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Comparative Effectiveness of Imaging Modalities for the Diagnosis of Upper and Lower Urinary Tract Malignancy A Critically Appraised Topic

Posted Aug 31, 2012 Updated Apr 10, 2023
By Seyed Amirhossein Razavi MD , Gelareh Sadigh MD , Aine M. Kelly MD MS , Paul Cronin MD MS
8 min read

Rationale and Objectives

The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower/bladder urinary tract cancer, transitional cell carcinoma (TCC).

Methods

A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome (PICO) method comparing computed tomography (CT) urography, magnetic resonance (MR) urography, excretory urography, and retrograde urography in the detection of TCC of the upper urinary tract. The same methods were used to compare CT cystography, MR cystography, and ultrasonography in the diagnosis of bladder cancer. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies.

Results

The retrieved sensitivity/specificity for the detection of TCC of upper urinary tract for CT urography, MR urography, excretory urography, and retrograde urography were 96%/99%, 69%/97%, 80%/81%, and 96%/96%, respectively. For detecting bladder cancer, the retrieved sensitivity/specificity for CT cystography, MR cystography, and ultrasonography were 94%/98%, 91%/95%, and 78%/96%, respectively.

Conclusions

CT urography is the best imaging technique for confirming or excluding malignancy in the upper urinary tract, whereas CT cystography has the best diagnostic performance for diagnosing bladder cancer.

Transitional cell carcinoma of the renal pelvis and ureter account for 7% of kidney tumors and 4% of upper urinary tract tumors, respectively . This cancer has a greater than 90% cure rate if superficial and confined to the renal pelvis and ureter . For more invasive tumors, the cure rate drops to 10%–15% . Current standard diagnostic modalities for evaluation of upper urinary tract malignancy include computed tomography urography (CTU) or excretory urography. If the patient has a contraindication to intravenous iodinated contrast media, retrograde urography or gadolinium enhanced magnetic resonance urography (MRU) are alternative options .

Bladder cancer will account for an estimated 73,510 new cases and 14,880 deaths in the United States in 2012 . Cystoscopy is the gold standard of diagnosing bladder cancer; however, it is an invasive technique . CT cystography (CTC) and MR cystography (MRC) are less invasive new modalities that have been proposed in the assessment of bladder cancer .

Ask

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Figure 1, Search strategy using PICO (patient, investigation, comparison, outcome)-focused keywords.

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Appraise

Upper Urinary Tract

CTU

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Table 1

Test Performances for Diagnosis of Upper Urinary Tract Malignancy

CT Urography MR Urography Excretory Urography Retrograde Urography Selected study Chlapoutakis et al Takahashi et al Jinzaki et al Cowan et al Sensitivity, % (95% CI) 96 (92–100) 69 (53–84) 80 (69–91) 96 (89–100) Specificity, % (95% CI) 99 (98–99) 97 (94–99) 81 (71–91) 96 (93–99) Prevalence 0.05 0.14 0.44 0.19 PPV 0.83 0.77 0.77 0.87 NPV 0.99 0.95 0.84 0.99 LR+ 96.31 21.45 4.24 27.93 LR- 0.03 0.32 0.24 0.04

CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; LR, likelihood ratio.

Figure 2, Graph of conditional probabilities for computed tomography (CT) urography of the upper urinary tract. As seen from this graph, CT urography is excellent at ruling in and ruling out (depending on whether it is positive or negative) upper urinary tract malignancy regardless of pretest probability.

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MRU

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Figure 3, Graph of conditional probabilities for magnetic resonance (MR) urography of the upper urinary tract. As seen from this graph, MR urography is excellent at ruling in (if the test result is positive) upper urinary tract malignancy. However, a negative test cannot rule out upper urinary tract malignancy.

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Excretory urography

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Figure 4, Graph of conditional probabilities for excretory urography of the upper urinary tract. As seen from this graph, excretory urography cannot rule in (if the test result is positive) and cannot rule out (if the test is negative) upper urinary tract malignancy.

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Retrograde urography

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Figure 5, Graph of conditional probabilities for retrograde urography of the upper urinary tract. As seen from this graph, retrograde urography is excellent at ruling in and ruling out (depending on whether it is positive or negative) upper urinary tract malignancy regardless of pretest probability.

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Lower Urinary Tract/Bladder

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Table 2

Test Performances for Diagnosis of Lower Urinary Tract/Bladder Malignancy

CT Cystography MR Cystography Ultrasonography Selected study Qu et al Qu et al Qu et al Sensitivity, % (95% CI) 94 (92–96) 91 (83–96) 78 (74–81) Specificity, % (95% CI) 98 (97–99) 95 (88–98) 96 (95–97) Prevalence NA NA NA PPV NA NA NA NPV NA NA NA LR+ 49.42 17.46 20.50 LR- 0.06 0.09 0.23

CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; LR, likelihood ratio; NA, not applicable.

Figure 6, Graph of conditional probabilities for computed tomography (CT) cystography of the lower urinary tract/bladder. As seen from this graph, CT cystography is excellent at ruling in and ruling out (depending on whether it is positive or negative) lower urinary tract/bladder malignancy regardless of pretest probability.

Figure 7, Graph of conditional probabilities for magnetic resonance (MR) cystography of the lower urinary tract/bladder. As seen from this graph, MR cystography is excellent at ruling in and ruling out (depending on whether it is positive or negative) lower urinary tract/bladder malignancy regardless of pretest probability.

Figure 8, Graph of conditional probabilities for ultrasonography of the lower urinary tract/bladder. As seen from this graph, ultrasonography is excellent at ruling in (if the test result is positive) lower urinary tract/bladder malignancy. However, a negative test cannot rule out lower urinary tract/bladder malignancy.

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Apply

Upper Urinary Tract

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Lower Urinary Tract/Bladder

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Evaluate

Upper Urinary Tract

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Lower Urinary Tract/Bladder

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References

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Academic Radiology, Volume 19, Issue 9
Journals General Radiology
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