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@UrologyQuiz Quiz4 Answer: Urothelial (Transitional cell) carcinoma of the bladder

(large arrow on tumour ,ass going into wall, small arrow showing seminal vesicles- most bladder cancers are isoechoic as in this case but occasionally parts hyperechoic if calcified see below)

Differential Diagnosis -Bladder Cancer (primary urothelial or other e.g. mesenchymal, secondary) -Prostate malignancy or benign -Bladder papilloma (benign) -Blood clot -Bladder sludge/debris (usually in dependent part of bladder) -Ureterocoele (usually other features and near ureteric orifice) -Foreign body unlikely but old scar/surgical material possible nb. Not stone because no acoustic shadowing- However some tumors may have calcification on them and so may have mixed echogeneicity +/- acoustic shadowing so may be mistakenly called stones Simple classification to remember for bladder mass: Intravesical, Mural, Extramural (this case mural)

Next step in treatment -History- Non-smoker with no industrial exposure to chemicals, no past history malignancy -Cystoscopy +/- urine cytology -Baseline FBE and Creatinine/Electrolytes -Upper Tract Imaging CTIVP or cystoscopy, retrograde pyelography and renal tract ultrasound Rest of management depends on pathology of lesion, staging and patient factors: For the record 65yo with T2 high grade urothelial carcinoma for radical cystectomy with extended nodes and neobladder, staging negative but hydronephrosis right. Data: A great summary of bladder ultrasound ial+diagnosis&source=bl&ots=GYs62XGJo9&sig=Z58gfb4keoEgYQwM8vbZS3gf7t8&hl=en&sa=X&ei=Ze0GU7ePGoej0AGnxo HwCg&ved=0CDYQ6AEwAwq

Teaching Points: 1) Ultrasound is actually a valuable tool in diagnosis of haematuria (despite what some references state). A mass is often diagnosed. The caveat is that carcinoma-in-situ (CIS) and subtle masses will be missed necessitating cystoscopy and upper tract imaging in almost every case. If renal tract ultrasound primary modality available must be supplemented with retrograde pyelography (or CTIVP) 2) Painless haematuria is not always benign although it often is (bleeding benign prostatic hyperplasia etc.). Urothelial carcinoma must always be excluded. Renal cell carcinoma may also present this way. In contrast Painful haematuria generally implies pathology stone, infection etc.