Performance of computed tomographic urography in diagnosis of upper urinary tract urothelial carcinoma, in patients presenting with hematuria: Systematic review and meta-analysis

Abstract

Computed tomographic urography (CTU) is a relatively new diagnostic imaging technique, which combines the diagnostic advantages introduced by helical tomographic imaging, with the established technique of imaging during the renal excretory phase, into one single examination. Increasing availability of multidetector computed tomography (MDCT) units, further promotes the technique as the “one-stop-shop” for the imaging investigation of patients with haematuria. We reviewed and meta-analyzed published literature, in order to evaluate the performance of CTU for the detection of upper urinary tract urothelial tumors. CTU proved to be a very sensitive and specific method for the detection of urothelial malignancy, with sensitivity ranging between 88% and 100%, and specificity between 93% and 100%. Pooled sensitivity was 96% (95% CI: 88–100%) and pooled specificity was 99% (95% CI: 98–100%). Direct comparison of the method with intravenous urography (IVU), confirmed the superiority of CTU over IVU in terms of sensitivity and specificity. Major drawbacks of CTU are increased radiation risk, injection of iodinated contrast media which may potentially be accompanied by serious side effects and increased cost, estimated as roughly three times that of IVU. According to our study, CTU is the method of choice for the detection of pathology in “high risk” haematuria patients, i.e. patients older than 40 years of age presenting with gross haematuria.

Introduction

Upper urinary tract urothelial neoplasms are rather uncommon, accounting for 5–7% of urothelial tumors [1]. Renal pelvic lesions are four times more common than the ureteric ones. Urothelial tumors most commonly present in male patients over the age of 40, occurring with a peak incidence in the sixth and seventh decade [2].

Gross or microscopic haematuria is the most common symptom in patients with renal pelvic or ureteric tumors, presenting in more than 75% of the patients. It is well documented that most adults with haematuria should undergo imaging evaluation [3]. This is often accompanied by evaluation of the lower urinary tract with conventional cystoscopy, especially in older patients presenting with gross haematuria.

While there is universal agreement for the necessity of imaging in patients with haematuria, there is no agreement about the most appropriate imaging examination. Traditionally, excretory urography (intravenous urography—IVU) [4] and ultrasound [5] have been the imaging modalities of choice for the evaluation of the patient with haematuria, with comparable diagnostic performances [6], [7].

Computed tomographic urography (CTU) is a relatively new diagnostic imaging technique, providing comprehensive evaluation of the urinary tract. CTU combines the diagnostic advantages introduced by helical tomographic imaging, consisting of isotropic or near-isotropic resolution and multiplanar reformations, with the established technique of imaging during the renal excretory phase, into one single examination. Increasing availability of multidetector computed tomography (MDCT) units further promotes the technique as the “one-stop-shop” for the imaging investigation of patients with hematuria.

The aim of the current study was to systematically review and meta-analyze published literature, in order to calculate the sensitivity, specificity and diagnostic accuracy of CTU for the detection of upper urinary tract urothelial tumors.