The European Association of Urology guidelines [31] recommendations specific to UTUC indicate that CTU is generally the most accurate and preferred modality for diagnosis and staging, both local and distant. This is supported by several studies concluding that CT, particularly CTU, is the most used imaging modality worldwide for the diagnosis and staging of urothelial malignancies [2], and CTU is the favored modality used for localizing, locoregional staging, and detecting distant metastases in UC [34]. The American Urology Association has recently published guidelines for UTUC separate to bladder cancer [19]. CTU is also essential to evaluate for synchronous UTUC or bladder UC. Approximately two-thirds of UTUCs present as high- grade invasive disease at the time of diagnosis, and multifocal disease has been reported in approximately 25% to 30% of UTUC [7,8]. A meta-analysis and systematic review of CTU for UTUC reported a pooled sensitivity of 96% (95% confidence interval [CI], 88%-100%) and a specificity of 99% (95% CI, 98%-100%) for identifying UC [113]. In a recent review by Mirmomen et al [35], CTU demonstrated a 91% diagnostic accuracy in detecting UCs, but it may miss very small or flat lesions that are more easily detected by direct visualization [23]. CT is commonly used to determine nodal involvement, but relying on size alone is not reliable because small nodes may be metastatic and large nodes may be reactive [83]. CT cannot detect microscopic tumor metastases in nonenlarged lymph nodes [5]. CT Abdomen and Pelvis Without and With IV Contrast There is limited literature to support the use of CT abdomen and pelvis without and with IV contrast (separate from CTU protocol) in the pretreatment staging of UTUC. There is no relevant literature documenting additional benefit of CT without and with IV contrast, relative to CT with IV contrast in this setting.
Pretreatment Staging of Urothelial Cancer. The European Association of Urology guidelines [31] recommendations specific to UTUC indicate that CTU is generally the most accurate and preferred modality for diagnosis and staging, both local and distant. This is supported by several studies concluding that CT, particularly CTU, is the most used imaging modality worldwide for the diagnosis and staging of urothelial malignancies [2], and CTU is the favored modality used for localizing, locoregional staging, and detecting distant metastases in UC [34]. The American Urology Association has recently published guidelines for UTUC separate to bladder cancer [19]. CTU is also essential to evaluate for synchronous UTUC or bladder UC. Approximately two-thirds of UTUCs present as high- grade invasive disease at the time of diagnosis, and multifocal disease has been reported in approximately 25% to 30% of UTUC [7,8]. A meta-analysis and systematic review of CTU for UTUC reported a pooled sensitivity of 96% (95% confidence interval [CI], 88%-100%) and a specificity of 99% (95% CI, 98%-100%) for identifying UC [113]. In a recent review by Mirmomen et al [35], CTU demonstrated a 91% diagnostic accuracy in detecting UCs, but it may miss very small or flat lesions that are more easily detected by direct visualization [23]. CT is commonly used to determine nodal involvement, but relying on size alone is not reliable because small nodes may be metastatic and large nodes may be reactive [83]. CT cannot detect microscopic tumor metastases in nonenlarged lymph nodes [5]. CT Abdomen and Pelvis Without and With IV Contrast There is limited literature to support the use of CT abdomen and pelvis without and with IV contrast (separate from CTU protocol) in the pretreatment staging of UTUC. There is no relevant literature documenting additional benefit of CT without and with IV contrast, relative to CT with IV contrast in this setting.