Case of the Month

Presentation

50 year old male presenting with a 4 month history of painless frank haematuria.

Investigations

 A haematuria-protocol CT demonstrates a mass occupying the superior calyces of the right kidney.  No stones or renal parenchymal masses were demonstrated.

 Left image: This is an image from an unenhanced CT, which demonstrated an absence of any renal or ureteric stones.  The arrow points to a mass, difficult to detect prior to IV Contrast administration.

 Centre and right images:  These are images from combined nephrographic and pyelographic acquisitions that demonstrate a mass lesion within the upper pole calyx of the right kidney (arrowed). This likely represents a transitional cell carcinoma of the right renal pelvis.

Discussion

 Haematuria is a common problem.  Investigation currently involves a multiphase CT of the kidneys, ureters and bladder, which has superceded ultrasound and intravenous urography as the standard of care.  Urological referral for cystoscopy is also recommended.

 "CT Haematuria" is a multiphase technique and consists of a low-dose unenhanced scan to exclude stones and a combined nephrographic (contrast transiting the renal parenchyma) and pyelographic (contrast excreted into the collecting system) scan.  The latter allows identification of masses occupying the renal parenchyma, as well as the bladder, ureter or renal pelvis.  Both of these phases can be obtained in a single acquisition by use of a staged, double-bolus contrast technique, thus minimizing radiation dose.

 "CT Haematuria" is appropriate for investigation of haematuria of unknown origin.  In the presence of a known renal mass, a 3 or 4 phase technique is usually employed to allow further characterisation and staging of the tumour.