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OConnor et al.
Hematuria
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Residents Section
Structured Review Article
Residents
inRadiology
Owen J. OConnor 1
Edward Fitzgerald2
Michael M. Maher 3
OConnor OJ, Fitzgerald E, Maher MM
Imaging of Hematuria
OBJECTIVE. In this article, we will discuss the current status of imaging in patients with
hematuria of urologic origin. Issues impacting evaluation of these patients with radiography,
excretory urography, retrograde pyelography, and sonography will be discussed.
CONCLUSION. Conventional radiography has no role in the detection of renal or
urothelial carcinoma. Low-dose CT offers much greater sensitivities for the detection of uri
nary tract calculi than radiography at doses equivalent to conventional radiography. Ultra
sound alone is insufficient for imaging of hematuria. Using ultrasound alone, it is often dif
ficult to differentiate renal transitional cell carcinoma from other causes of filling defects of
the renal collecting system such as blood clots, sloughed papillae, or fungus balls. The promi
nence of the role of excretory urography in the evaluation of patients with hematuria has di
minished, and MDCT urography is now preferred to excretory urography in most cases.
CME
This article is available for CME credit.
See www.arrs.org for more information.
WEB
This is a Web exclusive article.
AJR 2010; 195:W263W267
0361803X/10/1954W263
American Roentgen Ray Society
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Hematuria
Fig. 4
Retrograde
pyelogram in
77-year-old
woman with
transitional cell
carcinoma of
ureter shows
filling defect
(arrow) in
mid ureter.
This finding
is sometimes
referred to as
goblet sign.
Associated
proximal
hydronephrosis
and hydroureter
are also shown.
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OConnor et al.
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C
likely to be echogenic, which presents the ra
diologist with a problem in distinguishing a
small RCC from an angiomyolipoma [15].
Surveillance imaging or correlation with CT
is prudent in such cases.
Renal pelvic TCC typically appears as a cen
tral soft-tissue mass in the echogenic renal si
nus with or without hydronephrosis [7] (Fig. 7).
Renal sinus fat frequently hampers the detec
tion and exclusion of TCC in this region [15].
The sonographic appearances of TCC vary de
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Hematuria
and correlating imaging findings on ultra
sound and CT urography can be very help
ful. Although lesions may extend into the
renal cortex and cause focal contour distor
tion, TCC is typically infiltrative and does
not cause renal contour distortion [7].
The sensitivity of ultrasound for the detec
tion of bladder TCC has been reported as be
ing as high as 95% [15]. Bladder TCC typi
cally appears as a nonmobile mass or focus
of urothelial thickening. These findings are
not specific and must be confirmed by cys
toscopy and biopsy to exclude mimics of
TCC including cystitis, bladder outlet ob
struction, hematoma, postoperative change,
prostate carcinoma, lymphoma, neurofibro
matosis, and endometriosis [15].
Conclusion
In imaging patients with hematuria, radi
ography has no role in the detection of re
nal or ureteric neoplasms and its choice for
the detection of urinary calculi is now ques
tionable with the advent of low-dose MDCT.
Ultrasound remains an important diagnostic
tool for the evaluation of hematuria in chil
dren and in low-risk patients and for char
acterizing bladder abnormalities and cystic
renal lesions. Retrograde pyelography re
mains useful for the evaluation of indetermi
nate ureteric and bladder filling defects. Ul
trasound and excretory urography need to be
combined for the evaluation of renal and ure
teric malignancy, but CT urography and MR
urography are emerging as one-stop diagnos
tract abnormalities: initial experience with multidetector row CT urography. Radiology 2002;
222:353360
9. Kluner C, Hein PA, Gralla O, et al. Does ultralow-dose CT with a radiation dose equivalent to
that of KUB suffice to detect renal and ureteral
calculi? J Comput Assist Tomogr 2006; 30:44
50
10. Grossfeld GD, Litwin MS, Wolf JS, et al. Evalua
tion of asymptomatic microscopic hematuria in
adults: the American Urological Association best
practice policy. Part I. Definition, detection, prev
alence, and etiology. Urology 2001; 57: 599603
11. Cowan NC, Turney BW, Taylor NJ, McCarthy
CL, Crew JP. Multidetector computed tomogra
phy urography for diagnosing upper urinary tract
urothelial tumour. BJU Int 2007; 99:13631370
12. European Association of Urology Website. Tise
lius HG, Alken P, Buck C, et al. Guidelines on
urolithiasis. www.uroweb.org/nc/professional-re
sources. Published 2008. Accessed June 7, 2010
13. Shine S. Urinary calculus: IVU vs CT renal stone?
A critically appraised topic. Abdom Imaging
2008; 33:4143
14. Van Der Molen AJ, Cowan NC, Mueller-Lisse
UG, Nolte-Ernsting CC, Takahashi S, Cohan RH;
CT Urography Working Group of the European
Society of Urogenital Radiology (ESUR). CT
urography: definition, indications and techniques:
a guideline for clinical practice. Eur Radiol 2008;
18:417
15. Thurston W, Wilson SR. The urinary tract. In:
Rumack CM, Wilson SR, Charboneau JW, eds.
Diagnostic ultrasound, 3rd ed. St. Louis, MO: El
sevier Mosby, 2005:321393
APPENDIX 1: Risk Factors for the Development of Renal and Urologic Malignancies
Age > 40 years
Gross (macroscopic) hematuria
Smoking
Obesity
Analgesic abuse (e.g., phenacetin)
Exposure to chemical carcinogens (e.g., aromatic amines)
Occupational carcinogens (e.g., metal workers, painters, rubber manufacture)
Chronic inflammation of urinary tract (e.g., calculi, diverticula, and infection)
Congenital anomalies (e.g., horseshoe kidney)
Pelvic irradiation
F O R YO U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.
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