EAU 2018: European Society of Urogenital Radiology Lecture: Challenges in Imaging of UTUC

Copenhagen, Denmark (UroToday.com)  Dr. Cowan was the guest speaker for the ESUR lecture and focused on challenges in the imaging of urinary tract urothelial cancer (UTUC). He broke down the challenges that face us into 3 categories: those that relate to the disease, those that related to the urologist and radiologist and those that relate to the radiologist alone.


UTUC, as mentioned before, is a rare disease with low prevalence. It rarely presents with hematuria; hematuria evaluations often are associated with (in order of decreasing incidence): normal urinary tracts, bladder cancer, urolithiasis, renal cell carcinoma, UTUC (0.1-2.2% prevalence). As part of his thesis work, he found that UTUC was more common in women, and in older patients. UTUC also usually presents as small flat tumors, making imaging difficult.

False positives in the imaging diagnostics of UTUC are high, often leading to need for biopsy. The positive predictive value of CT urogram is between 57-90% in most series, and unfortunately, over diagnoses UTUC.

Urologist and Radiologist:

He emphasized the need to work together to help address the question of optimum diagnostic strategy. Specifically, which tests to order, what sequence to order them in, and its effect on management and outcomes. Avoid the 3C’s: Cliches, Conflicts of Interest, Convention. Basically, all specialties should acknowledge their limitations, forget about prior biases and question the current standards.

The components that need to be considered in coming up with a strategy are: diagnostic accuracy, patient acceptability, availability, and cost/reimbursement policies. Diagnostic accuracy, cost, and disease prevalence are difficult to overlap effectively.

Optimum patient journey:

Presentation  Risk Stratification  Diagnostic test (hopefully just 1)  Treatment

In UTUC: Presentation  Risk Stratification  CT Urogram  Biopsy

Risk stratification for hematuria should take into account available clinical/family history, urine cytology, prior imaging, and co-existing urothelial cancer history. 

Diagnostic testing:

  • Don’t do all tests in one patient!
  • Goal: Reduce cost and reduce time to diagnosis
Radiologist alone:

Goals for radiology: optimizing imaging technique, interpretation, reporting, diagnostic accuracy. Key to this is standardization!

One of the highlights of the talk was his discussion on CT Urography. Current tri-phasic CT has three key phases: Non-contrast, nephrogram phase (50-100 seconds), excretory phase (750 sec).

However, there are actually 7 distinct phases for CT Urography that may be used. There is a urothelial phase (30-50 seconds) that may be the most useful and most accurate. Its diagnostic accuracy (sensitivity, specificity, PPV, NPV) matches CT Urography (including excretory phase).

Challenges In Imaging of UTUC

He also noted that completing CT Urography during the expiratory phase are superior to inspiration as it straightens out the upper urinary tract.

Presented by: Nigel Cowan

Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark