Examining the upper urinary tract in patients with hematuria—time to revise the CT urography protocol?

  • Erik RudEmail author
  • Kristina Flor Galtung
  • Peter Mæhre Lauritzen
  • Eduard Baco
  • Tove Flatabø
  • Gunnar Sandbæk
Computed Tomography



Three-phase CT urography (CTU) is the gold standard for evaluating the upper urinary tract in patients with hematuria. We aimed to evaluate the accuracy of CTU for detecting upper urothelial cell carcinomas (UCC) in patients with hematuria and negative cystoscopy. Secondly, we aimed to determine the tumor visibility on each CTU phase.

Material and methods

This retrospective study included all patients with hematuria referred to CTU after a negative cystoscopy during 2016 and 2017. The original CTU reports were dichotomized as negative or positive. All patient charts were reviewed after a minimum of 18-month follow-up in order to register missed cancers. The results of biopsies and clinical follow-up were used as the reference standard. Two reviewers retrospectively evaluated the tumor visibility of each CT sequence in all true-positive CTUs.


We included 376 patients with hematuria who underwent CTU after a negative cystoscopy. Macroscopic and microscopic hematuria occurred in 87% (327) and 13% (49), respectively. The incidence of upper urothelial cell carcinoma was 1.9% (7), and the sensitivity of CTU was 100% (95% CI, 59–100), specificity was 99% (95% CI, 98–100), positive predictive value was 88% (95% CI, 47–99), and negative predictive value was 100% (95% CI, 99–100). The accuracy was 99% (95% CI, 90–100). All UCCs were visible on the nephrographic phase for both reviewers.


CTU is highly accurate for detecting upper UCCs. All cases were seen on the nephrographic phase. This suggests that the CTU protocol can be simplified.

Key Points

• CT urography is highly accurate for detecting upper urothelial cell carcinomas.

• All cancers were seen on the nephrographic phase.

• All cancers were detected in patients with macroscopic hematuria.


Hematuria Transitional cell carcinoma Renal cell carcinoma Urography 



Computed tomography urography


Renal cell carcinoma


Urothelial cell carcinoma


Funding information

The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Erik Rud, MD, PhD

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic study

• performed at one institution


  1. 1.
    Tawfiek ER, Bagley DH (1997) Upper-tract transitional cell carcinoma. Urology 50:321–329. CrossRefPubMedGoogle Scholar
  2. 2.
    Rabjerg M, Mikkelsen MN, Walter S, Marcussen N (2014) Incidental renal neoplasms: is there a need for routine screening? A Danish single-center epidemiological study. APMIS 122:708–714. CrossRefPubMedGoogle Scholar
  3. 3.
    Rouprêt M, Babjuk M, Comperat E et al (2013) European guidelines on upper tract urothelial carcinomas: 2013 update. Eur Urol 63:1059–1071. CrossRefPubMedGoogle Scholar
  4. 4.
    Van Der Molen AJ, Cowan NC, Mueller-Lisse UG et al (2008) CT urography: definition, indications and techniques. A guideline for clinical practice. Eur Radiol 18:4–17. CrossRefGoogle Scholar
  5. 5.
    Cowan NC (2012) CT urography for hematuria. Nat Rev Urol 9:218–226. CrossRefPubMedGoogle Scholar
  6. 6.
    Noorbakhsh A, Aganovic L, Vahdat N, Fazeli S, Chung R, Cassidy F (2019) What a difference a delay makes! CT urogram: a pictorial essay. Abdom Radiol (NY) 18:4–16. CrossRefGoogle Scholar
  7. 7.
    Kupershmidt M, Margolis M, Jang HJ, Massey C, Metser U (2011) Evaluation of upper urinary tract tumors with portal venous phase MDCT: a case-control study. AJR Am J Roentgenol 197:424–428. CrossRefGoogle Scholar
  8. 8.
    Metser U, Goldstein MA, Chawla TP, Fleshner NE, Jacks LM, O'Malley M (2012) Detection of urothelial tumors: comparison of urothelial phase with excretory phase CT urography--a prospective study. Radiology 264:110–118. CrossRefPubMedGoogle Scholar
  9. 9.
    Park JJ, Park BK, Kim CK (2016) Single-phase DECT with VNCT compared with three-phase CTU in patients with haematuria. Eur Radiol 26:3550–3557. CrossRefPubMedGoogle Scholar
  10. 10.
    Helenius M, Dahlman P, Lonnemark M, Brekkan E, Wernroth L, Magnusson A (2016) Comparison of post contrast CT urography phases in bladder cancer detection. Eur Radiol 26:585–591. CrossRefGoogle Scholar
  11. 11.
    Yecies T, Bandari J, Fam M, Macleod L, Jacobs B, Davies B (2018) Risk of radiation from CT urography in the evaluation of asymptomatic microscopic hematuria. J Urol. CrossRefGoogle Scholar
  12. 12.
    Shaish H, Newhouse JH (2017) Split-bolus CT urogram: is less more? Abdom Radiol (NY) 42:2119–2126. CrossRefGoogle Scholar
  13. 13.
    Kravchick S, Cherniavsky E, Verchovsky G, Peled R (2017) Multidetector computed tomographic urography (MDCTU): its practical role in diagnosis of upper tract urothelial cancer in patients 50 years and older with different types of hematuria. Pathol Oncol Res 63:1059–1056. CrossRefGoogle Scholar
  14. 14.
    Jung H, Gleason JM, Loo RK, Patel HS, Slezak JM, Jacobsen SJ (2011) Association of hematuria on microscopic urinalysis and risk of urinary tract cancer. J Urol 185:1698–1703. CrossRefPubMedGoogle Scholar
  15. 15.
    Bretlau T, Hansen RH, Thomsen HS (2015) CT urography and hematuria: a retrospective analysis of 771 patients undergoing CT urography over a 1-year period. Acta Radiol 56:890–896. CrossRefPubMedGoogle Scholar
  16. 16.
    Margulis V, Sagalowsky AI (2011) Assessment of hematuria. Med Clin North Am 95:153–159. CrossRefPubMedGoogle Scholar
  17. 17.
    O’Connor OJ, Fitzgerald E, Maher MM (2010) Imaging of hematuria. AJR Am J Roentgenol 195:W263–W267. CrossRefPubMedGoogle Scholar
  18. 18.
    Lang EK, Macchia RJ, Thomas R et al (2002) Computerized tomography tailored for the assessment of microscopic hematuria. J Urol 167:547–554CrossRefGoogle Scholar
  19. 19.
    Chow LC, Kwan SW, Olcott EW, Sommer G (2007) Split-bolus MDCT urography with synchronous nephrographic and excretory phase enhancement. AJR Am J Roentgenol 189:314–322. CrossRefPubMedGoogle Scholar
  20. 20.
    Szolar DH, Kammerhuber F, Altziebler S et al (1997) Multiphasic helical CT of the kidney: increased conspicuity for detection and characterization of small (< 3-cm) renal masses. Radiology 202:211–217. CrossRefPubMedGoogle Scholar
  21. 21.
    Birnbaum BA, Jacobs JE, Ramchandani P (1996) Multiphasic renal CT: comparison of renal mass enhancement during the corticomedullary and nephrographic phases. Radiology 200:753–758. CrossRefPubMedGoogle Scholar
  22. 22.
    Kopka L, Fischer U, Zoeller G, Schmidt C, Ringert RH, Grabbe E (1997) Dual-phase helical CT of the kidney: value of the corticomedullary and nephrographic phase for evaluation of renal lesions and preoperative staging of renal cell carcinoma. AJR Am J Roentgenol 169:1573–1578. CrossRefPubMedGoogle Scholar
  23. 23.
    Ascenti G, Mileto A, Gaeta M, Blandino A, Mazziotti S, Scribano E (2013) Single-phase dual-energy CT urography in the evaluation of haematuria. Clin Radiol 68:e87–e94. CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Radiology and Nuclear MedicineOslo University HospitalOsloNorway
  2. 2.Department of UrologyOslo University HospitalOsloNorway

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