Conclusions and Recommendations for Imaging Approach

To summarise, Table 2 (based on published reports and our own experience) offers an overview of the value of the several staging techniques for urinary bladder. MRI is superior to CT for staging, as CT cannot differentiate between the various layers of the bladder wall and cannot, therefore, distinguish lesions of the lamina propria from those invading the superficial and deep muscle wall. There are also difficulties in assessing tumors at the dome and trigone. The multiplanar and soft tissue characterization capabilities of MRI make it a valuable diagnostic tool among the non-invasive imaging modalities. Also, MR imaging is the most promising technique for the detection of nodal and bone marrow metastases. When MR imaging is available, CT is no longer needed. In addition, recent advances in MRI, such as fast imaging, fast dynamic Gd-enhanced techniques, and the use of specific contrast for the assessment of lymph nodes, improve the imaging quality and diagnostic accuracy for staging urinary bladder carcinoma. However, due to limited resources, this technique should only be used to obtain information that directly influences therapeutic management and outcome. To achieve this, both the knowledge of urologists in MR imaging and knowledge of the radiologist in clinical handling is required, therefore, continuous education and communication between these two specialties is a necessity.

Table 3 presents the diagnostic management of urinary bladder cancer. Detection of bladder cancer should be performed by cystoscopy. Once bladder cancer is diagnosed, the following step should be staging. For superficial tumors, clinical staging, which includes transurether-al resection, is the best technique. If, however, there is muscle invasion, further staging has to be performed with MR imaging. To avoid post-biopsy over-staging from edema and fibrosis, or the inconvenience of waiting 2-3 weeks after transurethral biopsy, we recommend fast dynamic imaging. Superficial tumors without muscle invasion (stages Ta-T1) are treated with local endoscopic resection with or without adjuvant intravesical installations. If cystoscopy reveals large multiple nodular or papillary tumors, a MRI examination can be helpful to provide an overview of the tumor prior to the biopsy.

Patients with muscle invasion (stages T2a-b) and with perivesical infiltration (stages T3a-b) or with invasion into prostate, vagina or uterus (stage T4a) will be treated by radical cystectomy and lymphadenectomy.

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