The British Journal of Radiology, 84 (2011), 10911099

Accuracy of contrast-enhanced ultrasound in the detection of

bladder cancer
1

C NICOLAU, MD, 1L BUNESCH, MD, 2L PERI, MD, 1R SALVADOR, MD, 2J M CORRAL, MD, 3C MALLOFRE, MD
and 1C SEBASTIA, MD
1

Diagnostic Imaging Center and Departments of 2Urology and 3Pathology, Hospital Clinic, University of Barcelona,
Barcelona, Spain

Objective: To assess the accuracy contrast-enhanced ultrasound (CEUS) in bladder

cancer detection using transurethral biopsy in conventional cystoscopy as the reference
standard and to determine whether CEUS improves the bladder cancer detection rate
of baseline ultrasound.
Methods: 43 patients with suspected bladder cancer underwent conventional cystoscopy
with transurethral biopsy of the suspicious lesions. 64 bladder cancers were confirmed in
33 out of 43 patients. Baseline ultrasound and CEUS were performed the day before
surgery and the accuracy of both techniques for bladder cancer detection and number of
detected tumours were analysed and compared with the final diagnosis.
Results: CEUS was significantly more accurate than ultrasound in determining presence
or absence of bladder cancer: 88.37% vs 72.09%. Seven of eight uncertain baseline
ultrasound results were correctly diagnosed using CEUS. CEUS sensitivity was also better
than that of baseline ultrasound per number of tumours: 65.62% vs 60.93%. CEUS
sensitivity for bladder cancer detection was very high for tumours larger than 5 mm
(94.7%) but very low for tumours ,5 mm (20%) and also had a very low negative
predictive value (28.57%) in tumours ,5 mm.
Conclusion: CEUS provided higher accuracy than baseline ultrasound for bladder cancer
detection, being especially useful in non-conclusive baseline ultrasound studies.

Carcinoma of the urinary bladder is the most common

malignancy of the urinary tract that must be ruled out in
patients with haematuria with negative upper urinary
tract findings [1]. Cystoscopy remains the most sensitive
method of detecting bladder cancer, but has several
limitations: it is an invasive procedure; it is uncomfortable in some patients and it requires sedation or
anaesthesia. Conventional ultrasound (US) is one of the
imaging techniques used to screen for bladder cancer,
but with variable accuracy. The best results are obtained
using the latest equipment and new imaging tools
such as three-dimensional (3D) ultrasound [25]. Angiogenesis is essential to allow growth of malignancies,
and the detection of tumoural neovascularisation is one
of the keys of imaging modalities to achieve a definite
diagnosis. CT and MRI are accurate techniques for
bladder cancer detection when they are performed with
the injection of intravascular contrast agents. Detection
relies on the identification of bladder cancer neovascularisation and recent studies have shown high accuracy
with both techniques [6, 7]. The introduction of microbubble contrast agents and the development of contrast-specific software have increased the value of
ultrasound in the field of oncology [8, 9]. Ultrasound
contrast agents are strictly intravascular and are very sensitive in revealing tumour microvascularisation, helping
Address correspondence to: C Nicolau, Diagnostic Imaging Center,
Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain. E-mail:
cnicolau@clinic.ub.es

The British Journal of Radiology, December 2011

Received 22 September
2009
Revised 21 March 2010
Accepted 13 April 2010
DOI: 10.1259/bjr/43400531
2011 The British Institute of
Radiology

in the detection and characterisation of malignancies [10

13]. Recently, the behaviour of bladder cancer has been
described after the administration of ultrasound contrast
agent, and its diagnosis relies on the detection of
hypervascular wall bladder thickening [14].
The aim of our study was to retrospectively assess the
value of contrast-enhanced ultrasound (CEUS) in bladder cancer detection in a selected high-risk group of
patients using transurethral biopsy in conventional
cystoscopy as the reference standard and to determine
whether CEUS improves the bladder cancer detection
rate of baseline ultrasound.

Methods
Patients
The study was approved by the Ethical Committee of
our institution and informed consent was obtained from
all study participants. From September 2007 to April 2008,
about 160 bladder tumours were diagnosed at our
hospital. From those patients with bladder tumours, we
selected a subgroup who were referred to the operating
theatre of the Department of Urology for conventional
cystoscopy under general anaesthesia. The selection of
this subgroup was at random, since it depended only
on the availability of the radiologists of the Radiology
Department to perform the ultrasound study on the
day prior to the surgical procedure. 43 non-consecutive
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C Nicolau, L Bunesch, L Peri et al

patients (ranging in age from 29 to 89 years, mean age

71.412.5 years) were included in this study. Flexible
cystoscopy was indicated because of the presence of
macroscopic haematuria (25 cases, 58.1%), surveillance
after transurethral resection (14 cases, 32.6%) and incidental sonographic findings (4 cases, 9.3%). When cystoscopically suspicious lesions were detected, transurethral
biopsies were performed and the final diagnoses were
obtained by histology.
All patients underwent blind baseline ultrasound and
CEUS the day before surgery. The urologists who
performed the cystoscopy did not know the results of
the previous ultrasound studies.

Imaging techniques
All ultrasound studies were performed by one of the
radiologists of the urogenital department who had at least
8 years of experience in ultrasound using Sequoia 512
equipment (Siemens Sequoia, Mountain View, CA). First
of all, a baseline ultrasound of the total bladder in
fundamental mode, using greyscale, was performed with
a multifrequency 4C1 convex array probe in order to
identify bladder wall thickening or bladder lesions.
Patients were instructed not to void for at least 1 h before
the ultrasound study and were not scanned until they had
the sensation of a full bladder in order to ensure good
bladder distension. After the baseline study, dynamic
CEUS of the whole bladder was performed using the
specific contrast software Cadence contrast pulse sequencing technology (CPS; Siemens, Erlangen, Germany),
which allows real-time evaluation of contrast agents with
minimum bubble destruction at low mechanical index
power levels. CPS was performed with the same convex
array probe, with a double focus in the area of interest,
using the following settings: insonating frequency,
3 MHz; acoustic power, 275 to 290 dB; frame rate, 17
20. A low mechanical index (,0.2) was used in order to
avoid microbubble disruption. CEUS studies were performed after the administration of 2.4 ml of Sonovue as a
bolus using a 21-gauge peripheral intravenous cannula
followed by a 5-ml saline flush.
Bladder wall enhancement was studied for up to 3 min.
Images and cineloops of baseline, arterial and venous
phases were selected and stored on digital cineloops by
the same radiologists who performed the ultrasound
studies for the off-line analysis after changing the names
of patients using a correlative code.

Imaging analysis
Two radiologists, each with at least 5 years of experience
in interpreting CEUS studies, independently interpreted the
acquired images and cineloops of the bladder off-line at least
3 weeks after the recruitment of patients. Both radiologists
were blinded to the final diagnosis, but they knew that
all patients were referred to cystoscopy because of a
diagnosis of bladder cancer by flexible cystoscopy. All
bladders were reviewed before and after contrast agent
injection. Reviewers were asked to identify, record the
presence, number and size and classify the location of
bladder tumours using the same classification of five
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segments used by the urologists on cystoscopy in our

centre (right lateral wall, left lateral wall, anterior wall
domus, fundus, posterior wallfloor). Ultrasound diagnoses of all discrepant studies were established by
consensus. In the baseline study, bladder cancer was
defined as the presence of focal bladder wall thickening or
the presence of focal masses protruding into the bladder
lumen. From the CEUS study, bladder cancer was defined
as the presence of focal hyperenhanced wall thickening or
enhancing masses that protrude into the bladder lumen. A
3-point scale was used for lesion detection using baseline
ultrasound and CEUS (1, absence of tumour; 2, presence
of bladder cancer; 3, results uncertain). The results of
baseline ultrasound and CEUS were compared with the
findings of conventional cystoscopy and biopsy, which
were considered the reference standard.

Statistical analysis
SPSS version 14.0 (SPSS, Chicago, IL) was used for
statistical analysis. Baseline characteristics of the patients
and bladder tumours are expressed as meanSE. The
relationship between the classification of cancer or absence
of cancer at baseline, CEUS and the final diagnosis were
analysed with the Fisher exact test. The overall sensitivity,
specificity, accuracy, positive predictive value and negative
predictive value for bladder cancer detection using ultrasound and CEUS were analysed by number of patients and
number of lesions. For the estimation of sensitivity,
uncertain results were classified as negative for cancer.
For the estimation of specificity, uncertain results were
classified as positive for cancer. A value of p,0.05 was
considered statistically significant.

Results
43 non-consecutive patients (36 men, 7 women) ranging
in age from 29 to 89 years (mean age 71.412.5 years) sent
to the operating theatre to undergo cystoscopy owing to
suspected bladder cancer were finally included in the
study. Reference standard tests (cystoscopy and biopsy)
revealed 64 bladder cancers in 33 out of 43 patients. All
cancers except one were transitional cell carcinomas.
The other was an undifferentiated carcinoma. Of the
10 patients without bladder cancer, absence of bladder
disease was confirmed by cystoscopy and biopsies in 7.
Biopsy of the other three patients showed chronic
inflammatory bladder wall changes (two cases) and a
papillary hyperplasia (one case). Of the 33 patients with
bladder cancer, the number of lesions in each bladder
detected by conventional cystoscopy was 1 in 22 patients,
and multifocal in 11 patients (range 27 lesions), with
a total of 64 bladder lesions. The size of the bladder
cancer lesions ranged from 0.3 to 7 cm, with a mean size
of 1.340.35 cm (1 tumour was not measured because of
diffuse occupation of the bladder). 39 tumours were larger
than 5 mm and the other 25 were 5 mm or less.

US/CEUS tumour detection

All US/CEUS studies were technically good and
considered suitable for diagnosis. Only one dose of
The British Journal of Radiology, December 2011

Accuracy of CEUS in the detection of bladder cancer

Figure 1. Flow diagram of baseline ultrasound based on Standards for Reporting of Diagnostic Accuracy. Two parameters
(presence or absence of bladder cancer and presence or absence with respect the total number of bladder cancers (in
parentheses) were evaluated in all patients.

contrast agent was necessary in all patients. Figures 1

and 2 summarise the results in the format of a Standards
for Reporting of Diagnostic Accuracy (STARD) flow
diagram [15]. Baseline ultrasound and CEUS were able to
detect tumours from 5 mm in size (Figure 3). Following
the established criteria, the baseline ultrasound suspicion
The British Journal of Radiology, December 2011

was of absence of tumour in 7 patients, presence of

bladder cancer in 28 patients and uncertain results in 8
patients. Causes of uncertain ultrasound results were
presence of bladder clots that could not be differentiated
from bladder cancer (two cases) and doubtful irregularity of the bladder wall without polypoid mass (six cases)
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C Nicolau, L Bunesch, L Peri et al

Figure 2. Flow diagram of contrast-enhanced ultrasound based on Standards for Reporting of Diagnostic Accuracy. Two
parameters (presence or absence of bladder cancer and presence or absence with respect to the total number of bladder cancers
(in parentheses) were evaluated in all patients.

(Figure 4). The final diagnosis of uncertain cases was

absence of cancer in five patients (included as ultrasound
false positives in our analysis) and presence of cancer in
three patients (included as false negatives in our
analysis). CEUS suspicion was of absence of tumour in
11 patients, presence of bladder cancer in 32 patients and
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uncertain results in 0 patients. All bladder cancers

identified with baseline ultrasound were also identified
with CEUS. The accuracy of baseline ultrasound in
bladder cancer detection per patient was 72.09% (31/
43 patients), with a sensitivity of 81.81% (27/33),
specificity of 40% (4/10), positive predictive value of
The British Journal of Radiology, December 2011

Accuracy of CEUS in the detection of bladder cancer

(a)

(b)

(c)

(d)

(e)
Figure 3. 62-year-old man with bladder cancer. (a) Greyscale baseline ultasound (US) of the bladder showed a 1 cm polypoid
mass on the left posterior wall of the bladder. (b) Contrast-enhanced (CE) ultrasound at 22 s showed early enhancement of the
polypoid lesion (arrow). Enhancement of the normal wall bladder (cap arrows) is almost imperceptible in the early arterial
phase. (c) CEUS at 40 s showed homogeneous enhancement of the polypoid lesion (arrow). Enhancement of the normal wall
bladder (cap arrows) is very tiny throughout the arterial and venous phases (Figure 1d) and cannot be differentiated from the
microvascularisation of the perivesical tissue. (d) CEUS at 120 s showed faint enhancement of the polypoid lesion. Enhancement
of the bladder wall is also faint at this time. (e) Cystoscopy confirmed the existence of a bladder wall tumour. Diagnosis by
biopsy (not shown) was urothelial bladder cancer.

The British Journal of Radiology, December 2011

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C Nicolau, L Bunesch, L Peri et al

(a)

(b)

(c)
Figure 4. 69-year-old man with suspicion of bladder cancer. (a) Baseline ultrasound (US) showed irregularity of the right
bladder wall that was suggestive but not conclusive of bladder cancer and classified as uncertain. (b) Contrast-enhanced (CE)
ultrasound at 42 s showed homogeneous enhancement of the bladder wall without focal masses, suggesting the absence of a
bladder tumour. (c) CEUS at 135 s did not show focal enhancing masses. Cystoscopy and bladder wall biopsies confirmed the
absence of bladder tumour.

81.81% (27/33) and negative predictive value of 40% (4/

10) (Figure 1). By contrast, the accuracy of CEUS to
detect bladder cancer per patient significantly increased
to 88.37% (38/43 patients), with a sensitivity of 90.9%
(30/33), specificity of 80% (8/10), positive predictive
value of 93.75% (30/32) and negative predictive value of
72.72% (8/11) (Figures 2 and 5). All bladder cancers
identified with baseline ultrasound were identified with
CEUS. Furthermore, CEUS was able to rule out the
presence or absence of bladder cancer in 87.5% (7/8) of
uncertain baseline US cases, with the detection of 3
bladder cancers not correctly identified by baseline
ultrasound. On analysing the accuracy of the technique
according to the number of bladder cancers detected, the
accuracy of baseline ultrasound was 58.1% (43/74) with
a sensitivity of 60.93% (39/64), specificity of 40% (4/10),
positive predictive value of 86.6% (39/45) and negative
predictive value of 13.79% (4/29) (Figure 1). By contrast,
the accuracy of CEUS according to the number of
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bladder cancers increased to 67.56% (50/74) with a

sensitivity of 65.62% (42/64), specificity of 80% (8/10),
positive predictive value of 95.45% (42/44) and negative
predictive value of 26.66% (8/30) (Figure 2).
There were only two false positive CEUS findings
for bladder cancer. The first was a patient with a growth
of the prostate mimicking a bladder tumour and the
other was a papillary hyperplasia, considered to be a
precursor lesion of bladder neoplasm by the World
Health Organization and the International Society of
Urological Pathologists [16], which was indistinguishable from bladder cancer by both CEUS and conventional cystoscopy. The false negative CEUS findings for
bladder cancer were 22 bladder cancers detected on
cystoscopy. 20 of these 22 were ,5 mm and were located
at the left lateral wall (n53), right lateral wall (n53),
domusanterior wall (n53), fundus (n55), or posterior
bladder wallfloor (n57), 2 of them at the bladder
neck. Only 2 sessile tumours larger than 5 mm (a 15-mm
The British Journal of Radiology, December 2011

Accuracy of CEUS in the detection of bladder cancer

(a)

(b)

(c)

(d)

Figure 5. 74-year-old man with bladder cancer. (a) Axial and (b) sagittal images of baseline ultrasound (US) that did not detect
bladder wall abnormalities. (c) Contrast-enhanced (CE) ultrasound at 90 s showed a homogeneous enhancing mass of 5 mm of
the left bladder wall (arrow). (d) Persistent enhancement of the small tumour was detected at 140 s (arrow). Urothelial bladder
cancer was confirmed by cystoscopy and resection.

tumour at the bladder fundus and a 10-mm tumour

at the left lateral wall) were missed. Therefore, CEUS
sensitivity for bladder cancer detection was significantly
higher for tumours larger than 5 mm, with a very low
sensitivity for bladder cancer #5 mm of 20% (5/25)
and a negative predictive value of 28.57% (8/28), which
rose to a sensitivity of 94.87% (37/39) and a negative
predictive value of 80% (8/10) for bladder cancer .5 mm
(Figure 6).

Discussion
This study demonstrates the high bladder cancer
detection rate of CEUS, which had a very high sensitivity
for the presence of bladder cancer per patient (90.9%).
Tumoural neovascularisation can be evaluated using
imaging modalities after the administration of contrast
agents and bladder cancer is a hypervascular tumour
that shows strong enhancement in the arterial phase,
The British Journal of Radiology, December 2011

followed by a plateau of enhancement and a slow

washout when evaluated with imaging modalities after
the administration of contrast agents [14, 1719]. Despite
conventional ultrasound currently being the preferred
non-invasive imaging technique for the screening of
bladder cancers, its accuracy depends on several factors,
including distension of the bladder, tumour size,
morphology and location of the lesions [2]. The main
limitation of ultrasound, which was found to be a factor
in the present study, is its low sensitivity in detecting
lesions smaller than 1 cm [3, 20]. CEUS sensitivity for the
number of detected bladder cancers was 65.5%, which
may be explained by the high number of tumours
#5 mm detected by cystoscopy (n525). These very small
tumours are usually flat and do not produce focal bladder
wall thickening or abnormal enhancement owing to the
absence of considerable neovascularisation, as has been
hypothesised in studies using other imaging techniques
[20]. Our results are slightly worse than those obtained
using CT or MRI with contrast agents [18, 2123], or using
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C Nicolau, L Bunesch, L Peri et al

(a)

(b)

Figure 6. 62-year-old man with multiple bladder cancers. (a) Baseline ultasound (US) showed three polypoid lesions on the
lateral bladder walls larger than 5 mm. (b) Contrast-enhanced (CE) ultrasound at 19 s showed the same number of polypoid
lesions of different sizes extending into the bladder lumen. At cystoscopy two more lesions smaller than 5 mm, not identified
using ultrasound or CEUS, were detected.

multidetector CT (MDCT) urography [2426]. In the study

by Kim et al [18], using MDCT, the detection rate was
97% for all bladder cancers and 85% for bladder cancers
smaller than 1 cm. However, all cancers detected in that
study were invasive and only 13 out of 77 were smaller than
1 cm. In a more recent study using dynamic contrastenhanced MDCT with multiplanar reconstructions, Jinzaki
et al [22] obtained an overall sensitivity of 90% and a sensitivity of 25% for bladder lesions 5 mm or smaller when
using 5-mm axial sections as the reconstruction protocol or a sensitivity of 58% using 2.5-mm axial sections
with a 1.25-mm overlap. With the use of MDCT urography,
Turney et al [25] and Sadow et al [26] found a sensitivity of
93% and 79%, respectively in detecting bladder cancer but
with a high number of equivocal (20% in the study by
Turney) or misinterpreted (9% in the study by Sadow)
studies.
With respect to location, we missed lesions from all
segments but especially on the bladder floor and fundus.
In the literature, there is no agreement regarding the
most difficult places to detect bladder cancers using
ultrasound. Those suggested include the anterior and
posterior bladder wall [3], the bladder neck or dome
areas [20] and the anterior wall [27]. Detection of small
tumours in the bladder floor can be a challenge in male
patients with benign prostatic hyperplasia (BPH) [2830]. A
large prostatic central gland protruding into the bladder
lumen can be difficult to differentiate from bladder cancer.
In our experience, bladder tumours enhance faster than the
normal prostate gland owing to its arterial neovascularisation, but intense enhancement in areas of benign
prostatic hyperplasia can be found using CEUS, mimicking
tumoural enhancement [31]. Another difficulty when
evaluating patients with BPH is the possibility of bladder
wall thickening with trabeculations, which in some cases
may mimic urothelial cancers.
When compared with baseline ultrasound, in our
study CEUS did not significantly improve the sensitivity
in detecting more bladder cancers, detecting only three
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lesions more. However, CEUS significantly increased the

accuracy of baseline ultrasound according to the presence
or absence of bladder tumour, especially in uncertain
baseline ultrasound cases. In clinical practice, several reasons such as the presence of bladder clots, surgical wall
changes, bladder wall trabeculation or the impossibility to
retain urine to totally distend the bladder may hamper
good visualisation of the bladder using baseline ultrasound. In our experience, CEUS is helpful in differentiating these entities from bladder cancer, detecting bladder
cancer neovascularisation enhancement [14].
One limitation of this study is the recruitment of patients
with high suspicion of bladder cancer obtained by flexible
cystoscopy who were to undergo rigid cystoscopy and the
absence of inclusion of healthy patients. However, radiologists who carried out the ultrasound and CEUS studies
and who reviewed the ultrasound and CEUS images did
not know the cystoscopic and histological results. With
the introduction of this recruitment bias, the real value of
CEUS as a screening for bladder cancer in patients with
haematuria cannot be provided.
In conclusion, CEUS improves the bladder cancer
detection rate of ultrasound, especially in ultrasound
studies that are non-conclusive.

References
1. Sutton JM. Evaluation of haematuria in adults. JAMA
1990;263:247580.
2. Francica G, Bellini SA, Scarano F, Miragliuolo A, De Marino
FA, Maniscalco M. Correlation of transabdominal sonographic and cystoscopic findings in the diagnosis of focal
abnormalities of the urinary bladder wall: a prospective
study. J Ultrasound Med 2008;27:88794.
3. Lopes RI, Nogueira L, Albertotti CJ, Takahashi DY, Lopes
RN. Comparison of virtual cystoscopy and transabdominal
ultrasonography with conventional cystoscopy for bladder
tumour detection. J Endourol 2008;22:17259.
4. Kocakoc E, Kiris A, Orhan I, Poyraz AK, Artas H, Firdolas F.
Detection of bladder tumours with 3-dimensional sonography

The British Journal of Radiology, December 2011

Accuracy of CEUS in the detection of bladder cancer

5.

6.

7.

8.

9.
10.

11.

12.

13.

14.

15.

16.

and virtual sonographic cystoscopy. J Ultrasound Med

2008;27:4553.
Mitterberger M, Pinggera GM, Neuwirt H, Maier E, Akkad
T, Strasser H, et al. Three-dimensional ultrasonography of
the urinary bladder: preliminary experience of assessment
in patients with haematuria. BJU Int 2007;99:11116.
Tuncbilek N, Kaplan M, Altaner S, Atakan IH, Sut N, Inci O,
et al. Value of dynamic contrast-enhanced MRI and
correlation with tumour angiogenesis in bladder cancer.
AJR Am J Roentgenol 2009;192:94955.
Park SB, Kim JK, Lee HJ, Choi HJ, Cho KS. Haematuria:
portal venous phase multi detector row CT of the bladder
a prospective study. Radiology 2007;245:798805.
Lencioni R, Della Pina C, Crocetti L, Bozzi E, Cioni D.
Clinical management of focal liver lesions: the key role
of real-time contrast-enhanced ultrasound. Eur Radiol
2007;17 (Suppl 6):F739.
Quaia E. Microbubble ultrasound contrast agents: an
update. Eur Radiol 2007;17:19952008.
Claudon M, Cosgrove D, Albrecht T, Bolondi L, Bosio M,
Calliada F, et al. Guidelines and good clinical practice
recommendations for contrast enhanced ultrasound
(CEUS)update 2008. Ultraschall Med 2008;29:2844.
Quaia E, Calliada F, Bertolotto M, Rossi S, Garioni L, Rosa
L, et al. Characterisation of focal liver lesions with contrast-specific ultrasound modes and a sulfur hexafluoridefilled microbubble contrast agent: diagnostic performance
and confidence. Radiology 2004;232:42030.
Albrecht T, Hohmann J, Oldenburg A, Skrok J, Wolf KJ.
Detection and characterisation of liver metastases. Eur
Radiol 2004;14 Suppl 8:P2533.
Nicolau C, Vilana R, Catala V, Bianchi L, Gilabert R,
Garcia A, et al. Importance of evaluating all vascular phases
on contrast-enhanced sonography in the differentiation
of benign from malignant focal liver lesions. AJR Am
J Roentgenol 2006;186:15867.
Nicolau C, Bunesch L, Sebastia C, Salvador R. Diagnosis
of bladder cancer: contrast-enhanced ultrasound. Abdom
Imaging 2010;35:494503.
Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou
PP, Irwig LM, et al. Towards complete and accurate
reporting of studies of diagnostic accuracy: The STARD
Initiative. Radiology 2003;226:248.
Epstein JI, Amin MB, Reuter VR, Mostofi FK. The World
Health Organization/International Society of Urological
Pathology consensus classification of urothelial (transitional
cell) neoplasms of the urinary bladder. Bladder Consensus
Conference Committee. Am J Surg Pathol 1998;22:143548.

The British Journal of Radiology, December 2011

17. Mac Vicar AD. Bladder cancer staging. BJU Int 2000;86:11122.
18. Kim JK, Park SY, Ahn HJ, Kim CS, Cho KS. Bladder cancer:
analysis of multi-detector row helical CT enhancement
pattern and accuracy in tumour detection and perivesical
staging. Radiology 2004;231:72531.
19. Caruso G, Salvaggio G, Campisi A, Melloni D, Midiri M,
Bertolotto M, et al. Bladder tumor staging: comparison of
contrast-enhanced and gray-scale ultrasound. AJR Am J
Roentgenol 2010;194:1516.
20. Itzchak Y, Singer D, Fischelovitch Y. Ultrasonographic
assessment of bladder tumours. I. Tumour detection. J Urol
1981;126:313.
21. Barentsz JO, Jager GJ, van Vierzen PB. Staging urinary
bladder cancer after transurethral biopsy: value of fast
dynamic contrast-enhanced MR imaging. Radiology 1996;
201:18593.
22. Jinzaki M, Tanimoto A, Shinmoto H, Horiguchi Y, Sato K,
Kuribayashi S, et al. Detection of bladder tumours with
dynamic contrast-enhanced MDCT. AJR Am J Roentgenol
2007;188:913918.
23. Kim B, Semelka RC, Ascher SM, Chalpin DB, Carroll PR,
Hricak H. Bladder tumour staging: comparison of contrastenhanced CT, T1- and T2-weighted MR imaging, dynamic
gadolinium-enhanced imaging, and late gadoliniumenhanced imaging. Radiology 1994;193:239245.
24. Cohan RH, Caoili EM, Cowan NC, Weizer AZ, Ellis JH.
MDCT Urography: Exploring a new paradigm for imaging
of bladder cancer. AJR Am J Roentgenol 2009;192:15018.
25. Turney BW, Willatt JM, Nixon D, Crew JP, Cowan NC.
Computed tomography urography for diagnosing bladder
cancer. BJU Int 2006;98:3458.
26. Sadow CA, Silverman SG, OLeary MP, Signorovitch JE.
Bladder cancer detection with CT urography in an
Academic Medical Center. Radiology 2008;249:195202.
27. Ozden E, Turgut AT, Turkolmez K, Resorlu B, Safak M.
Effect of bladder carcinoma location on detection rates by
ultrasonography and computed tomography. Urology
2004;69:88992.
28. Wasserman NF. Benign prostatic hyperplasia: a review and
ultrasound classification. Radiol Clin North Am 2006;44:
689710.
29. Hsu TH, Matin SF. Benign prostatic hyperplasia mimicking
bladder tumour. Urology 2001;57:1166.
30. Wong JT, Wasserman NF, Padurean AM. Bladder squamous cell carcinoma. Radiographics 2004;24:855860.
31. Halpern EJ. Contrast-enhanced ultrasound imaging of
prostate cancer. Rev Urol 2006;8(Suppl 1):S29S37.

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