Urinary: Bladder

Question 1

Which portion of the bladder has a peritoneal cover?

Answer 1

The bladder dome

Question 2

Why do pts with the prune belly developmental anomaly (Eagle Barrett Syndrome) develop cryptorchidism?

Answer 2

Bladder distention interferes with descent of the testes (and causes the hydroureteronephrosis seen in this condition)

Question 3

What type of cancer is most common in a urachal remnant?

Answer 3

Adenocarcinoma (not TCC)

Question 4

Midline soft tissue structure just above the bladder anteriorly with calcifications…

Answer 4

Think adenocarcinoma of a urachal remnant

Question 5

Answer 5

Hutch diverticulum (near ureteral orifice or lateral bladder)

Note: These are associated with ipsilateral reflux (“secondary reflux”).

Question 6

Answer 6

Bladder ears (“transitory exztraperitoneal herniation of the bladder” into the inguinal canal

Note: This is a transient finding during Valsalva and often associated with inguinal hernias.

Question 7

Gross hematuria…

Answer 7

Think bladder cancer first

Note: Microscopic hematuria is less specific.

Question 8

Diffuse circumferential bladder wall thickening…

Answer 8

• Infection/inflammation
• Chronic outlet obstruction
• Transitional cell carcinoma (only if asymmetric and irregular)

Question 9

What is the best contrast phase to look for bladder cancer?

Answer 9

Delayed/excretory phase

Question 10

Most common bladder cancer in children (<10 y/o)

Answer 10

Rhabdomyosarcoma

Question 11

What is the most common subtype of transitional cell carcinoma in the bladder?

Answer 11

Superficial papillary

Question 12

Squamous cell carcinoma of the bladder…

Answer 12

Think schistosomiasis infection (or longstanding suprapubic catheter)

Note: Squamous - Schistosomiasis - Suprapubic.

Question 13

Answer 13

Think schistosomiasis infection and be suspicious of squamous cell carcinoma of the bladder

Note: Any irregular bladder/ureteral calcifications should raise suspicion for squamous cell carcinoma.

Question 14

Adenocarcinoma of the bladder…

Answer 14

Think urachal remnant or bladder exstrophy

Question 15

Urinary hesitancy or dribbling

Answer 15

Think bladder leiomyoma

Note: Smooth, solid, homogenous soft tissue mass.

Question 16

40 y/o F

Answer 16

Think bladder leiomyoma

Note: Smooth, solid, homogenous soft tissue mass in the region of the trigone (most common location).

Question 17

What is the most common benign bladder tumor?

Answer 17

Leiomyoma

Question 18

Why do bladder diverticula cancers tend to have early perivesicle fat invasion?

Answer 18

Bladder diverticula have limited muscle in the wall to slow invasion)

Question 19

What is the most common location for bladder transitional cell carcinoma?

Answer 19

Bladder base (inferior posterior)

Note: Think where urine is most likely to layer dependently.

Question 20

Answer 20

Think papillary type transitional cell carcinoma

Note: These tend to have “frond like” branching (and are lower grade than the more aggressive non-papillary TCC).

Question 21

Which subtype of transitional cell carcinoma is more aggressive?

Answer 21

Non-papillary

Note: The “frond-like” papillary TCCs tend to be lower grade.

Question 22

What is the most common location for a bladder squamous cell carcinoma?

Answer 22

Trigone and lateral walls

Question 23

Bladder flap hematoma

Answer 23

Hematoma that collects between the bladder and uterus due to a defect in the anterior uterine wall (very common, somewhat expected, complication of a c section)

Note: It is generally considered normal if under 4 cm (and not superinfected).

Question 24

Fever s/p cesarean section

Answer 24

Think bladder flap hematoma with superinfection

Note: Fluid-fluid level in a fluid collection between the bladder and uterus s/p c section.

Question 25

Urinary diversion surgery

Answer 25

A broad category of procedures where bowel is used as a conduit or reservoir for urine after a radical cystectomy

Question 26

Common early complications of urinary diversion surgery

Answer 26

• Adynamic ileus (25%)
• Small bowel obstruction (3%)
• Urinary leakage (5%)
• Fistula

Question 27

Where is the most likely transition point if there is a small bowel obstruction shortly following a urinary diversion procedure?

Answer 27

The enteroenteric anastomosis

Question 28

Where is the most likely location of a urine leak following a urinary diversion procedure?

Answer 28

The ureteral-bowel reservoir anastomosis

Question 29

Major risk factor for fistula formation following urinary diversion procedure

Answer 29

Pelvic radiation

Question 30

What are common late complications of urinary diversion procedures?

Answer 30

• Urinary infection
• Urolithiasis
• Parastomal herniation
• Urinary stricture
• Tumor recurrence

Question 31

Major risk factor for parastomal herniation following urinary diversion

Answer 31

Obesity

Note: This occurs in 15% of pts will an ileal conduit. Most don’t require treatment, but 10% will need surgery.

Question 32

Urinary stricture following a urinary diversion procedure is significantly more likely on which side?

Answer 32

The left side (higher risk due to the angulation created as its brought through/under the mesentery)

Question 33

Answer 33

Psoas hitch procedure (pulling one side of the bladder superiorly and sewing it to the psoas muscle so that it can reach a shortened ureter following surgical resection of the distal ureter)

Note: In this case there must have been an injury/stricture/cancer involving the distal left ureter that was resected.

Answer 34

Emphysematous cystitis

Note: The pt is usually diabetic.

Question 35

Bladder is maximally distended

Answer 35

Tuberculosis infection

Note: This is the “thimble bladder” due to wall thickening/contraction.

Question 36

Answer 36

Bladder calcification should make you think schistosomiasis infection and worry about squamous cell carcinoma of the bladder

Note: Any irregular bladder/ureteral calcifications should raise suspicion for squamous cell carcinoma.

Question 37

Bladder fistulas are more common in…

Answer 37

• Men
• Women s/p hysterectomy

Note: The uterus protects the bladder from fistulization for those who have them.

Question 38

What are the most common causes of bladder fistulas?

Answer 38

• Diverticulitis (most common, usually a colovesical fistula)
• Crohns (usually a ileovescial fistula)
• Cancer/trauma (usually a rectovescial fistula)

Question 39

Answer 39

Neurogenic bladder

Note: This is the “pine cone” bladder.

Question 40

Classic imaging appearance of a neurogenic bladder

Answer 40

Small and contracted OR large and atonic

Note: “Pine cone” bladder is the most classic appearance.

Question 41

Neurogenic bladder increases the risk for…

Answer 41

• Urolithiasis
• UTIs
• Bladder cancer

Note: Due to urinary stasis (same reason bladder diverticula have these same risks).

Question 42

Bladder stones are associated with what type of cancer?

Answer 42

Both transitional cell carcinoma (more common) and squamous cell carcinoma

Question 43

Answer 43

Pear shaped bladder, think:

• Pelvic lipomatosis
• Hematoma

Question 44

Best imaging test for suspected bladder trauma

Answer 44

CT Cystography with a water soluble contrast agent

Question 45

How much contrast should you instill in the bladder for cystography in the setting of suspected bladder trauma?

Answer 45

300-400 mL or until detrussor contraction

Note: The key is the bladder needs to be fully distended with water-soluble (NOT barium) contrast.

Question 46

Traumatic bladder rupture is most commonly intraperitoneal/extraperitoneal

Answer 46

Extraperitoneal (80-90% of traumatic bladder ruptures)

Question 47

Trauma

Answer 47

Think extrapeitoneal bladder rupture and recommend cystography or delayed/excretory phase imaging

Note: This is the “molar tooth” sign of extraperitoneal bladder rupture.

Question 48

Molar tooth sign of extraperitoneal bladder rupture is due to contrast accumulation in what potential space?

Answer 48

Prevesicle space of Retzius

Question 49

If there is a traumatic pelvic fracture, the chance of a concurrent bladder rupture is…

Answer 49

10%

Note: If there is a bladder rupture, there is almost always a pelvic fracture.

Question 50

Pathophysiology of traumatic bladder rupture

Answer 50

• Pelvic fracture lacerating bladder (usually extraperitoneal)
• Blunt trauma to an already distended bladder causing it to “explode” (usually intraperitoneal because the bladder dome is the weakest part)

Question 51

Cystogram in the setting of traumatic injury

Answer 51

Intraperitoneal bladder rupture, requiring surgery

Note: Contrast is spreading “freely” in the peritoneal cavity, including left parabolic gutter (yellow arrow).

Question 52

Traumatic injury complicated by massively elevated creatinine

Answer 52

Think pseudoazotemia in the setting of an intraperitoneal bladder rupture

Note: Urine creatinine can be absorbed by the peritoneal lining if there is an intraperitoneal bladder rupture, causing massively elevated serum creatinine (even through the kidneys are actually functioning fine).

Question 53

How can you differentiate extraperitoneal and intraperitoneal bladder rupture?

Answer 53

Extraperitoneal rupture (much more common) results in leaked contrast accumulating near the bladder (e.g. molar tooth sign)

Intraperitoneal rupture (more rare) results in contrast freely flowing in the peritoneal cavity (look for it outlining bowel loops)

Question 54

Which type of bladder rupture requires surgical management?

Answer 54

Intraperitoneal (more rare)

Note: The more common extraperitoneal bladder rupture can usually be managed medically.