Haematuria work-up: a filling defect, wall thickening or a mass in the pelvicalyceal system or ureter on the excretory phase — and multifocality, because urothelial cancer is a field disease.
Orient first
- Upper-tract tumours are much rarer than bladder tumours but often multifocal and synchronous with bladder cancer.
- On excretory images they are filling defects or strictures; on nephrographic images an infiltrating tumour preserves the reniform shape (unlike RCC, which distorts it).
- Stones, clot and papillary necrosis are the mimics.
Acquire the study
- CT urography: unenhanced, nephrographic (~100 s) and excretory (8–15 min) phases, or split-bolus; thin slices with coronal MIP and curved reformats of the ureters.
The manoeuvre
- Unenhanced series: stones and clot (higher attenuation than tumour).
- Excretory phase: every calyx, the pelvis and both ureters to the bladder — filling defects, irregularity, amputated calyx.
- Nephrographic phase: enhancing soft tissue in the collecting system or wall thickening; measure the enhancement in HU.
- Periureteric and renal sinus fat invasion; nodes (para-aortic, interaortocaval).
- Bladder: a synchronous tumour.
What confirms it
- An enhancing filling defect or wall thickening in the upper tract without a stone or clot explanation; ureteroscopy with biopsy confirms.
What licenses you to exclude it
- Well-opacified, smooth collecting systems and ureters on the excretory phase make an upper-tract tumour very unlikely.
The classic misread
- Reading an unopacified ureteric segment (peristalsis) as normal — add a prone or delayed image series.
- Missing a tumour inside a hydronephrotic system that never opacifies.