Clinical Urology IVU AND US IN BLADDER CARCINOMA DIAGNOSIS

International Braz J Urol Vol. 30 (3): 185-191, May - June, 2004

Official Journal of the Brazilian Society of Urology

ROLE OF INTRAVENOUS UROGRAPHY AND TRANSABDOMINAL

ULTRASONOGRAPHY IN THE DIAGNOSIS OF BLADDER CARCINOMA
MUHAMMAD RAFIQUE, ABRAR A. JAVED

Instar Medical College, Multan, Pakistan

ABSTRACT

Introduction: The present study was carried out to compare the efficacy of transabdominal
ultrasonography and intravenous urography in the diagnosis of bladder carcinoma in those patients
presenting painless hematuria.
Materials and Methods: Medical records of 100 patients who had both ultrasonography and
intravenous urography were studied. The reported findings of these investigations were correlated
with those of cystoscopy.
Results: Ultrasonography was significantly more sensitive (96%) in the detection of bladder
carcinoma compared to urography (87%). By applying the test of equality of proportions, the value of
Z is 2.28, which is statistically significant (p < 0.01). In addition, ultrasonography was more sensitive
in clarifying the pathology in upper renal tracts i.e. ureteric obstruction secondary to bladder carcinoma
when urography failed due to none or poor excretion of contrast.
Comments: We recommend the use of ultrasonography as the initial radiological investigation
for detection of bladder carcinomas in patients presenting hematuria. Ultrasonography is safe, easily
available, cost effective and provides images of both upper and lower renal tract. Patients diagnosed
to be suffering from bladder carcinoma by ultrasonography should be scheduled directly and promptly
for cystoscopy and bladder tumor resection.

Key words: bladder; bladder neoplasms; ultrasonography; intravenous urography

Int Braz J Urol. 2004; 30: 185-191

INTRODUCTION Ultrasonography is safe and easily available and

provides images of both upper and lower renal tract.
Bladder cancer is a disease of significant Confirmation of the bladder carcinoma requires
concern. In Europe (1) and USA (2) it is the fourth cystoscopy and histopathological diagnosis of the
most common cancer in men. In Pakistan, it is one of resected tumor tissue.
the top ten common cancers in men and is the most The present study was carried out in the
common urological malignancy. The majority of departments of Urology and Oncology of Nishtar
patients present painless hematuria, usually as the Medical College Hospital, Multan, to compare the
sole presenting symptom (3). It has been the standard efficacy of urography and ultrasonography in the
urological practice to request an intravenous urogram diagnosis of bladder carcinoma.
as the initial radiological investigation of patients with
hematuria. Various authors have reported on the use MATERIALS AND METHODS
of transabdominal ultrasonography as the initial
radiological investigation for detection of bladder In this case controlled retrospective study
carcinomas in patients presenting hematuria (4-6). medical records of 122 patients who presented

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painless hematuria secondary to bladder carcinoma Table 1 – Failure of urography to detect bladder carcinoma
from January 2001 to June 2003 were evaluated. Only (n = 13).
those patients who had both ultrasonography of
urinary tract and urography were included in the study.
A hundred patients satisfied this criterion. Those Clots in bladder 3
Poor excretion of contrast 1
patients who had only one investigation i.e. urinary
Small tumors 6
tract ultrasonography or urography and those who had Anterior wall tumor 1
hematuria secondary to any other pathology like Small capacity bladder 1
urinary tract stones, renal carcinoma etc. were Deformed bladder 1
excluded from the study. Urinary tract ultrasonography
and urography were performed by different duty
consultant radiologists. Ultrasonography was contralateral nephrogram. In 9 patients there was non-
performed with Toshiba just vision and Toshiba excretion of contrast on one side. On the other hand
Capasi machines available in the radiology urinary tract ultrasonography detected the bladder
department. All patients had renal tract and carcinoma in 96 (96%) patients. In addition,
abdominal ultrasound examination performed with ultrasonography accurately determined the size,
full bladder. The bladder was examined with location and multiplicity of bladder carcinomas.
transverse and vertical probes. Scanning was Ultrasonography failed to detect bladder carcinoma in
performed both pre and post micturition. Urography 4 patients (Table-2). In 3 patients bladder carcinoma
was carried out following empiric bowel preparation was missed on ultrasonography, all these tumors were
and included plain KUB X-ray and 5 min, 15 min, small and less than 0.5 cm. In one patient, the
30 min and post void films. It was done without radiologist failed to detect a 3.5 cm bladder carcinoma
tomography. and reported it as a vesical stone. In all those cases
All patients underwent cystoscopy and when urography failed to provide information about
transurethral resection of bladder carcinoma. the upper urinary tract, ultrasonography accurately
Confirmation of the bladder carcinoma was achieved defined the pathology. In 3 patients there was unilateral
by histopathogical examination of the submitted absence of kidneys and in 11 patients there was
tumor in each case. hydronephrosis and hydroureter secondary to ureteric
In all cases the reported findings of urinary involvement by bladder carcinoma.
tract ultrasonography and urography were correlated Smaller tumors detected on ultrasonography
with those at cystoscopy. are shown in Figures-1 and 2 while smallest tumors
detected on urography are shown in Figures-3 and 4.
RESULTS The data show that the proportion of the
correctly detected bladder carcinoma by
The patient’s age ranged from 18 years to 85 ultrasonography is higher (0.96) than this proportion
years (average 55 years). Male to female ratio was 4:1. by urography (0.87). For testing of this hypothesis
Thirty seven patients had superficial and 63 patients we applied the test of equality of 2 proportions. The
had invasive bladder carcinoma. In 87 (87%) patients value of Z is 2.28, which is statistically significant (p
urography accurately diagnosed the bladder carcinoma. < 0.01).
In 13 patients urography failed to suggest the diagnosis
due to various reasons (Table-1). In 86 patients there Table 2 – Failure of ultrasonography to detect bladder
was no abnormality in the upper urinary tracts while carcinoma (n = 4).
in 14 patients various findings were reported. There
was unilateral non-excretion of contrast in 3 patients Small tumors 3
with history of previous nephrectomy. In 2 patients Tumor falsely reported as vesical stone 1
there was good unilateral excretion but only

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Figure 1 – A small tumor 0.9 x 0.6 cm in left posterolateral wall Figure 2 – A tumor 1.8 x 1.4 cm in left posterolateral wall of
of urinary bladder. urinary bladder.

Figure 3 – An intravenous urogram showing a small papillary Figure 4 – An intravenous urogram showing a small solid tumor
tumor as filling defect in the right lateral wall of urinary bladder. as filling defect in the right lateral wall of urinary bladder.

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DISCUSSION ultrasound. The echogenic line around the bladder is

absent when a tumor has invaded the bladder wall
The standard initial investigations most (14). Transabdominal ultrasonography is a simple and
useful for patients presenting painless hematuria quick investigation. It requires no special preparation
secondary to bladder carcinoma include urine and is not associated with any complication inherent
microscopy, urine cytology, intravenous urography to urography. It can safely be performed in elderly
and ultrasonography. patients and those with renal failure.
The traditional initial radiological investigation Factors that affect the detection of bladder
has been intravenous urography. Useful information carcinoma include the operator’s skill, obesity of
about the primary bladder carcinoma can be obtained patient and degree of bladder distension (15). Accurate
from urography (7). Scrupulous technique is required detection also depends on the size and location of
to eliminate artifacts caused by under-filling or tumor. Tumors smaller than 0.5 cm can be difficult to
external compression (8). Large tumors appear as detect (16) and tumors located in the bladder neck
filling defects in the bladder on cystogram phase of and dome can also be missed on sonography (17).
urogram. Small tumors may not be seen on urography Regardless of the location and size,
as they are lost in the contrast medium in full bladder sonographic detection rates of bladder carcinoma
and in postvoid films it may be difficult to recognize range from 82% to 95% (16,17). In the present study
them as the urothelium of collapsed bladder adopts a the sonography detected 96% bladder carcinomas and
corrugated configuration. Tumors within a bladder the smallest carcinoma detected was 0.8 cm in size.
diverticulum may not be seen on urography (9). The major argument in favor of retaining the
Urography has its own risks. It exposes the patient to urography as the initial investigation is the exclusion
a small risk of ionizing radiation, equivalent to a 0.1% of synchronous multifocal urothelial carcinoma in the
incidence of radiation induced carcinoma (10) and upper urinary tract (18). Ultrasonography, however,
contrast induced renal failure has been reported in is at a disadvantage compared with urography in that
0.8% of patients without preexisting renal disease normal ureter is not identified and anatomical detail
(11). In addition, severe adverse reactions occur in obtained of the renal pelvis is inferior.
0.22% of the ionic and 0.04% of the non-ionic contrast Urothelial tumors of the upper renal tract are
media examinations (12). rare compared with bladder tumors and most ureteric
The reported detection rates of bladder tumors present upper tract dilatation, which would
carcinomas by urography range from 26% to 86% be identified by ultrasonography (19). In the present
(8,9). In addition authors vary in their confidence in study no synchronous upper renal tract tumor was
detecting small carcinomas, quoting values of 0.5-1 found. The other argument in favor of urography is
cm as their lower limit of sensitivity (5,7,9). that it can detect the ureteral dilatation caused by the
In the present study 87% bladder carcinomas muscle invasive bladder carcinoma (18). However,
were detected at urography and the size of the smallest ureteric dilatation can be documented equally well
tumors detected at urography was 1.5 cm. by sonography (5). Because of the poor or non-
Urography as the standard investigation has excretion of contrast, urography failed to depict the
been increasingly criticized over recent years, since pathology of the affected upper renal tracts in 14
the widespread introduction of ultrasonography. patients. Ultrasonography accurately defined the
Technological improvements in ultrasound equipment pathology in all such cases. In 3 patients no kidney
have brought the diagnostic accuracy of this was present because of previous nephrectomy and in
examination even superior to urography. Ultrasound others there was ureteric dilatation secondary to
depicts the bladder carcinoma as a soft tissue structure involvement of distal ureters by invasive bladder
of low to intermediate echotexture projecting in to carcinomas.
the filled urinary bladder lumen (13). The extent of In the present study ultrasonography was
invasion of bladder wall can be assessed with superior (96%) to urography (87%) in the detection

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of bladder carcinoma. By applying the test of equality Ultrasonography is safe, easily available, cost
of proportions the value of Z is 2.28, which is effective and provides images of both upper and lower
statistically significant (p < 0.01). renal tract. We present a flow diagram (Figure-5) that
We recommend the utilization of will be helpful in investigating patients presenting
ultrasonography as the initial radiological with hematuria of suspected bladder carcinoma origin.
investigation for detection of bladder carcinomas in It is hoped that by employing ultrasonography as
patients presenting with hematuria. primary imaging modality in patients with hematuria

Figure 5 – Flow diagram for investigation of patients presenting with hematuria of suspected bladder carcinoma origin.

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more new cases of bladder carcinoma will be detected films necessary as part of intravenous urography for
especially in developing countries where hematuria? BJU Int. 2000; 87: 806-10.
ultrasonography is easily available compared with 10. Mariani AJ, Mariani MC, Macchioni C, Stams UK,
urography. Patients diagnosed to be suffering from Hariharan A, Moriera C.: The significance of adult
bladder carcinoma by ultrasonography should be hematuria: 1000 hematuria evaluations including a risk-
benefit and cost effectiveness analysis. J Urol. 1989:
scheduled directly and promptly for cystoscopy and
141: 350-5.
bladder tumor resection. 11. Teruel JI, Marcen R, Onaindia JM, Serrano A, Quereda
C, Ortuno J.: Renal function impairment caused by
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Received: August 25, 2003

Accepted after revision: May 12, 2004

Correspondence address:
Dr. M Rafique
5, Altaf Town, Tariq Road
Multan. Pakistan
E-mail: rafiqanju@ hotmail.com

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EDITORIAL COMMENT
In this study, ultrasonography was effective and the need for a process so that patients with a
in showing obstruction and involvement of the lower “negative” ultrasonography do not escape adequate
ureter by the bladder tumor. Ultrasonography does evaluation and followup.
not adequately evaluate the mid or upper ureter or In many countries where computed
the upper collecting system and calices. tomography (CT) scanning is readily available, the
Regarding excretory urography; it is not, in CT-urogram (multi-phase CT with noncontrast of
most uroradiologist’s opinion, an adequate abdomen and pelvis for calculi, nephrogram phase of
examination for bladder carcinoma, and most will add the kidneys, and delayed imaging of the kidneys and
the caveat of “cystoscopy is necessary to adequately ureters) is becoming the gold standard in evaluating
evaluate the bladder for tumor” or something to that patients suspected of having “surgical” hematuria not
effect. The intravenous urography, done well (i.e. with due to simple stone disease. However, this “high-tech”
nephrotomography), does provide excellent approach has disadvantages, i.e. higher radiation dose,
evaluation of the ureters and upper collecting system high cost and impact on health care costs and, of
and that is its role; it thereby precludes the need for course, availability.
retrograde ureteropyelography either at the time of Regarding the evaluation of bladder cancer,
cystoscopy or later if the cystoscopy is negative. it is my impression that cystoscopy and biopsy is the
But, in many countries, this approach of gold standard. Newer magnetic resonance imaging
ultrasonography as the initial evaluation of patients techniques may ultimately be helpful, but
with hematuria and suspected bladder cancers makes confirmation of efficacy is still in progress.
considerable sense as optimizing provision of health The paper presents a nice flow diagram of
care, recognizing the limitations of ultrasonography patient management.

Dr. William H. Bush, Jr.

Director, Genitourinary Radiology
University of Washington Medical Center
Seattle, Washington, USA

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