension due to the elevated catecholamines secreted by the tumor leads to vasoconstriction in the central vessels of the tumor, resulting in necrosis.”
The good, the bad, and the ugly: uncommon CT appearances of pheochromocytoma
Renu Berry· Kiran Busireddy · Linda C. Chu · Pamela T. Johnson · Elliot K. Fishman
Abdominal Radiology (2022) 47:1406–1413
- “This observer study investigates the effect of computerized artificial intelligence (AI)-based decision support system (CDSS-T) on physicians’ diagnostic accuracy in assessing bladder cancer treatment response. The performance of 17 observers was evaluated when assessing bladder cancer treatment response without and with CDSS-T using pre- and post-chemotherapy CTU scans in 123 patients having 157 pre- and post-treatment cancer pairs. The impact of cancer case difficulty, observers’ clinical experience, institution affiliation, specialty, and the assessment times on the observers’ diagnostic performance with and without using CDSS-T were analyzed. It was found that the average performance of the 17 observers was significantly improved (p = 0.002) when aided by the CDSS-T. The cancer case difficulty, institution affiliation, specialty, and the assessment times influenced the observers’ performance without CDSS-T. The AI-based decision support system has the potential to improve the diagnostic accuracy in assessing bladder cancer treatment response and result in more consistent performance among all physicians.”
Computerized Decision Support for Bladder Cancer Treatment Response Assessment in CT Urography: Effect on Diagnostic Accuracy in Multi-Institution Multi-Specialty Study
Di Sun et al.
Tomography 2022, 8, 644–656. - “We have developed a computerized artificial intelligence (AI)-based decision supportsystem for muscle-invasive bladder cancer treatment response assessment (CDSS-T) to assist physicians to evaluate the response to treatment of these cancers on pre- and posttreatment CT urography (CTU) scans . It is critical to gain understanding of variousfactors that may affect the impact of CDSS-T on physician performance in identifying bladder cancers with complete response after neoadjuvant chemotherapy through observer studies that can guide the design of future clinical trials. Patients with complete response may be considered for organ preservation therapy instead of cystectomy (the removal of the bladder).”
Computerized Decision Support for Bladder Cancer Treatment Response Assessment in CT Urography: Effect on Diagnostic Accuracy in Multi-Institution Multi-Specialty Study
Di Sun et al.
Tomography 2022, 8, 644–656. - "The performance comparisons of experienced and inexperienced physicians are shown in Table 5. We can see there was no observable difference between their performances. The level of statistical significance of the inexperienced radiologists was slightly higher (p = 0.007) after using CDSS-T compared to that of experienced radiologists (p = 0.06). The use of CDSS-T resulted in more consistent performance among all subgroups of physicians (all AUC = 0.77).”
Computerized Decision Support for Bladder Cancer Treatment Response Assessment in CT Urography: Effect on Diagnostic Accuracy in Multi-Institution Multi-Specialty Study
Di Sun et al.
Tomography 2022, 8, 644–656. - "In conclusion, our study demonstrated that the computerized decision support system (CDSS-T) has the potential to improve the diagnostic accuracy in assessing the complete response of muscle-invasive bladder cancer to neoadjuvant chemotherapy prior to radical cystectomy. The use of CDSS-T aid has resulted in improved and more consistent diagnostic performance among the physicians from multiple institutions and multiple specialties.”
Computerized Decision Support for Bladder Cancer Treatment Response Assessment in CT Urography: Effect on Diagnostic Accuracy in Multi-Institution Multi-Specialty Study
Di Sun et al.
Tomography 2022, 8, 644–656.
- “Three-dimensional (3D) visualizations of volumetric data from computed tomography (CT) acquisitions can be important adjuncts to interpretation of two-dimensional (2D) reconstructions. Recently, the 3D technique known as cinematic rendering (CR) was introduced, allowing photorealistic images to be created from standard CT acquisitions. CR methodology is under increasing investigation for use in the display of regions of complex anatomy and as a tool for education and preoperative planning. In this article, we will illustrate the potential utility of CR for evaluating the urinary bladder and associated pathology. The urinary bladder is susceptible to a multitude of neoplastic and inflammatory conditions and their sequelae. The intrinsic properties of CR may prove useful for the display of subtle mucosal/luminal irregularities, the simultaneous display of soft tissue detail with high-resolution maps of associated tumor neovasculature, and the improved display of spatial relationships to aid pre-procedural planning. Further refinement of presets for CR image creation and prospective evaluation of urinary bladder CR in real-world settings will be important for widespread clinical adoption.”
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press) - "Cinematic rendering (CR) is a relatively new method of 3D volume visualization that utilizes a complex global lighting model in order to provide enhanced surface detail and realistic shadowing. Relative to traditional VR methods, CR is qualitatively more photorealistic and gives the reader the perception of added image depth. CR allows for the rapid understanding of anatomy in the pre-operative planning setting and appears to offer utility in the evaluation of complex pathology in the cardiovascular system, the musculoskeletal system, and other regions with multiple structures with intricate relative positions.”
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press) 
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press)
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press)- "The high-contrast that is possible with appropriate windowing with CR can produce high conspicuity of bladder tumors, given that they are generally outlined by low-attenuation urine in the early phases of a multi-phase CT and by excreted intravenous contrast in the delayed/excretory phase. Fig. 2 is an example of the typical appearance of muscle-invasive bladder cancer (arrows), with a primarily intraluminal tumor that grows along the bladder wall, demonstrates some degree of heterogeneity, and contains frond- like projections. These characteristics are appreciated on both 2D multi-planar reformatted images as well as the CR visualizations. However, the heterogeneity of the tumor at its interface with the bladder wall is more apparent on CR.”
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press) - "Muscle-invasive urothelial cancers are aggressive tumors and frequently metastasize. The high contrast and detail inherent to CR images provides adequate visualization of both primary and metastatic urothelial tumors. Beyond that, the CR technique demonstrates the internal heterogeneity and textural features of tumors, and may be able to improve efforts at radiomic- and machine-learning-based prognosis.”
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press) - “A variety of pathologic conditions involving the urinary bladder are amenable to evaluation with CR. The intrinsic high surface detail and image depth of CR, combined with the potential to display structures with widely varying attenuations in single images by appropriate manipulation of presets and trapezoidal functions on voxel histograms, and the textural features that become apparent with CR visualizations, all indicate this technique may become an important part of CT evaluation of the bladder. Further study will be needed to elucidate the specific scenarii in which CR adds clinical value.”
Evaluation of the urinary bladder using three-dimensional CT cinematic rendering
S.P. Rowe, A.R. Meyer, MA Gorin, L.C. Chu, E.K. Fishman
Diagnostic and Interventional Imaging (2020) (in press)
- Air in the Bladder: Differential Dx
• Gas-forming urinary tract infection (typically E coli),
• a bowel-bladder fistula
• recent instrumentation
- “Although calcification is seen in rare in- stances as a sequela of previous infections, schistosomiasis, previously treated malig- nancy, and even intravesical bacille Calmette-Gue?rin therapy, the presence of any calcifi- cation along the bladder wall, particularly in association with bladder wall thickening, should prompt further evaluation with cystoscopy.”
Bladder Malignancies on CT: The Underrated Role of CT in Diagnosis
Raman SP, Fishman EK
AJR 2014; 203:347–354 - “The presence of a discrete bladder mass or nodule should be considered suspicious for malignancy . In many cases, such lesions may be better appreciated on early phase images when surrounded by low-attenuation urine, particularly when the lesion is avidly enhancing, although a discrete filling defect may not be difficult to appreciate on delayed images when the nodule is large.”
Bladder Malignancies on CT: The Underrated Role of CT in Diagnosis
Raman SP, Fishman EK
AJR 2014; 203:347–354 - “ Evaluation of the bladder has been largely considered the domain of cystoscopy, and
the bladder regularly goes ignored by the radiologist. However, several imaging findings should strongly suggest the presence of malignancy whether CT is performed as CT urography for hematuria or routinely in the emergency setting. The cases in this article illustrate the importance of early phase imaging through the bladder, which is often the most sensitive technique for detecting subtle urothelial thickening, nodularity, and hyperenhancement that may suggest the presence
of an underlying tumor.”
Malignancies on CT: The Underrated Role of CT in Diagnosis
Raman SP, Fishman EK
AJR 2014; 203:347–354 - “In other words, although TCC has typically been regarded as a hypovascular tumor, these lesions have considerable urothelial hypervascularity and are typically most conspicuous on early phase images. As a result, any focal hyperenhancement of the bladder urothelium must be considered suspicious for malignancy.”
Malignancies on CT: The Underrated Role of CT in Diagnosis
Raman SP, Fishman EK
AJR 2014; 203:347–354 - Mimics of Bladder Cancer on CT
- Inflammatory Cystitis
- Radiation cystitis
- Bladder hematoma or blood clot
- Enlarged prostate
- Bladder leiomyoma
- Bladder lymphoma
- “ Multidetector computed tomography (MDCT) cystography is rapidly becoming the most recommended study for evaluation of the bladder for suspected trauma.”
Bladder trauma: multidetector computed tomography cystography
Ishak C, Kanth N
Emerg Radiol (2011)18:321-327 - Bladder Trauma: Facts
Trauma mechanisms
- Blunt trauma (60-85%)
- Penetrating trauma (15-40%)
- Iatrogenic trauma (5%) - Bladder Trauma: Facts
- GU trauma occurs in 5-10% of all patients with trauma
- Bladder injury occurs in 1.6% of blunt trauma cases
- Bladder rupture occurs in 2-11% of patients with pelvic trauma
- However, 60-90% of patients with bladder rupture have a pelvic fracture - Bladder Trauma: Facts
- 70-80% of cases are extraperitoneal rupture
- 15-20% of cases are intraperitoneal rupture
- 5-10% of cases are combined bladder rupture
- intraperitoneal rupture has higher morbidity and mortality
- Calcifications in the Ureter and Bladder: Differential Dx
- TB
- Schistosomiasis
- Alkaline encrusted pyelitis
- Radiation injury
- "Bladder cancer tends to show peak enhancement with the 60-second scanning delay. Multidetector row helical CT is useful in the detection and staging of bladder cancer."
Bladder Cancer: Analysis of Multidetector Row Helical CT Enhancement Pattern and Accuracy in Tumor Detection and Perivesical Staging
Kim et al.
Radiology 2004; 231:725-731
- "Sensitivity and specificity in the diagnosis of perivesical invasion were 89% and 95% respectively, in 67 patients and increased to 92% and 98% respectively, in 44 patients with a time interval of 7 or more days between TURP and CT."
Bladder Cancer: Analysis of Multidetector Row Helical CT Enhancement Pattern and Accuracy in Tumor Detection and Perivesical Staging
Kim et al.
Radiology 2004; 231:725-731
- "The cancer detection rate and positive predictive value for cancer detection was 97% and 95% respectively, in 67 patients and increased to 100% and 100% in 44 patients with a time interval of 7 or more days between TURP and CT."
Bladder Cancer: Analysis of Multidetector Row Helical CT Enhancement Pattern and Accuracy in Tumor Detection and Perivesical Staging
Kim et al.
Radiology 2004; 231:725-731
- Bladder Cancer Enhancement
Attenuation Value 40 second scanning delay 60 second scanning delay 100 second scanning delay Mean plus standard deviation 75 ± 14 106 ± 14 84 ± 14 range 55-107 78-129 55-119
Radiology 2004; 231:725-731