Actas Urológicas Españolas

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Actas Urol Esp. 2012;36(10):624---625
Actas Urológicas Españolas
www.elsevier.es/actasuro
LETTERS TO THE EDITOR
Evaluating the role of computerized
tomography triphasic urography in
patients with painless hematuria: A
practical view夽
Evaluar el papel de la urografía por tomografía
computarizada trifásica en pacientes con
hematuria sin dolor: una visión práctica
Dear Sir,
Computed tomography triphasic urography (CTU) is a
relatively new diagnostic imaging examination providing
comprehensive anatomical and clinical evaluation of the
upper and lower urinary tract. As CTU has become more
widely available, CTU began to replace other imaging
techniques, especially intravenous urography and ultrasonography in investigating painless hematuria.1,2 We
assessed our experience regarding the use of CTU as first
line imaging modality in patients with painless hematuria who attended one stop hematuria clinic for flexible
cystoscopy.
A total of 50 patients presented to our institution with
painless hematuria over a two-year period were included.
Mean age was 63.5 years. Male to female ratio was 3:1.
CTU, flexible cystoscopy findings and risk factors were all
documented for each patient. Overall abnormal findings of
CTU were 66% (33/48). 23 patients developed macroscopic
hematuria (Fig. 1). 12 patients were cigarette smokers.
Malignant causes were 3 renal cell carcinomas and 3 bladder
transitional cell carcinomas (TCC) (12%). Cystoscopy findings of bladder tumors corresponded to their CTU results.
Benign causes were 14 renal cysts, consisting of 12 simple and 2 complex (Bosniak II), 3 calculi (1 kidney and 2
ureteric), 1 renal infarction, 4 bladder wall thickening and
1 benign adrenal adenoma. Malrotated and horseshoe kidney were also diagnosed on CTU. All the bladder tumors
that were seen on flexible cystoscopy had been imaged on
CTU.
夽 Please cite this article: Raheem OA, et al. Evaluar el papel de
la urografía por tomografía computarizada trifásica en pacientes
con hematuria sin dolor: una visión práctica. Actas Urol Esp.
2012;36:624---5.
Figure 1 Results of computed tomography triphasic urography (CTU). (A) Phase without contrast: the primary interpolar
tumor is not clearly visible. (B) Nephrographic phase: a solid
lesion (arrowhead) shows uptake in the interpolar region of
the right kidney. (C) Excretory phase: right calyces, pelvis, and
proximal ureter without evidence of hydronephrosis.
CTU can image kidneys, ureters and bladder in one investigation with a greater sensitivity for identifying the cause
of hematuria. This systematic study showed an incidence
of urological malignancy of 12% and overall abnormal findings of 66%. Where available, it is recommended to use CTU
as first-line investigation in hematuria patients, replacing
ultrasonography and intravenous urography, particularly in
high-risk patients. Adding to this, CTU serves as a critical
adjuvant to cystoscopy in evaluating patients with hematuria and excluding bladder carcinoma.
2173-5786/$ – see front matter © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.
Documento descargado de http://www.elsevier.es el 18/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
LETTERS TO THE EDITOR
References
1. 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;18:4---17.
2. O’Keeffe SA, McNally S, Keogan MT. Investigating painless haematuria. BMJ. 2008;337:a260.
Bone metastases in muscle invasive
bladder carcinoma: Clinical consideration夽
Metástasis Óseas en el Carcinoma Vesical
Músculo Invasivo: Examen Clínico
Dear Sir,
Metastatic transitional cell carcinoma (mTCC) of the bladder to the bone is uncommon occurrence when compared
to the breast and prostate carcinoma.1 This may be due to
intrinsic biological properties of tumor cells and/or mechanisms of metastases. Notably, high-grade, muscle-invasive
bladder carcinoma metastasizes more commonly to regional
lymph nodes, at lower rate to the lungs and liver.2---5
We sought to evaluate and establish the prevalence of
bone metastasis of muscle invasive bladder carcinomas in
well-defined cohort of bladder carcinoma patients at a single
academic institution and commented on their subsequent
management over an 8-year period. Between July 2000 and
June 2008, 376 cases of TCC of bladder were diagnosed. Of
these, 8 patients demonstrated mTCC to bony structures.
The male to female ratio was 5---3 and the mean age at the
time of diagnosis was 67.7. TCC grade and stage (T, tumor;
N, nodes; M, metastasis), interval diagnosis of bone metastasis, bone metastasis site, imaging and treatment were also
documented.
The prevalence of bone mTCC of bladder was 0.02%
(8/376). Pathologically, T2 G2 and T3 G2 were the most common histological category (3/8 in each category) whereas
T1b G2 was demonstrated in 2 patients. Spinal and femoral
metastases were the most common bone mTCC bladder (5/8
and 2/8 patients, respectively). One patient with mTCC
had bony metastasis to the ribs. Isotope bone scan was the
imaging modality of choice to establish the bony metastatic
lesions. 4 patients required external beam radiotherapy to
alleviate symptoms of bony metastatic lesions. 2 patients
of femoral metastasis required surgical radical excision and
夽 Please cite this article as: Raheem OA, et al. Metástasis óseas en
el carcinoma vesical músculo invasive: examen clínico. Actas Urol
Esp. 2012;36:625.
625
O.A. Raheem ∗ , R.G. Casey, E. Elmusharaf, D.J. Galvin,
T.E.D. McDermott, R. Grainger , T.H. Lynch
Servicio de Urología, St James’s Hospital, Dublin, Ireland
Corresponding author.
E-mail address: [email protected] (O.A. Raheem).
∗
intramedullary nailing and another 2 patients were treated
with systematic chemotherapy.
We reported on the prevalence of bone mTCC of bladder
and commented on their management. With the advancement of skeletal imaging in the form of isotope nuclear
scans, the metastatic trends are thought to be changing.
Urologists and clinicians should be vigilant to look for bony
lesions in the patients with TCC of the bladder when they
present with bony or skeletal-related pain and should be
prompted by imaging such as isotope nuclear scan. The
answer will only be found in a large randomized study where
patient’s survival and oncological outcomes are endpoints.
References
1. Taher AN, Kotb MH. Bone metastases in muscle-invasive bladder
cancer. Egypt Natl Canc Inst. 2006;18:203---8.
2. Petković M, Muhvić D, Zamolo G, Jonjić N, Mustać E, MrakovćićSutić I, et al. Metatarsal metastasis from transitional cell cancer
of the urinary bladder. Coll Antropol. 2004;28:337---41.
3. Chua WC, Martin PA, Kourt G. Orbital metastasis from transitional
cell carcinoma of the bladder. Clin Experiment Ophthalmol.
2004;32:447---9.
4. Adriazola Semino M, Ortiz Cabria R, García Cobo E, Tejeda Bañez
E, Alonso Villalba A, Romero Rodríguez F. Distal bone metastases
of transitional-cell carcinoma of the bladder. Apropos of a case.
Arch Esp Urol. 2002;55:69---70.
5. Punyavoravut V, Nelson SD. Diffuse bony metastasis from transitional cell carcinoma of urinary bladder: a case report and review
of literature. J Med Assoc Thai. 1999;82:839---43.
O.A. Raheem a,∗ , A. Molloy b , R.G. Casey a , T.H. Lynch a
a
Department of Urology, St James’s Hospital, Dublín,
Ireland
b
Department of Orthopedics, St James’s Hospital, Dublín,
Ireland
Corresponding author.
E-mail address: [email protected] (O.A. Raheem).
∗