Imaging Pearls ❯ GU Misc ❯ Bladder
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- “Paraganglioma is a neuroendocrine neoplasm that secretes catecholamines. Functional BPG may present with elevated levels of catecholamines, especially during micturition. This phenomenon is referred to as “micturition attacks” and is usually manifested by headache, palpitations, and syncope. However, 10% of functional tumors may exhibit only minimal or nonspecific symptoms, which is so dangerous. Seven cases of above did not present typical clinical symptoms, but the blood pressure both rose higher than 200 mmHg during operation.”
Bladder Paraganglioma: Three Cases Report and Literature Review
Yaoji Yuan et al.
International Medical Case Reports Journal 2021:14 765–771 - “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 by Zhai et al. (mean age 50 years). However, in a cohort which included genetically high-risk individuals undergoing regular screening, a lower average age at presentation of 29 years has been reported. The incidence is almost equal 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 of metastatic 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
- "RALRP is a minimally invasive surgery for localized prostate cancer, and its use has increased recently. Intraperitoneal extension of vesicourethral anastomotic leak after RALRP can occur, which is not associated with radical retropubic prostatectomy. MDCT cystography is a fast and accurate method for detection and evaluation of the extent of anastomotic leak after RALRP."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601 - "RALRP provides several advantages over open and laparoscopic prostatectomy, such as precise dissection through improved instrument control with articulating tips, 3D vision and magnified views, intuitive eye-hand coordination, motion scaling, and filter of tremor."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601 - "Robot-assisted laparoscopic radical prostatectomy (RALRP) is a minimally invasive surgery for localized prostate cancer using robotic surgical technology. There has been an evolution of surgical treatment of prostate cancer from open prostatectomy to laparoscopic prostatectomy to RALRP in recent years."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601 - "On CT cystography, when a leak is present, the site and extent of the leak is easily assessed. For an extraperitoneal leak, contrast material extending from the vesicourethral anastomosis confines to the extraperitoneal space. When a pelvic fluid collection or hematoma is seen on CT, CT cystography can show the presence or absence of communication of the anastomotic leak to the pelvic fluid collection or hematoma."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601 - "Intraperitoneal anastomotic leak from vesi- courethral anastomosis is an uncommon complication after RALRP. In patients with intra- peritoneal leak, unenhanced CT often shows ascites. On CT cystography, contrast material from the anastomotic leak extend- ing into the peritoneal space is easily detected."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601 - "The reported incidence of anastomotic leak after open radical prostatectomy is quite variable, ranging from 3.9% to 23% in the prior studies. For laparoscopic radical prostatectomy, anastomotic leak occurred in approximately 10–17% of patients, grossly similar to RALRP."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601 - "Anastomotic leak after RALRP is seen in approximately 10% of patients and is mostly limited to the extraperitoneal pelvic space, which is usually transient and requires no fur- ther intervention. Rarely, intraperitoneal leak may occur after RALRP. Most patients with intraperitoneal leak were treated conserva- tively. MDCT cystography is a fast and ac- curate method for detection and evaluation of the extent of anastomotic leak after RALRP."
Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation With MDCT Cystography With Multiplanar Reformatting and 3D Display
Satomi Kawamoto et al.
AJR 2012; 199:W595–W601
- “CT urography is an accurate noninvasive test for detecting bladder cancer in patients at risk for the disease. The high NPV of CT urography in patients with hematuria may obviate cystoscopy in selected patients.”
Bladder cancer detection with CT urography in an Academic Medical Center.
Sadow CA et al
Radiology. 2008 Oct;249(1):195-202 - “The overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (NPV) for bladder cancer detection were 79% (117 of 149), 94% (649 of 689), 91% (766 of 838), 75% (117 of 157), and 95% (649 of 681) for CT urography and 95% (142 of 149), 92% (634 of 689), 93% (776 of 838), 72% (142 of 197), and 99% (634 of 641) for cystoscopy. The NPV of CT urography was higher in patients evaluated for hematuria alone (98%, 589 of 603).”
Bladder cancer detection with CT urography in an Academic Medical Center.
Sadow CA et al
Radiology. 2008 Oct;249(1):195-202 - “In conclusion, CT urography is an accurate, noninvasive test for detecting bladder cancer in patients at risk for the disease. Unlike cystoscopy, CT urography can be used to evaluate the upper tracts concomitantly, an important step in the evaluation of patients with bladder cancer. The high NPV of CT urography in patients with hematuria could help physicians decide which patients may avoid further evaluation with cystoscopy.”
Bladder cancer detection with CT urography in an Academic Medical Center.
Sadow CA et al
Radiology. 2008 Oct;249(1):195-202 - “However, CT urography is not as accurate in patients with a history of urothelial malignancy, many of whom have had prior bladder tumor resections or intravesical therapy; cystoscopy should remain the test of choice for bladder cancer detection in this patient population.”
Bladder cancer detection with CT urography in an Academic Medical Center.
Sadow CA et alRadiology. 2008 Oct;249(1):195-202
- “Carcinoma of the urinary bladder is the most common malignancy in the Middle East and parts of Africa where schistosomiasis is a widespread problem. Much evidence supports the association between schistosomiasis and bladder cancer: this includes the geographical correlation between the two conditions, the distinctive patterns of gender and age at diagnosis, the clinicopathological identity of schistosome-associated bladder cancer, and extensive evidence in experimentally infected animals. Multiple factors have been suggested as causative agents in schistosome-associated bladder carcinogenesis. Of these, N-nitroso compounds appear to be of particular importance since they were found at high levels in the urine of patients with schistosomiasis-associated bladder cancer.”
Relationship between Schistosomiasis and Bladder Cancer
Mostafa MH et al.
Clin. Microbiol. Rev. January 1999 vol. 12 no. 1 97-111 - “The urachus is a midline remnant of at least two embryonic structures: the cloaca and allantois. It is located extraperitoneally and is bounded by the transverse fascia ventrally and the parietal peritoneum dorsally. This area is called the Retzius space. In late fetal life, the urachus usually deteriorates to a fibrous band, also known as the median umbilical ligament, which extends from the anterior dome of the bladder toward the umbilicus. Incomplete regression of the urachus results in four types of congenital urachal anomalies: patent urachus, umbilical-urachal fistula, vesicourachal diverticulum, and urachal cyst.”
Urachal Carcinoma
Koster IM et al.
Radiographics. 2009 May-Jun;29(3):939-42 - “Although the urachus is normally lined by transitional epithelium, most urachal tumors are adenocarcinomas (90%). These are thought to result from metaplasia of the urachal mucosa into columnar epithelium, followed by malignant transformation. Adenocarcinoma of the bladder is an uncommon neoplasm, accounting for only 0.5%–2% of all bladder carcinomas, and is classified as primary vesical, urachal, or metastatic. Thirty-four percent of bladder adenocarcinomas are urachal in origin. Urachal carcinomas tend to have a male predilection and are found in adults who are between 40 and 70 years old. The most common clinical feature is hematuria. Other signs and symptoms are dysuria, abdominal pain, a suprapubic mass, and discharge of blood, pus, or mucus from the umbilicus.”
Urachal Carcinoma
Koster IM et al.
Radiographics. 2009 May-Jun;29(3):939-42 - “ Adenocarcinoma of the bladder is an uncommon neoplasm, accounting for only 0.5%–2% of all bladder carcinomas, and is classified as primary vesical, urachal, or metastatic. Thirty-four percent of bladder adenocarcinomas are urachal in origin. Urachal carcinomas tend to have a male predilection and are found in adults who are between 40 and 70 years old. The most common clinical feature is hematuria. Other signs and symptoms are dysuria, abdominal pain, a suprapubic mass, and discharge of blood, pus, or mucus from the umbilicus.”
Urachal Carcinoma
Koster IM et al.
Radiographics. 2009 May-Jun;29(3):939-42 - “Because of their extraperitoneal location, urachal carcinomas typically are silent and often show local invasion or metastases to the pelvic lymph nodes, lung, brain, liver, or bone at presentation. The prognosis is slightly better than that of nonurachal adenocarcinomas . Depending on the histologic subtype, stage, and resectability of the tumor, the 5-year survival rate for patients with urachal carcinoma ranges from 6.5%–61%. As in our case, signet-ring tumors are aggressive and tend to have the worst prognosis.”
Urachal Carcinoma
Koster IM et al.
Radiographics. 2009 May-Jun;29(3):939-42 - “An estimated 73,510 new cases of urinary bladder cancer will be diagnosed in the United States (55,600 men and 17,910 women) in 2012.1 Bladder cancer, the fourth most common cancer, is three times more common in men than in women in the United States. During the same period, approximately 14,880 deaths (10,510 men and 4,370 women) will result from bladder cancer. Bladder cancers are rarely diagnosed in individuals younger than 40 years. Because the median age of diagnosis is 65 years, medical comorbidities are a frequent consideration in patient management.”
NCCN Guidelines Version 1.2014 Bladder Cancer - “ More than 90% of urothelial tumors originate in the urinary bladder, 8% originate in the renal pelvis, and the remaining 2% originate in the ureter and urethra. Urothelial (transitional cell) carcinomas, the most common histologic subtype in the United States, may develop anywhere transitional epithelium is present, from the renal pelvis to the ureter, bladder, and proximal two thirds of the urethra. The distal third of the urethra is dominated by squamous epithelium. The diagnosis of squamous cell tumors, which constitute 3% of the urinary tumors diagnosed in the United States, requires the presence of keratinization in the pathologic specimen.”
NCCN Guidelines Version 1.2014 Bladder Cancer - “ The distal third of the urethra is dominated by squamous epithelium. The diagnosis of squamous cell tumors, which constitute 3% of the urinary tumors diagnosed in the United States, requires the presence of keratinization in the pathologic specimen.”
NCCN Guidelines Version 1.2014 - “Of the other histologic subtypes, 1.4% are adenocarcinomas and 1% are small-cell tumors (with or without an associated paraneoplastic syndrome). Adenocarcinomas often occur in the dome of the bladder in the embryonal remnant of the urachus, in the periurethral tissues, or with a signet ring-cell histology. Urothelial tumors often have a mixture of divergent histologic subtypes, such as urothelial (transitional cell) and squamous, adenocarcinoma, and more recently appreciated nested micropapillary and sarcomatoid subtypes. These should be treated as urothelial carcinomas.”
NCCN Guidelines Version 1.2014 Bladder Cancer - “ Approximately 70% of newly detected cases are non-muscle-invasive disease – exophytic papillary tumors confined largely to the mucosa (Ta) (70%) or, less often, to the submucosa (T1) (25%) or flat high- grade lesions (CIS, 5%).These tumors tend to be friable and have a high propensity for bleeding. Their natural history is characterized by a tendency to recur in the same portion or another part of the bladder, and these recurrences can be either at the same stage as the initial tumor or at a more advanced stage.”
NCCN Guidelines Version 1.2014 Bladder Cancer - “An estimated 31% to 78% of patients with a tumor confined to the mucosa or submucosa will experience a recurrence or new occurrence of urothelial (transitional cell) carcinoma within 5 years. These probabilities of recurrence vary as a function of the initial stage and grade, size, and multiplicity. Refining these estimates for individual patients is an area of active research.”
NCCN Guidelines Version 1.2014 Bladder Cancer
- Colovesicle Fistulae: Causes
- Diverticulitis
- Crohns disease
- Foreign body perforation
- Radiation injury
- Surgical misadventure - Colovesicle Fistulae: Facts
- Can be reliably diagnosed with CT using rectal contrast or contrast in the bladder but not both
- Surgery is the treatment of choice to avert complications with high morbidity and mortality
- In crohns disease fistulae usually between ileum and bladder
- Colovesicle Fistulae: Causes
- Diverticulitis
- Crohns disease
- Foreign body perforation
- Radiation injury
- Surgical misadventure - Colovesicle Fistulae: Facts
- Can be reliably diagnosed with CT using rectal contrast or contrast in the bladder but not both
- Surgery is the treatment of choice to avert complications with high morbidity and mortality
- In crohns disease fistulae usually between ileum and bladder - Emphysematous cystitis
“ Emphysematous cystitis is a rare clinical entity, more commonly seen in diabetic, immunocomprimised patients. A conservative treatment approach using antibiotics and bladder catheterization is typically successful, with a complication rate of only 18.8%.”
Emphysematous Cystitis
Reese AC, Stoller ML
Urology 2010 Jun;75(6):1315-6 - Bladder Trauma: Facts
- 10% of GU system injuries are to the bladder
- Bladder injures occur in 1.6% of blunt abdominal trauma cases
- Bladder rupture occurs in 2-11% of patients with pelvic fractures
- 60-90% of patients with bladder rupture have a pelvic fracture - Bladder Trauma: Etiology
- Blunt trauma (60-85%)
- Penetrating trauma (15-40%)
- Iatrogenic trauma (5%) - Bladder Trauma: 5 Categories
- Contusion
- Intraperitoneal (15-20%)
- Interstitial or bladder wall hematoma
- Extraperitoneal (70-80%)
- Combined (5-10%)
---Lower Urinary Tract Trauma
---Sandler CM et al
---World J Urol 16:69-75 - Intraperitoneal Bladder Rupture: Facts
- 15-20% of cases of rupture
- Delayed diagnosis results in increased mortality due in part to risk of chemical peritonitis
- Patients require surgical management - “ MDCT cystography should be done when pelvic fluid is present, especially when there are fractures or gross hematuria, to define which of the patients has a bladder rupture and to define the type of bladder rupture.”
Bladder trauma: multidetector computed tomography cystography
Ishak C, Kanth N
Emerg Radiol (2011) 18:321-327