Bladder Carcinoma

00:01 So let's talk a little bit about imaging of the urinary bladder.

00:04 The urinary bladder is a very thin walled structure that?s located within the pelvis. It's best seen on CT and ultrasound images.

00:13 Delayed CT images results in filling of the bladder with contrast, so that the wall can no longer be seen and to look for bladder abnormalities, a contrast-enhanced CT scan performed in the delayed phase, is really the ideal imaging study.

00:26 On ultrasound it appears as a fluid filled structure, and grows abnormalities can be seen on ultrasound as well.

00:33 So doppler imaging can be used to identify the ureteral jets.

00:36 Ureteral jets are jets of urine that enter the urinary bladder from each ureter.

00:40 When the bladder is not fully distended with urine, the wall may appear artifactually thickened on both ultrasound and CT.

00:47 So the delayed phase of a CT urogram is really the best to be able to see a fully distended urinary bladder.

00:53 If the bladder is being evaluated by ultrasound, the patient is asked to drink before the ultrasound, so that the bladder can be filled.

01:00 This is the normal CT appearance of the urinary bladder, when it's not filled with contrast, you can see that it's a fluid-filled structure within the pelvis and this is relatively distended.

01:10 You can see its oval shape and a very thin wall, which is actually not that well seen.

01:15 On ultrasound it appears to be again of fluid-filled sac.

01:18 You can see that it's completely anechoic and you don't see the wall and ultrasound as well either.

01:23 This is an example of doppler ultrasound and how it's used to see the ureteral jets bilaterally.

01:28 This is an example of the right jet and the left jet and if you actually don't see that ureteral jets then it could signify a ureteral obstruction.

01:38 So it's important to try the doppler ultrasound and make sure that both jets are visualized.

01:42 So bladder carcinoma is one the most common malignancies of the urinary bladder and it's usually a transitional cell carcinoma.

01:48 The imaging appearance is usually a focal thickening of the wall of the urinary bladder or it can present as a focal soft tissue density seen within the urinary bladder.

01:58 Cystitis is one of the most common differentials in a patient with bladder wall thickening.

02:02 This is inflammation of the urinary bladder.

02:05 So let's take a look at some imaging findings of cystitis.

02:08 Cystitis can result in diffuse thickening of the urinary bladder wall.

02:11 There's increase wall enhancement because of hyperemia and inflammatory changes that surrounds the urinary bladder walls.

02:18 So if you take a look at this image here, this is urinary bladder which is fluid-filled and that appears normal.

02:23 This is probably a very small area of the of the foley catheter, that's seen here and then here you see diffuse bladder wall thickening.

02:32 You can also see a little bit of inflammation surrounding the urinary bladder here.

02:36 And this is a classic finding of cystitis.

02:39 So emphysematous cystitis is a very rare infection of the urinary bladder and that's caused by a gas producing organism.

02:46 It causes the appearance of air in the wall of the urinary bladder.

02:50 So let's take a look at this image.

02:52 If you remember this image is performed in lung windows which are very useful to identify any abnormal collections of air.

02:58 And you can see here, this is the urinary bladder.

03:01 Again, not as well seen because it's in lung window and not in soft tissue window. However, what we do see well is a focus of air within the urinary bladder, which maybe from recent bladder manipulation or it maybe from a gas producing organism, which is very likely in this case, if you look at the urinary bladder wall, there's actually quite a bit of air within the urinary bladder wall, which is again typical in a case of gas producing organism.

03:25 So let's take a look at this case. This patient is presenting with hematuria.

03:30 You can pause here and take a good look at the findings.

03:39 So what do you see here? The urinary bladder is not fully distended which again can artifactually thicken the urinary bladder wall.

03:46 However, there is pretty significant diffuse thickening of the bladder wall, which looks like it's real.

03:51 It doesn't look like it's just due to artifactual decompression.

03:54 There also some mild surrounding inflammatory changes that we see.

03:58 So the differential in this case include cystitis or bladder carcinoma.

04:02 And the really the only way to differentiate is with cystoscopy and urine cytology.

04:07 We can give an idea based on the imaging that there is an abnormality and then further evaluation is always done with cystoscopy.

04:13 So what do you think about the calcified structure superior to the urinary bladder? So here we have contrast within the urinary bladder and then here we have multiple coarse calcifications just above the urinary bladder, including this large one right here, what do you think this represents? A hint is this is a female patient.

04:37 So this is a calcified uterine fibroid or multiple calcified uterine fibroids, and this is common to see in females and the location of the uterus is again just above the urinary bladder.

04:50 In this patient the diagnosis was actually bladder carcinoma, and this was confirmed with cystoscopy.

04:56 So bladder carcinoma can be highly suspected on imaging but again it can't be diagnosed unless they're sampling.

05:01 But it should always be included along with a differential diagnosis of a possible cystitis.

05:07 So let's take a look at another case.

05:11 This patient is presenting with left flank pain and hematuria.

05:15 So what do you see? Again, take a good look at this study.

05:18 You can pause and take a good look.

05:25 This is the non contrast examination and it was performed to evaluate for stones.

05:29 Given the history of left flank pain and hematuria.

05:32 No stones were identified and this patient was sent off.

05:34 So what do you think this is? This wasn't seen on the initial examination because it's a very subtle finding, and again the examination was performed to evaluate for stones.

05:51 Unfortunately, this patient came back two years later, and these are now the findings. So take a good look at this and what do you see here? This is urinary bladder, this is fluid within the urinary bladder, and then you see all of this around here which is diffuse irregular thickening, with some nodularity.

06:09 You also see surrounding inflammatory change.

06:18 So this patient actually had interval progression of bladder carcinoma, which went undetected for two years, given the very subtle findings seen on the initial CT scan.

06:27 So the important thing to remember here is make sure that you look at the entire study.

06:33 Don't focus on the clinical history because often times that's something that will throw you off and you may miss an important finding.

06:39 So whenever you're looking at any kind of radiological study.

06:42 It's important to look at the entire study from top to bottom and not focus on one area. So in this lecture we've reviewed multiple abnormalities of the urinary bladder. So something to keep in mind as we further review the rest of radiology.