Urinary bladder Flashcards
- Infltrating papillary TCC is diagnosed from a mass at the renal pelvis. Which is the single best answer?
A. 50% of TCC are infltrating papillary tumours
B. Have a broad base and frond-like morphology
C. On CT have a density lower than urine and higher than renal parenchyma
D. CT value of TCC is around 50-60 HU
E. Demonstrate avid enhancement post-contrast
B. Have a broad base and frond-like morphology
Over 85% of TCCs are infltrating papillary tumours.
CT density is 8-30 HU, slightly higher than urine and lower than renal parenchyma.
Post-contrast there is mild to moderate enhancement to 18-55Hu
- Which of the following favours a diagnosis of infiltrating papillary TCC rather than ureteral endometriosis?
A. Age 35 years
B. An intramural nodule
C. Soft tissue component outside ureter larger than in it
D. High signal intensity on T1 and ‘shading’ on T2
E. Location in proximal third of ureter
E. Location in proximal third of ureter
Ureteral endometriosis is usually in childbearing age and in the lower third of ureters, often co-existent with other
sites of abdominal and pelvic disease.
- Regarding retroperitoneal fbrosis(RPF):
A. Is common in females in the primary form
B. Beta-blockers are a common cause
C. Desmoplastic response to malignancy is the most common case in secondary RPF
D. Causes lateral deviation of the mid ureter
E. In the primary form responds to steroids
E. In the primary form responds to steroids
Two thirds of cases of RPF are primary and one third are secondary.
Both forms are more common in males.
Secondary causes include drugs such as methysergide, beta-blockers, phenacetin.
Medial deviation of the ureter occurs in the mid third.
- Which of the following indicates T3 disease in a 66-year-oldman with bladder cancer?
A. Tumour size 2.5cm
B. Tumour invading inner half or superfcial muscle
C. Invasion of perivisical fat
D. Tumour invading deep muscle
E. Invasion of the rectum
C. Invasion of perivisical fat
Invasion of perivesical fat indicates T3 disease.
Invasion of surrounding organs, pelvic or abdominal wall is T4 disease.
T1-T2b tumours are treated with a conservative approach including TURB and local chemotherapy,
whereas radical cystectomy and urinary diversion are reserved for invasive cancer.
- A 40-year-old diabetic presents with Urinary Tract Infection (UTI). Abdominal radiograph demonstrates
small rounded curvilinear lucencies outlining the bladder wall. What is the diagnosis?
A. Emphysematous cystitis
B. Enterovesical fstula
C. Penetrating trauma
D. Post-cystoscopy
E. Pneumatosis intestinalis
A. Emphysematous cystitis
Emphysematous cystits occurs more commonly in females and is usually due to E.coli. Gas is present in the
bladder mucosal lumen. On ultrasound there is a thickened bladder wall with echogenic foci and acoustic
shadowing.
14) A 60-year-old male, treated long term for hypertension with hydralazine, develops bilateral hydronephrosis.
On CT KUB, the ureters are deviated medially and obstructed by a large, plaque-like, para-aortic, soft-tissue
density. The aorta appears ‘taped-down’ to the vertebral column rather than elevated by the para-aortic tissue.
Which of the following is the most likely diagnosis?
a. enlarged retroperitoneal lymph nodes due to Hodgkin’s disease
b. enlarged retroperitoneal lymph nodes due to non-Hodgkin’s lymphoma
c. retroperitoneal fibrosis
d. bilateral ureteral transitional cell carcinoma
e. metastatic lymph node enlargement from testicular embryonal cell carcinoma
c. retroperitoneal fibrosis
Retroperitoneal fibrosis can cause extrinsic compression of both ureters and retroperitoneal vascular structures such as the aorta, inferior vena cava and iliac vessels.
It can be idiopathic or secondary to inflammatory aortic aneurysm, retroperitoneal metastases, haemorrhage, abscess, urinoma, diverticulitis, appendicitis, Crohn’s disease, and drugs such as ergot alkaloids and hydralazine.
Malignant retroperitoneal lymphadenopathy causing ureteric obstruction tends to encircle the aorta, elevating it off the vertebral column.
In contrast, retroperitoneal fibrosis rarely extends between the aorta and the vertebrae, therefore appears to tape the aorta down to the spine.
16) On CT performed for staging purposes, a primary bladder tumour involves bladder muscle without perivesical
extension. Malignant enlarged lymph nodes of 4 cm greatest dimension in the ipsilateral internal iliac and 1.5 cm
greatest dimension in the common iliac lymph node groups are present. Which of the following is the most
accurate TNM stage?
a. T1 N1 M0
b. T2 N1 M0
c. T2 N2 M0
d. T2 N1 M1
e. T3 N1 M0
c. T2 N2 M0
Bladder cancer achieves the T3 status by perivesical involvement.
The N status is determined by the greatest dimension of the regional nodes.
When the greatest dimension is less than or equal to 2cm, the nodal status is N1.
N2 is for regional nodes measuring 2–5cm.
N3 is achieved when the greatest dimension of the largest regional node is more than 5cm.
Inguinal and retroperitoneal nodes are staged as metastases
21) A patient is found to have a renal pelvis transitional cell carcinoma. The cancer invades adjacent renal
parenchyma and extends into perinephric fat. No significantly enlarged lymph nodes and no metastases are seen
on CT of the chest, abdomen and pelvis. Which of the following is the overall stage for this patient’s disease?
a. I
b. II
c. III
d. IV
e. V
d. IV
In the TNM staging of urothelial malignancies, T1 refers to invasion of the subepithelial connective tissue,
whereas a T2 tumour invades the muscularis. T3 tumours in the renal pelvis invade the peripelvic fat or renal
parenchyma, whereas those in the ureter invade the periureteric fat. T4 tumours invade adjacent organs or
perinephric fat, as in this case. For renal and ureteric transitional cell carcinoma, the group stages I–III are
determined by the T status, all these stages having no involved nodes and no metastases. T4 primaries or any
involved nodes or metastases give stage IV disease. There is no stage V.
@# 41) A patient with a lower ureteric transitional cell carcinoma has an MRI for locoregional staging purposes and a CT of the abdomen and pelvis for lymph node involvement and metastases. An 8 mm short axis node is recorded. In which of the following abdominopelvic groups would this be significant by size criteria?
a. inguinal
b. common iliac
c. external iliac
d. internal iliac
e. retroperitoneal
d. internal iliac
A short axis measurement of 7mm or greater represents significant enlargement of internal iliac nodes.
Regarding other nodal regions, significant enlargement
for inguinal nodes is 10mm,
for common iliac 9mm,
for external iliac 10mm,
for obturator 8mm
and for retroperitoneal nodes between renal arteries and the aortic bifurcation 12mm.
In addition to size, there may be morphological clues to nodal involvement by cancer.
Clustering of nodes, round nodes, nodes with irregular capsules, and nodes sharing CTor MRI characteristics of the primary tumour (attenuation, signal, cystic or necrotic changes, and contrast-enhancement pattern) are features suggesting lymph node involvement
48) A CT KUB is performed on a 55-year-old South African man with unilateral loin pain. This demonstrates
moderate ipsilateral hydroureteronephrosis with a stricture in the distal ureter. There is also widespread bladder
calcification and bilateral distal ureter calcification. The responsible organism is most likely to be which of the
following?
a. Escherichia coli
b. Schistosoma mansoni
c. Schistosoma haematobium
d. Schistosoma japonicum
e. Mycobacterium tuberculosis
c. Schistosoma haematobium
Schistosomiasis (bilharzia) is a parasitic infection that, worldwide, is the commonest cause of bladder wall
calcification. Schistosoma japonicum and S. mansoni cause gastrointestinal tract infection, while S. haematobium
affects the genitourinary tract. Schistosomiasis is endemic in South Africa, Egypt, Nigeria, Tanzania, Zimbabwe
and Puerto Rico. The calcification spreads proximally up the ureters. In contrast, tuberculosis begins in the
kidneys and spreads distally. Transitional cell carcinoma and cyclophosphamide-induced cystitis also cause
bladder wall calcification. Causes of calcification within the urinary bladder lumen include stones and encrusted
foreign bodies such as catheter balloons
53) An 80-year-old man undergoes cystoscopy for macroscopic haematuria. He is found to have a 6 cm bladder
tumour, biopsy of which confirms small-cell bladder cancer. He is considered suitable for radical treatment.
Which of the following is the most appropriate staging strategy?
a. whole-body PET/CT
b. MRI of the bladder
c. MRI of the bladder plus CT of the abdomen and pelvis with intravenous contrast
d. MRI of the bladder plus CT of the chest, abdomen and pelvis with intravenous contrast
e. MRI of the bladder plus CT of the brain, chest, abdomen and pelvis with intravenous contrast
d. MRI of the bladder plus CT of the chest, abdomen and pelvis with intravenous contrast
MRI is indicated for local (in fact locoregional) staging. CT of the chest is required in addition to the abdomen
and pelvis because of the histological tumour type. 18FDG PET is not useful for staging urothelial tumours
because of the urinary excretion of this radiotracer
57) Cystoscopy is attempted on a 65-year-old female for persistent microscopic haematuria, but the scope cannot
be advanced along the urethra. A biopsy is taken and MRI is performed. Axial T2W images show a mass of high
signal intensity disrupting the normal, target-like, zonal anatomy of the urethra. Which of the following cell types
is the most likely histology from the biopsy?
a. squamous cell
b. transitional cell
c. adenocarcinoma
d. clear cell
e. mastocyte
a. squamous cell
Urethral tumour is rare and occurs more in women than in men. Squamous cell carcinoma is the most common
histological type followed by transitional cell carcinoma and then adenocarcinoma. MRI is the technique of choice
for local staging.
19 An 80 year old woman presents with vague lower abdominal pain. AXR shows translucent linear streaky areas
in the pelvis. USS shows a thickened bladder wall with echogenic foci within it. CT demonstrates areas of gas
within the bladder wall. Which of the following is not consistent with the described condition?
(a) Diabetes mellitus
(b) The patient’s demographics
(c) Staphylococcal infection
(d) Tuberculosis
(e) Bladder outlet obstruction
(d) Tuberculosis
Emphysematous cystitis is usually seen in women over the age of 50 with poorly controlled diabetes mellitus.
Other risk factors include neurogenic bladder and recurrent UTls. Causes other than infection include trauma, recent instrumentation and enterovesical fistula. Classically the organism is E. coli, but a variety of organisms including Staphylococcus, Streptococcus, Klebsie/la and Clostridium perfringens have been described.
TB causes an irritable hypertonic low capacity bladder and occasionally calcification of the bladder wall is seen.
25 A 30 year old patient is admitted with multiple stab wounds to the lower abdomen. His pulse is 110/ min and
his blood pressure 80/40 mm Hg after fluid resuscitation. He has frank haematuria. A urethral catheter is passed
freely and a normal cystogram performed in the emergency department. Initial CT in the portal venous phase with
shows free fluid in the pelvis towards the right side but no major injury to the solid viscera. A ureteric injury is
suspected. Which imaging investigation would you recommend next?
(a) Single shot IVU
(b) Full IVU with delayed phase imaging
(c) Ultrasound kidneys
(d) Retrograde ureterogram
(e) Nephrostomy insertion followed by nephrostogram
(a) Single shot IVU
Traumatic ureteric injury is extremely rare. In this situation with an unstable patient who will imminently require
emergency surgery, a one shot IVU to localize the injury should be performed. If the patient was clinically stable,
either CT with delayed phase imaging or a full IVU could be performed.
26 A 60 year old man presents with frank haematuria. Cystoscopy demonstrates a transitional cell carcinoma of
the bladder. Which of the following statements is true regarding his staging investigations?
(a) CT has no role
(b) Extension of the tumour into the outer half of the muscle layer is stage T2a disease
(c) At MRI tumour is isointense to muscle on T1W and hyperintense on T2W
(d) T2W is the optimal sequence to detect extension into perivesical fat
(e) T1W is the optimal sequence to assess depth of muscle invasion
(c) At MRI tumour is isointense to muscle on T1W and hyperintense on T2W
MRI is the local staging investigation of choice.
T2W is good for assessment of degree of muscle invasion and differentiating tumour from fibrosis, whilst T1 W is good for assessing invasion into the perivesical fat.
T2a disease involves the inner half of the muscle layer; T2b the outer half and T3 describes invasion of the perivesical fat.
4 A 46 year-old woman presents with abdominal pain, .dysuria and abdominal distension. A plain AXR is
performed, which shows air within the right ureter and renal pelvis. Which of the following is the least likely
aetiology?
(a) Caecal tumour
(b) Urinary tract infection with Clostridium spp.
(c) Meckel’s diverticulum
(d) Pelvic actinomycosis
(e) Small bowel MALT
(e) Small bowel MALT
The finding of air within the right ureter and pelvis implies either a colovesical fistula, or UTI by a gas-producing organism.
Diverticulitis is the commonest cause of a colovesical fistula (of which Meckel’s diverticulum can be
a rare cause).
Colorectal tumour, Crohn’s disease, ulcerative colitis, previous radiotherapy, and pelvic infection/infective colitis are other causes.
Lymphoma typically encases bowel and blood vessel and is cause fistulation.
@# 14 A 50 year old woman is found to have multiple, round, well defined filling defects in her left ureter on IVU.
Which of the following is the least likely diagnosis?
(a) Emphysematous ureteritis
(b) Ureteritis cystica
(c) Malakoplakia
(d) Leukoplakia
(e) Cervical carcinoma
(a) Emphysematous ureteritis
The differential diagnosis for ureteric filling defects also includes TCC and radiolucent calculi. Emphysematous
ureteritis typically causes streak like filling defects on IVU.
19 A 48 year old man presents with urinary frequency, urgency and dysuria. A cystogram demonstrates superior
and anterior displacement of the bladder with a ‘teardrop’ appearance. IVU shows medial displacement of the
distal ureters with mild bilateral hydronephrosis. What is the likeliest diagnosis?
(a) Liposarcoma
(b) Lipoblastoma
(c) Pelvic lipomatosis
(d) Hibernoma
(e) Teratoma
(c) Pelvic lipomatosis
A ‘teardrop’ or ‘pear’ shaped bladder on cystography is the classic finding of pelvic lipomatosis.
CT shows symmetrical abundant intrapelvic fat.
Lipoblastomas are rare soft tissue neoplasms derived from foetal adipose tissue, seen in children.
Hibernomas are rare benign, soft tissue tumours composed of brown fat, that present in adult as a firm, painless, slowly growing mass.
22 Regarding traumatic urethral injury, which of the following statements is true?
(a) It occurs in 1 % of all pelvic fractures
(b) The posterior urethra is more commonly injured than the anterior
(c) It is equally common in males and females
(d) It is associated with bladder rupture in 50% of cases
(e) At urethrography, the AP view provides most information
(b) The posterior urethra is more commonly injured than the anterior
Urethral trauma is common in the presence of pelvic fractures (up to 24%) and typically presents with haematuria,
meatal blood, perinea! swelling or a high riding prostate on DRE in men and labial oedema, vaginal bleeding or
urinary leak PR in women. It is more common in men and the posterior urethra, particularly the distal membranous
urethra is most commonly injured. It is associated with bladder rupture in 20%. At urethrography, if the patient
is able, a right or left anterior oblique view is commonly employed.
38 A 35 year old man is involved in a high speed RTA and sustains a Malgaigne’s type pelvic fracture. A small
urethral catheter is successfully passed in the emergency department. The patient subsequently develops dark
haematuria. Which of the following statements is true?
(a) The haematuria is most likely to be related to catheter trauma
(b) 70% of patients with pelvic fractures have a bladder rupture
(c) At cystography, widening of fat planes of obturator internus on control film suggests intraperitoneal rupture
(d) Extraperitoneal rupture accounts for 40% of traumatic bladder injuries
(e) 10% of ruptures can only be detected after emptying the bladder of contrast medium at cystography
(e) 10% of ruptures can only be detected after emptying the bladder of contrast medium at cystography
High velocity trauma with a significant pelvic fracture means that bladder injury must be excluded. 70% of
traumatic bladder ruptures are associated with pelvic fracture. On control film at cystography, widening of the fat
planes of obturator internus along with a homogeneous soft tissue density and displacement of ileal loops suggest
extraperitoneal rupture. Overall, extraperitoneal ruptures account for 80% of ruptures. 10% of ruptures are
detected on post micturition imaging only.
48 A 70 kg, 55 year old man undergoes a CT KUB for suspected ureteric colic. Reviewing the study, with the
patient on the table, an opacity is identified on the side of the pain which lies approximately 5 cm from the VUJ,
however it is difficult to be certain whether or not the opacity lies within the ureter. Which of the following is the
next best step?
(a) Repeat unenhanced examination with the patient prone
(b) Repeat examination post i. v. contrast medium, acquiring at 50s post administration
(c) Repeat examination post i. v. contrast medium, acquiring at 100s post administration
(d) Repeat unenhanced examination in 24 hours
(e) Repeat examination with post i.v. contrast medium, acquiring at 300s post administration
(e) Repeat examination with post i.v. contrast medium, acquiring at 300s post administration
Although exact techniques vary from department to department, the principles remain the same. In this situation,
an excretory phase image is required to determine whether or not the opacity is in the ureter. This phase begins
at 240 secs post contrast administration. The nephrographic phase (80-120 secs) provides homogeneous
enhancement of the parenchyma and is best for identifying parenchymal lesions. Turning the patient prone can
be useful in delineating VUJ calculi and is performed routinely in some centres.
56 A 50 year old man presents with chronic dull flank pain. US shows normal sized kidneys with mild prominence
of their calyces. IVU shows ureterectasis above L4, medial displacement of the ureters bilaterally in their middle
thirds and subsequent distal tapering. CT shows a retroperitoneal periaortic mass of attenuation similar to muscle.
What is the most likely diagnosis?
(a) Retroperitoneal fibrosis
(b) Lymphoma
(c) Liposarcoma
(d) Leiomyoma
(e) Amyloid
(a) Retroperitoneal fibrosis
Retroperitoneal fibrosis may be primary (2/3 of cases) where it may be associated with fibrosis in other organ
systems, or secondary to drugs, radiation therapy or a desmoplastic reaction to local tumours.
57 A 52 year old woman presents with a suprapubic mass. CT shows a 6 cm mass lying anterosuperior to the
bladder extending along the course of the urachus. The mass demonstrates heterogeneous enhancement and has
peripheral stippled psammomatous calcifications within it. Which of the following is the likeliest histological
subtype?
(a) Transitional cell carcinoma
(b) Papillary cell carcinoma
(c) Adenocarcinoma
(d) Squamous cell carcinoma
(e) Teratoma
(c) Adenocarcinoma
Urachal carcinoma is a relatively rare tumour characterized by a midline suprapubic mass that may or may not
invade the bladder. 10% lie at the umbilical end. Peripheral curved or stippled calcifications are pathognomonic
of the mucinous adenocarcinoma subtype which may be complicated by pseudomyxoma peritonei.
58 A 50 year old recent immigrant from Tanzania presents with a history of vague flank pain. CT KUB shows
coarse calcification in a thickened bladder wall with extension of the calcification into the walls of the distal
ureters. What is the least likely diagnosis?
(a) Tuberculosis
(b) Transitional cell carcinoma
(c) Schistosomiasis
(d) Lymphoma
(e) Histoplasmosis
(c) Schistosomiasis
Although schistosomiasis is rare in the west, it is the commonest cause of mural calcification worldwide. TB
causes calcification relatively rarely. TCC can cause mural calcification but this is usually thin curvilinear
calcification outlining a normal sized bladder
59 A 60 year old diabetic woman presents with a history of recurrent coliform UTls. CT urogram shows multiple
smooth dome shaped filling defects within the bladder and both distal ureters. At ureteroscopy the lesions have a
yellow appearance and biopsy demonstrates the presence of Michaelis-Gutmannbodies. What is the likely
diagnosis?
(a) Polureteritis cystica
(b) Actinomycosis
(c) Squamous cell carcinoma
(d) Malakoplakia
(e) Leukoplakia
(d) Malakoplakia
A rare condition characterised by altered host response to infection (E. coli in 94%) at the macrophage level. It is
multifocal in 75% and bilateral in 50%. Renal involvement is less common, is usually unilateral, and is
characterised by diffuse renal enlargement with displacement and distortion of the pelvi-calyceal system
- An 84 year old diabetic female is investigated for recurrent E. coli urinary tract infections and microscopic
haematuria. An intravenous urogram is performed, which shows numerous small filling defects in the ureter and
small mural plaque-like defects within the bladder. Which one of the following is the most likely diagnosis?
a. Malakoplakia
b. Leukoplakia
c. Emphysematous cystitis
d. Emphysematous pyelonephritis
e. Pyeloureteritis cystica
- a. Malakoplakia
Malakoplakia is the most likely diagnosis based on the history provided. This is a rare granulomatous infection
affecting elderly females with a history of E. coli infections. It primarily affects the bladder, and affects the
remainder of the renal tract with decreased incidence as one progresses proximally. Leukoplakia may have similar
appearance, but is more common in males with bladder involvement, and is characterised by the passage of gritty
soft-tissue flakes. Pyeloureteritiscystica typically produces multiple round filling defects rather than plaques.
- A 36 year old man suffers pelvic fracture following a road traffic accident. On examination, blood is noted at
the urethral meatus and the patient has urinary retention. Regarding urothelial injuries:
a. Associated bladder injuries are seen in 50% of patients
b. Anterior urethral injuries are commoner with pelvic fractures
c. They are more commonly associated with pelvic fractures in females rather than males
d. Posterior urethral injuries can be seen in up to 20% of pelvic fractures in males
e. Impotence is a rare complication of male urethral injury
- d. Posterior urethral injuries can be seen in up to 20% of pelvic fractures in males
Urethral injuries are seen in up to 20% of male patients following pelvic fractures. They are much less common
in women. The posterior urethra is the commonest site; impotence can develop in up to 40% of these patients.
- A 31 year old male is involved in a road traffic accident. The patient was catheterized immediately in A&E
and the bladder was found to be empty. A trauma series CT is requested and a left-sided pelvic fracture is noted.
A CT cystogram is therefore performed and bladder rupture is diagnosed. Which of the following signs would be
an unexpected finding with this history?
a. Contrast extravasation into the paracolic gutters
b. Contrast extravasation into the perivesical fat
c. Contrast extravasation into the anterior abdominal wall
d. Flame-shaped contrast extravasation
e. Contrast extravasation into the upper thigh
- a. Contrast extravasation into the paracolic gutters
Extraperitoneal rupture of the bladder is associated with pelvic fractures following trauma and cystography should
be performed if this is suspected. The injury is usually at the base of the bladder, anterolaterally. Contrast is seen
to extravasate with a streaky or flame-shaped appearance and collects in the space of Retzius, upper thighs,
inguinal regions, perivesical fat and anterior abdominal wall. Contrast in the paracolic gutters suggests
intraperitoneal rupture of the bladder. This is associated with a different method of injury, typically rupture at the
bladder dome following blunt trauma with a distended bladder or secondary to iatrogenic injury such as
cystoscopy.
- A 60 year old female presents with a large abdominal mass. CT demonstrates a large retroperitoneal fatcontaining mass. Which of the following is true about the different fat-containing retroperitoneal masses?
a. Predominantly low signal on T1-weighted and a high signal on T2-weighted images preclude a diagnosis of
liposarcoma
b. Calcification within a liposarcoma is usually associated with a better prognosis
c. Lipomas are rare in the retroperitoneum
d. An extremely FDG-avid retroperitoneal fat-containing tumour is almost certainly a liposarcoma
e. Given time, most lipomas will dedifferentiate into liposarcomas
- c. Lipomas are rare in the retroperitoneum
Liposarcomas are the most common sarcomas in the retroperitoneum. Whilst welldifferentiated liposarcomas are
the commonest, myxomatous and dedifferentiated liposarcomas can have varying appearances and so low T1-
weighted signal does not preclude a diagnosis of liposarcoma. Lipomas, whilst exceedingly rare in the
retroperitoneum, almost undergo malignant changes. Whilst liposarcomas can have minimal-to-increased FDG
uptake, a very FDG-avid fat-containing retroperitoneal tumour is quite likely a hibernoma.
- A 29 year old male has microscopic haematuria and symptoms suggesting left ureteric colic. An unenhanced
CT abdomen and pelvis is requested. A 4 mm calcific density is seen near the bladder in the left hemi-pelvis.
Which one of the following signs may be useful to help differentiate between a phlebolith and ureteric calculi?
a. Lobster claw sign
b. Soft-tissue rim sign
c. Signet ring sign
d. Nubbin sign
e. Drooping lily sign
- b. Soft-tissue rim sign
The soft-tissue rim sign is thickening of the ureteric wall around the calculus due to oedema. It has a reported
specificity of up to 92% for renal calculi. Other signs that mayfavour a diagnosis of ureteric calculi include
asymmetrical perinephric fat stranding, periureteral oedema, hydronephrosis and unilateral renal enlargement.
The lobster claw and signet ring signs concern papillary necrosis on intravenous urogram. The nubbin and
drooping lily signs both refer to ureteral duplication.
- A 49 year old African male presents to the outpatient urology clinic with a five-month history of macroscopic
haematuria. A plain KUB X-ray is requested, which reveals thin arcuate calcification outlining the bladder and
the distal ureters. Which one of the following causes is most likely?
a. Transitional cell carcinoma
b. Squamous cell carcinoma
c. Schistosomiasis
d. E. coli cystitis
e. Proteus cystitis
- c. Schistosomiasis
The differential for bladder calcification includes tuberculosis, post-radiotherapy cystitis, urachal carcinoma,
TCC, and squamous cell carcinoma. However, schistosomiasis is the commonest cause, especially in the African
population, where it is often endemic. The bladder is usually a normal size and shape, with thin curvilinear
calcifications. Ureteric strictures, inflammatory pseudopolyps and vesicoureteric reflux are seen in addition to
bladder and ureteric calcification
- A 58 year old man presents with haematuria and suprapubic pain. Ultrasound reveals the presence of an area
of bladder wall thickening and a mobile avascular mass within the urinary bladder. A degree of right
hydronephrosis is also demonstrated. Which of the following is true regarding transitional cell carcinoma (TCC)?
a. The ureter is the second commonest site of TCC after the urinary bladder
b. TCC is the most common tumour of the urinary tract
c. In the ureter, the lower ureter is the commonest site
d. It is the commonest tumour arising in the urachus
e. Previous schistosomiasis is a well-recognised risk factor
- b. TCC is the most common tumour of the urinary tract
TCC is the commonest cancer in the urinary tract. Whilst a predominant majority of them develop in the bladder,
the renal pelvis is the second commonest site. In the ureter, the upper ureter is the commonest site.
Adenocarcinoma is the commonest tumour in urinary tract. Schistosomiasis is associated with SCC.
- A 60 year old patient with a history of previous urinary tract interventions presents with right hydronephrosis
and deranged renal function. Imaging suggests a mid-ureteric stenosis. An MR urogram is planned. Which of the
following is true?
a. A static-fluid MR urography is performed using gadolinium-enhanced T1-weighted imaging
b. Excretory MR urogram is preferred in patients with severe renal impairment
c. T1-weighted imaging is useful in differentiating between clot and calculi
d. Renal sinus cyst can be differentiated from dilated intrarenal collecting system on T1-weighted imaging
e. Smaller filling defects are better seen on the MIP images rather than the source data
- c. T1-weighted imaging is useful in differentiating between clot and calculi
A static-fluid MR urogram is a heavily T2-weighted technique similar to MRCP. Excretory urogram is a postgadolinium injection T1-weighted technique. A static-fluid MR urogram is preferred in patients with renal failure.
Renal sinus cysts cannot often be differentiated from dilated intrarenal collecting systems on T1-weighted and
T2-weighted images. They are better appreciated on the excretory urogram. Source data should be reviewed to
ensure that small filling defects are not missed.
QUESTION 2
A 65-year-old man with transitional cell carcinoma of the bladder undergoes a pelvic MRI. On Tlw sequences,
there is a 2-cm papillary bladder wall growth that returns signal intensity higher than that of the surrounding urine
and extends into the bladder wall. On T2w sequences, an uninterrupted low signal intensity line clearly separates
the tumour from the surrounding perivesical fat. No perivesical stranding is seen. Which one of the following
options best describes the staging of the tumour?
A T2a
B T2b
C T3a
D T3b
E T4a
C T3a
MRI is the most accurate imaging modality to differentiate T3a from T3b carcinoma. On T2w sequences, an
uninterrupted low signal intensity bladder wall seen between the tumour and the surrounding fat excludes
extension into the perivesical fat, limiting the tumour to stage T3a.
QUESTION 14
A 58-year-old man recently migrated to the UK from Kenya. He has been experiencing haematuria, weight loss
and dysuria for several months. A series of imaging investigations are requested by the urologists and reveal
evidence of renal tract TB. Which one of the following statements best describes the likely radiological findings
in renal tract tuberculosis?
A A chest radiograph is normal in 75—80% of cases.
B Bladder calcification is more commonly seen than renal or ureteric calcification.
C Free vesicoureteric reflux into a widely dilated upper renal tract is frequently seen.
D Tramline calcification is seen within the seminal vesicles.
E Findings usually present as bilateral renal tract disease.
C Free vesicoureteric reflux into a widely dilated upper renal tract is frequently seen.
- A 22-year-old male front seat passenger is admitted following a RTA. On examination in A&E, blood
is noted at the external urethral meatus and there is swelling of the penis. An urethrogram is performed
which demonstrates contrast extravasation below the urogenital diaphragm only. What type of urethral
injury does this represent?
A. Anterior urethral injury.
B. Disruption of the membranous urethra.
C. Bladder neck injury extending into the proximal urethra.
D. Bladder base injury.
E. Penile fracture.
- A. Anterior urethral injury.
Urethral injuries are rarely life-threatening but have significant long-term morbidity. Complications include
stricture, incontinence, and impotence. The male urethra extends from the bladder base to the external meatus
and is divided into the posterior (prostatic and membranous) and anterior (bulbous and penile) urethra. The
anterior and posterior urethra are separated by the urogenital diaphragm. The Goldman classification of urethral
injury emphasizes anatomic location.
