Haematuria: an imaging guide

[Urinary bladder tamponade-an urological emergency]

BACKGROUND

Urinary bladder tamponade is a urological emergency that is part of the clinical routine of every urologist and requires immediate and adequate diagnosis and therapy.

OBJECTIVES

Presentation of the clinical picture of urinary bladder tamponade including etiology, diagnostics, and therapy as well as formulation of recommendations for action for clinical routine.

MATERIALS AND METHODS

Structured presentation of the diagnosis and therapy of urinary bladder tamponade with practical recommendations for action based on a current literature search and a clinical case study.

RESULTS

Urinary bladder tamponade is a usually painful filling of the urinary bladder with blood clots as part of gross hematuria. The central pillars of diagnostics are anamnesis, targeted physical examination, and sonography. Therapy involves the rapid insertion of a flushing catheter with manual evacuation of the tamponade. A flushing catheter with at least 20 French should be used here.

CONCLUSION

Timely diagnosis and prompt treatment are crucial. This usually includes transurethral catheter insertion with manual evacuation. If the tamponade is unsuccessfully removed, further measures such as endoscopic evacuation or, as a last resort, sectio alta or radical cystectomy are available.

From haematuria to nephroureterectomy via urine cytology-A case study

Upper urinary tract urothelial carcinomas (UTUCs) are uncommon, accounting for only 5%‐10% of urothelial carcinomas. Radical nephroureterectomy with bladder cuff excision is the standard treatment of high‐risk UTUC. Therefore, accurate preoperative diagnosis, including the use of urine cytology, is essential for appropriate patient management. This case study details a patient's pathway from haematuria to nephroureterectomy.

Ultrasonographic and contrast-enhanced CT imaging diagnosis of idiopathic renal hematuria with bilateral hydronephrosis and hydroureter in a dog

A 5-year-old spayed female Maltese presented with a 1-week history of severe hematuria. Abdominal ultrasonography and thoracic, and abdominal computed tomography identified bilateral hydronephrosis and hydroureter due to an obstruction at the left ureter and urinary bladder lesion with no evidence of metastasis. After surgical removal of the material and placement of a temporary ureteral stent, the patient was able to urinate normally. Histological examination revealed a massive blood clot. Based on our review of the literature, this is the first published report describing the imaging diagnosis of obstructive hydronephrosis and hydroureter induced by idiopathic renal hematuria in a dog.

Side-by-side evaluation of virtual non-contrast and post-contrast images improves detection of clinically significant urolithiasis on single-phase split bolus dual-energy CT urography

OBJECTIVES

Studies show insufficient sensitivity of virtual non-contrast (VNC) reconstructions for stone detection in dual-energy CT urography (DE-CTU). The aim of this study was to investigate if side-by-side-evaluation of both VNC and post-contrast images could increase the sensitivity of single-phase split bolus DE-CTU.

METHODS

Consecutive patients with haematuria who underwent split bolus DE-CTU on the same dual-source DE-CT scanner were retrospectively enrolled in the study. Intravenous furosemide and oral hydration were employed. Two readers, independently and then jointly in two separate sessions, recorded the location and the longest axial stone diameter on three randomised sets of images: separate VNC and post-contrast images, and side-by-side-reconstructions. True non-contrast (TNC) images served as the standard of reference.

RESULTS

A total of 83 urinary stones were detected on TNC images. Independent reader side-by-side-evaluation of VNC and post-contrast images yielded higher stone detection sensitivity (76 and 84%, respectively) compared to evaluation of only VNC (71 and 81%, respectively) or post-contrast images (64 and 80%, respectively). The sensitivity of joint reader evaluation of side-by-side-images reached almost 86% and was not significantly different from TNC images (p = 0.77). All stones larger than 3 mm were correctly detected by side-by-side-evaluation. Dose reduction of 55% could be achieved by omitting TNC scans.

CONCLUSION

Side-by-side-VNC and post-contrast image evaluation enable detection of clinically significant urolithiasis on single-phase split bolus DE-CTU with significant dose reduction.

ADVANCES IN KNOWLEDGE

This study shows that single-phase DE-CTU is feasible if VNC imaging is simultaneously utilised with post-contrast images.

Accuracy of ultrasound vs computed tomography scan for upper urinary tract malignancies and development of a risk-based diagnostic algorithm for haematuria in a UK tertiary centre

PURPOSE

There is no consensus across guidelines on a diagnostic algorithm for upper urinary tract (UUT) evaluation following presentation with haematuria. Our aim is to compare the diagnostic accuracy of ultrasound (USS) compared to CT-scan for UUT malignancies and also determine the considerations important for a risk-based diagnostic protocol for haematuria.

METHODS

We reviewed our 'haematuria clinic' database to identify patients who had both USS and CT-scan for UUT evaluation between September 2015 and August 2017, and calculated the diagnostic accuracy of these imaging modalities for histologically confirmed UUT cancers. Furthermore, we identified risk factors in our diagnostic algorithm for haematuria and conducted regression analysis to determine their ability to predict UUT malignancies.

RESULTS

Overall, 575 patient records were studied. Age range was 21-92 years, M:F was 1.4:1, majority (81.2%) had visible haematuria, and 12 (2.1%) UUT cancers were diagnosed [renal cell carcinoma-1.4%; upper tract urothelial cancer-0.7%]. USS and CT-scan had diagnostic accuracy for UUT cancers of 95.8 and 99.1%, respectively (p < 0.001). Haematuria type was a significant consideration only on univariate analysis, while multivariate binary logistic regression showed that male gender, smoking, occupational exposure, and positive urologic history were the main risk factors associated with UUT malignancies.

CONCLUSION

USS and CT-scan have comparably high diagnostic accuracy for detecting UUT malignancies. USS may, therefore, be considered as the first-line UUT imaging modality when utilized in a risk-based diagnostic algorithm. Larger, multicentred studies are needed to validate our findings and influence guideline development.

Split bolus dual-energy CT urography after urine dilution: a one-stop shop for detection and characterisation of urolithiasis

AIM

To determine the diagnostic performance of split-bolus dual-energy computed tomography (CT) urography (SBDECTU) in the detection and characterisation of urolithiasis.

MATERIALS AND METHODS

This single-centre Institute Ethics Committee (IEC)-approved prospective study was conducted from April 2014 to November 2015. One hundred and thirty consenting adults with microscopic haematuria underwent dual-energy true non-enhanced CT (DETNE) of the whole abdomen followed by a SBDECTU. The SBDECTU protocol consisted of synchronous nephrogram-urogram acquisition following urine dilution by oral hydration and normal saline injection. Calculi were detected and characterised using virtual non-enhanced (VNE) images derived from SBDECT were compared with DETNE (the reference standard). The subjective image quality and radiation dose were compared.

RESULTS

Twenty-six participants had one or more calculi (total 129 calculi) detected on DETNE CT. The sensitivity and specificity of VNE on a per-patient basis were 100%. Of the 129 calculi, 118 were detected on VNE, with a sensitivity of 91.47% and an accuracy of 91.47%. Of the calculi, 83.9% (99/118) could be characterised on SBDECTU images. On VNE images, complete iodine subtraction was seen in 73.1% (19/26). By omitting DETNE CT, the mean dose-length product of 537.6±152.9 mGy and volume CT dose index of 10.9±2.9 mGy•cm² could have been saved.

CONCLUSION

SBDECTU has high diagnostic accuracy in the detection and characterisation of clinically significant urinary calculi at potentially half the radiation dose.

Clinics in diagnostic imaging (201). Small bowel intramural haematoma induced by anticoagulation therapy with associated reactive ileus

A 74-year-old woman receiving long-term anticoagulation with warfarin for chronic atrial fibrillation presented with severe acute abdominal pain, diarrhoea and vomiting. Initial laboratory workup revealed a deranged coagulation profile. Computed tomography of the abdomen and pelvis demonstrated spontaneous distal jejunal intramural haematoma with associated reactive ileus. No overt pneumatosis intestinalis, intraperitoneal free gas or haemoperitoneum was seen. Based on clinical and imaging findings, a diagnosis of over-anticoagulation complicated by small bowel intramural haematoma was made. The patient was managed non-operatively with analgesia, cessation of warfarin and reversal therapy with vitamin K. Warfarin therapy was recommenced upon resolution of symptoms and optimisation of coagulation status. The clinical presentation, radiological features and overall management of anticoagulation-induced bleeding are further discussed in this article.

Ultrasound and the Complete Urologist Part 1: Methodology

Computed tomography (CT) scanning is considered as the imaging study of choice for asymptomatic microhematuria according to the American Urological Association guidelines. For those patients with persistence of microhematuria after a negative initial examination, the guidelines suggest repeating the evaluation including CT scanning within 3 to 5 years. However, the cost and risk involved for utilizing this technology going forward is an issue, especially when the yield of finding significant pathology on subsequent imaging studies is exceedingly low. To minimize those concerns, I have proposed incorporating the utilization of ultrasound rather than the guideline-recommended CT for reasons and considerations to be discussed. In addition, I propose extending the use of ultrasound beyond evaluation of asymptomatic microhematuria to the routine urologic physical examination as it is superior to the current standard of palpation and percussion. The original concept of applying sound to a physical examination led to the technique of percussion. Technological advancement has taken the same sound, converted it to a digital image, and allowed us to see what we hear to achieve a greater diagnostic accuracy. The literature on this subject is reviewed and demonstrates support for just such a change in the delivery of urologic healthcare. I conclude by proposing that the quality of urologic care can be enhanced during a routine urologic physical examination through upgrading the technique of palpation and percussion by routinely utilizing ultrasound, creating the Complete Urologist.