■ Wall Changes

Diffuse Wall Thickening

Bladder-Wall Hypertrophy

Flat Bladder Tumor

Urinary Tract

Malformations

Dilated Renal Pelvis and Ureter Renal Pelvic Mass, Ureteral Mass Changes in Bladder Size or Shape Intracavitary Mass

Wall Changes

Diffuse Wall Thickening Circumscribed Wall Thickening Concavities and Convexities

Bladder-Wall Hypertrophy

Bladder-Wall Edema

Bladder Carcinoma

Blood Clots

Bladder-WallHypertrophy

The differential diagnosis should include clots or sludge adherent to the bladder wall, a flat circumscribed tumor, and especially a faulty examination technique with inadequate bladder filling.

Fig. 11.96 Wall hypertrophy in a trabeculated bladder with incipient pseudodiverticula. HB = bladder.

a B-mode image, lower abdominal transverse scan: relatively long, serrated area of circumscribed wall thickening (arrows) with adherent, fluid-filled bowel segment (D). Tumor was excluded by cystoscopy. Side-lobe artifacts are also visible.

b Color Doppler shows scattered vascular spots but no tumor vascularity. DA = bowel wall.

Fig. 11.98 Staging of bladder carcinoma.12

Urinary Tract

Malformations

Dilated Renal Pelvis and Ureter Renal Pelvic Mass, Ureteral Mass Changes in Bladder Size or Shape Intracavitary Mass

Wall Changes

Diffuse Wall Thickening Circumscribed Wall Thickening Concavities and Convexities

Ureteroceles

Diverticula

Congenital bladder diverticula are based on a congenital weakness in the bladder wall, allowing a localized full-thickness herniation of the wall. They may be solitary or multiple and range in size from very small to extremely large. Diverticula predispose to stone formation and diverticular carcinoma (Fig.11.105),

which is why they should be surgically removed.

At ultrasound, diverticula typically appear as anechoic round or oval masses located outside the bladder wall. Most diverticula are connected to the bladder lumen by a neck or stalk. The wall of the diverticulum is thinner than the rest of the bladder wall. Diverticula may reach

Tips, tricks, and pitfalls

●Bladder polyps and tumors are among the most common accidental findings. Therefore, always pay attention to the bladder and minor pelvis (“sono-optic window”, which is more effective with a fully filled bladder).

●Masses in the bladder present great difficulties in differentiating blood clots from solid tumors. Detectable vessels inside of a mass

may exclude sediments and clots. CEUS improves the differential diagnosis of intraluminal echoic masses, allowing the detection of tumors, which are vascularized and thus enhance, while clots do not enhance (Fig. 11.107).7

References

[1]Hohenfellner R, Walz RH. Primärer und sekundärer Megaureter. In: Hohenfellner R, Thüroff JW, Schulte-Wissermann H. Kinderurologie in Klinik und Praxis. Stuttgart: Thieme, 1986; p. 268

[2]Kröpfl D. Harnleiteranomalien. In: Jocham D, Miller H (eds.). Praxis der Urologie. Stuttgart: Thieme, 1995; p. 377

[3]Tuma J, Schwarzenbach HR. Die Sonographie bei Nierenkolik [Ultrasound for renal colic]. Praxis (Bern 1994) 2004;93:1767–1774

[4]Gladisch R. Praxis der abdominellen Ultraschalldiagnostik. 2nd ed. Stuttgart: Schattauer, 1992

An obstructed–dilated urinary tract is readily differentiable:

●Always examine the region of the occlusion (Fig. 11.107). Small calculi are optimally diagnosable in the ureterovesical junction.

●Ureteral calculi are detectable in a high percentage of cases (up to 98%3) by considering all of the clinical and sonographic diagnostic possibilities (color Doppler, twinkling artifact, compression, and observing the course of the ureter).

●In case of urinary stasis the cause of obstruction should always be diagnosed: in acute stasis it is usually calculi, and in chronic stasis more often a tumor (ovary, prostate, colorectal.

[5]Jequier S, Paltiel H, Lafortune M. Ureterovesical jets in infants and children: duplex and color Doppler US studies. Radiology 1990;175(2):349–353

[6]Riedmiller H, Köhl U. Vesikoureteraler und vesikorenaler Reflux. In: Jocham D, Miller H (eds.). Praxis der Urologie. Stuttgart: Thieme, 1995; pp. 384–388

[7]Piscaglia F Nolsøe C, Dietrich CF, et al. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): Update 2011 on non-hep- atic applications. Ultraschall Med 2012; 33(1):33–59

[8]Eble JN, Sauter G, Epstein JI, Sesterhenn IA (eds.). World Health Organization Classifica-

Fig 11.107 Ectated renal pelvis (P) caused by a cyst in the lower pole compressing the upper ureter (arrow).

tion of Tumours. Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon: IARC Press, 2004

[9]Gottfried HW. Ultraschall in der Urologie. In: Jocham D, Miller H (eds.). Praxis der Urologie. Stuttgart: Thieme, 1995; pp. 55–75

[10]Jocham D. Maligne Tumoren der Harnblase. In: Jocham D, Miller H (eds.). Praxis der Urologie. Stuttgart: Thieme, 1995; pp. 49–115

[11]Malone PR, Weston-Anderwood J, Aron PM. Transcutaneous ultrasound in the detection of superficial bladder cancer. Br J Urol 1985;58 (6):664–667

[12]Wilmanns W, Huhn D, Wilms K. Internistische Onkologie. Stuttgart: Thieme, 2000; p. 534