Elliot K. Fishman M.D.
Johns Hopkins Hospital

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In a patient with hematuria, CT urogram should be performed, and includes precontrast, arterial, venous and delayed acquisitions

• All 4 phases are required to evaluate for both renal and urothelial neoplasms
• Radiation exposure can be reduced by use of mAs and kVp modulation techniques, as well as limiting coverage
  • Precontrast– kidneys only
  • Arterial @ 25-30 seconds – abdomen and pelvis
  • Venous @ 60 seconds– abdomen only
  • Delayed @ 5 minutes– top of kidneys through bladder

• Arterial phase imaging through the bladder can disclose bladder cancer as well as the delayed phase in many cases.
• Urothelial masses will enhance against the background of low attenuation urine
• Bladder distention is important in these cases (patient should drink water prior the CT).

77 year old woman with papillary transitional cell cancer of the bladder

“ 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

Radiology 2004; 231:725-731

Bladder Diverticula

• Bladder cancer occurs in 0.8-10% of patients with diverticula
  • Region of relatively higher malignant risk due to urinary stasis
• TCC is most common pathology in a diverticulum
• Lack of muscular layer may facilitate tumor extension.
• Transurethral diagnosis and treatments are challenging in these patients

Urachus (Adenocarcinoma)

• 1/3 of bladder adenocarcinoma occurs within the urachus

79 year old male with history of bladder diverticula and recent onset hematuria

Axial (A), sagittal (B) and coronal (C) images from oral and IV contrast enhanced CT show multiple large bladder diverticulae, one of which contains a soft tissue mass (arrow).

• Traditional belief was that TCC within diverticular disease portended an ominous prognosis.
• In cohort of 39 patients with bladder diverticular TCC, 1/3 of patients had superficial disease, 1/3 had superficially invasive tumors and 1/3 had invasive (extra diverticular) disease
• Prognosis was related to tumor extension alone without correlate to anatomic location (diverticulum).

57 year old male with recurrent bouts of right pelvic pain “concerning for prostatitis”. Images from outside CT.

Precontrast (A), venous phase (B) and delayed phase (C) axial images from IV contrast enhanced CT show an enhancing mass posterior to the right bladder wall.

Differential diagnostic considerations included a mass arising from the seminal vesicle, paraganglioma/neuroendocrine tumor, adenopathy or a diverticulum (although no communication with the bladder was observed. Repeat CT and MRI imaging were performed…

“BPG is a rare bladder tumor that is often missed by clinicians. It can be predicted based on micturition attacks and/or signs and symptoms of catecholamine excess. We suggest that bladder tumors larger than 3 cm in diameter can be used as an additional predictor of functional BPG. Patients who are suspected to have functional BPG should undergo MRI scan, 123/131 MIBG scan, and have their catecholamine levels tested. Once a functional tumor is confirmed, patients should be initiated on fluid replacement therapy and adrenergic blockade to abate the disorders associated with catecholamine excess.” 
Bladder Paraganglioma: Three Cases Report and Literature Review 
Yaoji Yuan et al.
International Medical Case Reports Journal 2021:14 765–771 

“Bladder PGLs are rare, representing less than 6% of all extraadrenal PGLs, and less than 0.06% of all bladder tumors. In a systematic review of 106 patients, the mean age at presentation was reported as 43 years, ranging from 11to 84 years, with similar figures reported more recently byZhai et al. (mean age 50 years). However, in a cohortwhich included genetically high-risk individuals undergoingregular screening, a lower average age at presentationof 29 years has been reported. The incidence is almostequal between males and females. As with pheochromocytomas it is not possible to determine which bPGL are malignant from imaging or pathological assessment; all bPGL should be considered to have some malignant potential, with malignancy only confirmed with development ofmetastatic disease.”
Bladder paragangliomas: a pictorial review
Samuel J. Withey et al.
Abdominal Radiology (2022) 47:1414–1424

”On CT, bPGLs are usually identified with reported sensitivity of up to 91%. They may be more challenging to identify if the bladder is underfilled or if the image acquisition phases are suboptimal or too few. Submucosal and intramural location can be suggested on CT. Avid arterial enhancement is classic. When large, bPGL can be seen extending into the bladder wall and the presence of prominent peritumoral vessels may suggest the diagnosis . Calcification, although not a specific finding, can be easily identified on CT.”
Bladder paragangliomas: a pictorial review
Samuel J. Withey et al.
Abdominal Radiology (2022) 47:1414–1424

”Bladder PGLs are rare, complex tumors that require multidisciplinary input from the radiologist, urologist, oncologist, endocrinologist, and geneticist. Imaging plays a key role at all stages of their diagnosis, staging, management, and follow-up. An understanding of the contents of this manuscript should equip the radiologist with the information required to identify these tumors and to advise on the appropriate imaging at each stage of the patient journey.”
Bladder paragangliomas: a pictorial review
Samuel J. Withey et al.
Abdominal Radiology (2022) 47:1414–1424