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Introduction

BLADDER ANATOMY

The bladder is a sub-peritoneal, hollow muscular sac that serves to reservoir urine and to allow its expulsion.

This highly deformable organ is located in the pelvic cavity, behind the symphysis pubis, below the parietal peritoneum. The size and shape of the urinary bladder change depending on how much urine it holds (total storage is up to 500ml), and the pressure exerted by other organs. In particular, when filled, the bladder acquires a round or oval form (1).

The bladder's anatomical structure is complex. Macroscopically, it is divided into four parts: the apex or dome, which is directed antero-superiorly; the body; the fundus; and the neck, which is positioned inferiorly. The bladder's floor has three openings, creating the trigone. The base of the trigone is formed by two openings coming from the ureters, that come from a short, oblique, intramuscular course. The third opening is the urethral opening, located at the bladder neck, precisely at the inferior angle of the trigone, where urine is expelled from the bladder (2,3).

Microscopically, the bladder features a layered composition, similar to that of the ureters. The inner lining of the bladder is made up of a transitional epithelium, known as the urothelium, which consists of transitional cells. In a relaxed state, the urothelium is five to seven layers thick, but it can stretch to accommodate increased urine volume. Beneath the urothelium lies the lamina propria or submucosa, which is a subepithelial connective tissue containing muscle fibers with variable disposition. The next layer, the muscularis propria, is composed of the detrusor muscle, featuring three layers: inner longitudinal, middle circular, and outer longitudinal. This smooth muscle is responsible for contracting and releasing urine from the bladder. The bladder's walls are covered by serosa, a thin connective tissue layer that continues with the peritoneal layer of the abdominal wall and contains various blood vessels. In areas without serosa, the bladder is enveloped by the adventitia, a layer of loose connective tissue (4,5).

BLADDER CANCER

Bladder cancer (BCa) is a prevalent and aggressive malignancy worldwide, secondary to prostate cancer considering urogenital tumors. (6) The International Agency for Research on Cancer (IARC) has documented that the following represents associated with BC’s risk factors: tobacco smoking; certain occupational exposures, such as working in industries like aluminum production, rubber production, painting, firefighting, and exposure to various dyes (e.g., magenta and auramine) or dye intermediates (e.g., 4-aminobiphenyl); environmental factors like X radiation, gamma radiation, and arsenic; specific medications like cyclophosphamide; opium consumption; and Schistosoma infection. Furthermore, other risk factors, such as dietary elements, microbiome imbalances, gene-environment interactions, exposure to diesel exhaust emissions, and pelvic radiotherapy, have shown correlative associations with the development of bladder cancer (7).

The most common presentation symptom of BCa is an asymptomatic macro or microhematuria, known as “painless hematuria”, which occurs in about 85% of patients. To identify the origin of the bleeding, it is necessary to carefully characterize the hematuria as initial, terminal, and total hematuria (8). The other frequently presenting symptoms of BCa are linked to bladder irritability, such as urinary frequency, urgency, and dysuria. The flank pain appears when ureteral obstruction occurs. Less common are the lower extremity edema and the palpable pelvic mass. In advanced cases, patients present with weight loss and abdominal or bone pain because of distant metastases (9,10).

Urothelial Carcinoma (UC) is the most common subtype of BCa, followed by squamous cell carcinoma, sarcoma, lymphoma, and adenocarcinoma. Two-thirds of all BCa are non-muscle-invasive BC (NMIBC), while one-third are muscle-invasive BC (MIBC) and are related to a higher risk for metastasis and a significantly worse prognosis (7). BCa morphology can vary depending on tumor growth and progression. For example, horizontal growth is typical of Carcinoma-in-situ (CIS), while exophytic polypoid masses or sessile infiltrative lesions are typical of invasive forms (8, 6).

BCa is staged using the standard TNM system and as with other hollow organs, the T parameter is based on the depth of invasion of wall’s layers. In particular, the pTa refers to the papillary carcinoma, a type of NMIBC that presents as an exophytic mass lesion, while the pTis refers to the flat CIS, included in the NMIBC forms. At the T1 stage, the tumor invades the lamina propria and is typically treated with Trans-Urethral Resection of the Bladder Tumor (TURBT) and adjuvant intravesical therapy; at stage T2 the tumor invades the detrusor muscle becoming an MIBC. When a tumor infiltrates the perivesical fat is classified as a T3, while when it affects surrounding organs is a T4. Stage T2 and above tumors require more aggressive management, such as radical cystectomy (11). The N parameter considers the lymph node involvement with an N1 and N2 requiring the presence in the true pelvis of one or multiple nodes respectively; in an N3 staging, there is a metastasis in a common iliac node. The M1 indicates the presence of metastasis, with a subclassification in M1a when there is a non-regional lymph node involvement and M1b when there are other distant metastases (5,12).

IMAGING MODALITIES

Imaging modalities, including Ultrasound (US), Computed Tomography Urography (CTU), and Magnetic Resonance Imaging (MRI), play an important role in diagnosing and staging BCa. They are crucial for the detection of BCa, as well as for differentiating a T1 from a T2, considering that the treatment changes significantly between the two stages (13).

Considering the sensitivity of detection of BCa, this parameter increases from US to CTU, reaching a very high rate with the MRI examination. Nevertheless, the latter is gaining more and more application, as it is essential to differentiate an NMIBC from an MIBC.

International guidelines recommend the US, not excluding the physical examination, as the first step in the diagnostic work-up of a suspicious tumor, as in the case of painless hematuria, and requires a cystoscopy examination and a subsequent biopsy for the final diagnosis (8).

This narrative review also includes imaging modalities such as Dual Energy CT (DECT) and Contrast-Enhanced Ultrasound (CEUS) that are not mentioned in the habitual diagnostic work-up but have utility in particular applications.

ULTRASOUND

Technique

The patient should drink 300-500ml of water before the exam to enable adequate distension of the bladder, which should be moderately filled. If under-distended the evaluation of the bladder wall is limited as a wall thickening or a focal mass can be overestimated, while overdistention leads the patient to feel discomfort and be less collaborative.

The transabdominal kind of exam is the mostly performed, and the one taken in analysis in this review. The transvaginal examination is performed in females to improve spatial resolution if needed, while in males, a transrectal approach can be performed if the transabdominal approach is limited.

The examination is performed with the patient in the supine position, with lateral decubitus when required.

The convex probe (4.5-6 MHz) is the more appropriate and an abdomen/renal preset is suggested. To provide a right evaluation of the organ the probe should be placed just above the symphysis pubis and angled caudally, then scanning should be performed in the two orthogonal planes and also in the oblique. In this way, the bladder is always centered within the field of view during the examination.

The bladder wall appears as layered with the hypoechoic muscle between two hyperechoic layers corresponding to the serosa and mucosa. While the lateral and posterior walls are well visualized with US, the anterior wall is affected by the reverberation phenomena, that can be adjusted with the time-gain compensation (TGC). To selectively explore the anterior wall and the vesical cupola the examination can be performed using a higher frequency linear transducer (>7.5 MHz). To evaluate the ureteral jet, which is a normal and periodic efflux of urine from the ureter into the bladder, it is necessary to turn on Color Doppler in the trigone of the posterior wall, to exclude a complete ureteral obstruction.

The US allows the evaluation of the vesical capacity and the residual urine volume. The volume of urine is estimated by taking the three dimensions in the two orthogonal planes and applying an automated formula that includes a correction factor (k) that considers the complex bladder shape (11, 14).

Applications

The transabdominal US is influenced by various factors such as the amount of vesical filling, the patient’s constitution, the size and distribution of the tumor, or previous treatments performed (radiotherapeutic, chemotherapeutic, or surgical) (13). US is reported to be 63% sensitive; in particular, the sensitivity decreases when male patients suffer from prostate hypertrophy which determines irregularity of the bladder base wall. On the other hand, the sensitivity increases compared to the cystoscopy in the case of a tumor within the diverticula, because of the limitation of cystoscopy in evaluating the narrow neck (14).

Generally, the BCa can be easily detected when is localized on the lateral and posterior walls, considering that most UC are localized in the posterior walls, and when of larger size, which is the most important factor influencing the diagnostic sensitivity of US. The tumors can only be detected when their maximum diameter is more than 5 mm. A larger size is often associated with other signs such as wall rigidity and asymmetrical distension of the bladder. The site of origin of the tumor is a less important factor in influencing sensitivity, even though some regions are more difficult to evaluate for technical reasons (dome, anterior wall, base) (11).

Bladder masses are commonly echogenic, and irregularly shaped such as cauliflower-like, and are found either mounted on the bladder wall or in areas of irregularly increased bladder wall thickness. However, BCa features in the US can differ depending on morphology and appear as papillary, infiltrating, or invasive, as well as with mixed features of papillary and infiltrating. The papillary forms appear as small echogenic masses originating from the bladder wall and projecting into the lumen, easily detected when larger than 2-3mm. On the other hand, if the tumor is a superficial carcinoma, it can be recognized only because of a soft wall thickening, which presents a normal echo structure and is not a sign of invasions. Infiltrating tumors can be recognized because of their typical small papillary component and their hypo-echogenicity compared to the echogenicity of the vesical wall and the perivesical adipose tissue (11, 13, 14).

If a focal mass is detected in the US, the focus of attention should be the search for additional lesions, considering that one-third of tumors are multifocal, and an additional evaluation with the Doppler that can be useful to identify the internal vascularity with a rich blood flow signal or a stellate morphology and to differentiate a potential tumor from a blood clot. The latter can be excluded by asking the patient to change position from supine to lateral to assess for the lesion mobility typical of a clot or eventually performing bladder irrigation followed by another US scan (11) (Figure 1).

CONTRAST ENHANCED ULTRASOUND

Technique

CEUS is a novel technology that can objectively reflect tissue perfusion, using Ultrasound Contrast Agent (UCA). As for the conventional US, the bladder should be adequately distended before the examination. At first, a complete baseline US evaluation should be performed before the examination with CEUS. The most commonly used UCA is sulfur hexafluoride (SonoVue), which is a blood pool tracer that never leaves the blood vessel and can be used for real-time dynamic imaging of microcirculation perfusion. It is injected intravenously (IV) in an amount of 2.4mL, using a 21gauge peripheral cannula, followed by approximately 5cc of saline. The UCA remains in circulation for a period sufficient to reach the organ and guarantee an adequate interpretation of both arterial and venous phases. The study is conducted in basal B-mode conditions and with a low mechanical index to reduce the rupture of the microbubbles.

In normal conditions, a normally distended bladder has a thin wall of approximately 2mm, with little signal to the CD and almost imperceptible in the initial phase of administration of the contrast medium and with a progressive enhancement of the signal up to approximately 2 minutes (15).

Applications

CEUS utilizes the biological principle that tumors exhibit distinct patterns of neovascularization, leading to variations in contrast agent wash-in and wash-out times when compared to non-neoplastic conditions. One key advantage of CEUS is its real-time capability. Unlike CT or MRI, which require determining the optimal acquisition time for better differentiation of tumors from the surrounding bladder wall, CEUS doesn't necessitate such precise timing. This is because the enhancement pattern can vary among patients due to factors like cardiovascular health or the extent of micro-vascularization in bladder cancer. With CEUS, a dynamic real-time assessment of enhancement can be performed continuously, eliminating the need to pinpoint a specific moment.

Moreover, the prolonged enhancement of bladder cancer allows for a comprehensive exploration of bladder walls with just one dose of contrast agent, making it useful in detecting multiple cancer foci in cases of multicentric cancers. In the presence of arterial neovascularization, a common feature of bladder cancer, the signal enhancement in both papillary and sessile lesions or small focal thickening areas is immediately noticeable, similar to what occurs in the arterial phase of uro-CT. The signal increase is typically uniform, except in larger, high-grade, invasive cases where it may be non-uniform, especially in the presence of necrotic regions within the tumor (16).

Following the rapid arterial phase, most tumors reach a plateau with slow washout, although the venous phase can vary based on size and cellular differentiation. CEUS is particularly valuable for differential diagnosis, helping distinguish neoplastic growths from other bladder wall alterations that may mimic tumors, such as intravesical clots, adherent lithiasis, benign prostatic hypertrophy-related thickening, or inflammation-induced wall thickening. Focal or nodular enhancement is indicative of neoplasia in these situations.

Detecting bladder cancer with CEUS relies on identifying areas of focal hyper-enhanced wall thickening or enhancing masses protruding into the bladder lumen. The use of a contrast agent in ultrasound improves the detection of bladder cancer, particularly in cases where traditional ultrasound studies may be inconclusive due to factors like inadequate bladder distension, prior bladder surgeries, obesity, or the presence of an intravesical catheter.

The depth of wall invasion, histological grade, and extension beyond the bladder are the main factors for determining the prognosis and treatment approach for bladder cancer. While MR and CT are the preferred modalities for local staging, CEUS can aid in evaluating wall invasion by assessing the enhancement pattern of the bladder wall. It can help differentiate between noninvasive urothelial carcinoma and infiltrating carcinoma based on the presence or absence of a hypoechoic layer and the enhancement pattern after arterial enhancement. (15).

Bladder malignant tumors exhibit distinct enhancement patterns compared to benign lesions, making CEUS a valuable tool for distinguishing between them and improving diagnostic accuracy. CEUS enables real-time observation of the blood flow in bladder tumors, aiding in the differentiation between benign and malignant tumors. However, its usefulness in bladder staging for infiltrating carcinomas is limited compared to CT and MRI, as it cannot assess perivesical fat infiltration and retroperitoneal lymph nodes (16) (Figure 2).

COMPUTED TOMOGRAPHY UROGRAPHY

Technique

CTU is a CT examination of the urinary tract that is performed with an unenhanced scan and after intravenous (IV) contrast material administration with a multiphasic acquisition to obtain a set of images that show a fully opacified and distended intrarenal collecting system, ureters, and bladder (17).

More precisely, the protocol includes an unenhanced scan of the abdomen and pelvis; after IV administration of contrast agent the phases obtained are a corticomedullary phase at 30-40 seconds after the injection, resulting in an arterial phase; a nephrographic phase at 100 seconds after the injection; an excretory phase scan at 8-12 minutes after the injection. The scan should be directed in a cranio-caudal way and the extension on the Z axes should start from the diaphragmatic dome to reach the pubic symphysis, especially in the unenhanced and nephrographic scan, while the corticomedullary and the excretory can start from the upper pole of the kidney.

However, the main limitation of a multiphasic protocol is the high radiation exposure, ranging from 25–35 mSv, for this reason, especially in a young patient, a split-bolus technique is suggested. It includes a two-phase protocol with an unenhanced scan, followed by two IV injections of contrast agent, respectively of about 80ml and 40ml. After the first administration, it is necessary to wait 20 seconds to obtain the corticomedullary scan. After an 8-minute delay, the second bolus is administered, and it is followed by a scan at 100 seconds to obtain a nephrographic-excretory phase. The scan should be directed in a cranio-caudal way and the extension on the Z axes should start from the diaphragmatic dome to reach the pubic symphysis, especially in the unenhanced and nephrographic-excretory scan, while the corticomedullary can start from the upper pole of the kidney (18).

Both protocols may be completed with an administration of 10 mg of IV furosemide a few minutes (2–3 min) before the corticomedullary scan to obtain adequate distension of the upper urinary tracts and the bladder. Therefore, an under-distended bladder can appear thickened, particularly along its anterior wall, and the lumen can show an incomplete mixing of non-opacified urine and contrast material, resulting in a urine contrast level since the specific gravity of contrast medium is higher than urine (17).

Applications

CTU of the abdomen represents the most commonly used technique thanks to its many advantages: wide availability, fast scanning, and creation of multiplanar reformatted and three-dimensional reconstructed images. In patients with suspected or diagnosis of BCa, the examination is performed for the detection and staging of BCa, in the latter case to assess the loco-regional and distant extension of disease.

Each phase of the protocol required in a CTU has its advantages. The unenhanced CT scan is used to measure the basal attenuation of the mass to compare it after contrast enhancement and also to identify the presence of stones, calcifications, hemorrhages, and clots. The corticomedullary phase is used to evaluate suspected vascular abnormalities or arterial enhancement. The nephrographic phase is used to detect and characterize renal masses. The excretory phase is used to assess the urothelium because the bladder is filled with dense contrast material and an endoluminal soft-tissue lesion will appear as a filling defect (19).

BCa can appear as a focal region of thickening of the bladder wall or as a mass protruding into the bladder lumen or extending into adjacent tissues in advanced cases. Considering not adequate distension of the bladder, a focus of attention should be the asymmetry of the thickening. Generally, the masses are of soft-tissue attenuation and may be encrusted with small calcifications.

CTU has the highest accuracy with a pooled sensitivity of 92% and a pooled specificity of 95% in the detection and staging. Concerning T staging, it is limited in differentiating NMIBC from MIBC but can distinguish T3 and T4 tumors. Concerning N staging, it enables lymph node morphology and size assessment. About the size, the suspect occurs when pelvic and abdominal-retroperitoneal lymph nodes have a short axis, respectively, greater than 8 mm and 10 mm. Regarding the morphological criterion, the presence of confluent lymph nodes or those with a necrotic center is considered a clear sign of lymph node metastasis. The limitation of CTU in the study of the lymph nodes is the potential over-staging, detected in about 30% of cases with reactive lymphadenopathies with a short axis greater than 10 mm; and the potential sub-staging when lymph nodes are malignant but have dimensions within the limits. Concerning M staging, BCa most frequently metastasizes to the pelvic and retroperitoneal lymph node stations. Bone is the most common site for distant bladder cancer metastases; most appear sclerotic but can also be lytic or mixed lytic sclerotic. For solid organs, the liver and lung are the most frequent sites of metastasis, with the involvement of other organs occurring far less frequently (11).

Following the diagnostic workup, subsequently, to a detection requiring further examination, an endoscopy with biopsy may be indicated to confirm the diagnosis and determine the number, extent, and localization of the urothelial tumors (18).

DUAL ENERGY COMPUTED TOMOGRAPHY

Technique

DECT is a novel imaging technology that operates two X-ray tubes with different kilovoltages (one lower and one higher) to produce a set of images reconstructed in post-processing.

Considering the purpose of the examination such as the detection of a suspicious BCa or its staging, the most useful types of images are the Virtual Mono-Chromatic (VMC), the Virtual Non-Contrast (VNC), the Iodine Map, and the Atomic Map.

VMC generates images that are like those of the conventional single-energy CT from a quality point of view, but it provides more reliable attenuation values. The lower energy kilovoltage setting can increase the contrast among near structures, thanks to the elevated beam attenuation of iodine. As a result, a parietal lesion is easier to recognize. The higher energy kilovoltage setting can decrease noise and artifacts. The comparison between the two different kilovoltages set, from VMC-acquired images, also produces a spectral attenuation curve, which is a function of energies. The latter due to its properties is useful to improve lesion characterization.

VNC generates images “without contrast” by suppressing the iodine material uptake from scans acquired post-contrast. Therefore, VNC images are also known as Iodine Removed images. In this way, the radiation dose could be reduced as the patient has not undergone the first unenhanced scan.

The iodine Map is a material-specific image in opposition to the Iodine Removed image, as the Iodine is selected and not suppressed to show all areas characterized by the iodine uptake. This kind of image results in a color map able to quantify the iodine uptake expressing it in milligrams/millimeter (mg/mL). Moreover, it allows one to distinguish a vascularized lesion from a non-vascularized lesion considering the amount of iodine filling the aorta.

The effective Atomic Number Map is a quantitative method for assessing material differentiation and evaluating attenuation variations as a function of energy (3).

Applications

DECT is a new imaging method that with its qualities may be useful to overcome the main limitations of CT such as ionizing radiation overexposure typical of oncological patients who underwent repeated acquisition phases and tight follow-up.

Moreover, DECT allows a better lesion characterization thanks to post-processing reconstruction. In particular:

VNC images provide a true unenhanced image helpful to exclude the presence of stones, calcifications, and fresh bleeding that appear hyperdense in the typical basal scan, as well as to measure the attenuation value of reference for the subsequent post-contrast graphic scans.

The Spectral Curve, in case of a thickening of the bladder wall, shows a curve tending to increase from lower values of kilovoltage setting.

VMC images at low energy kilovoltage settings generate better contrast of the tumor despite the nearby regions and increase the sensitivity in detecting the tumor. Moreover, normalizing the iodine quantification to that of the aorta, in the nephrographic phase, this type of image increases the specificity when a threshold of 3.0 mg/ml or higher is reached and allows the differentiation between a vascular and non-vascular lesion. The formula is the following: |I| normalized=|I|  lesion⁄|I|  aorta (20,21).

DECT advantages also concern the staging of BCa as iodine maps make it easier to evaluate the tumor infiltration of wall layers, including the muscular one in differentiating an NMIBC from a MIBC, and evaluating lymph node involvement and the presence of metastases.

For treatment planning the application of this technology may be crucial as it can better assess the relationship between the tumor and a vascular structure, with the increased contrast obtained with the VMC at a lower kilovoltage setting, offering an important parameter for the surgeon (22) (Figure 3, 4).

MAGNETIC RESONANCE IMAGING

Technique

To obtain an adequate examination the preparation of the patient with a moderate distention of the bladder is crucial. The patient should urinate and start drinking 500ml of water respectively about two hours and half an hour before undergoing the exam.

A targeted scan with the localizer can provide a guide for the technician to start the exam when the bladder is properly distended.

Distension of the bladder, as mentioned before, is essential in the evaluation of the BCa the bladder wall may appear thickened and lead to a misdiagnosis if there is an under-distension; on the other hand, an excessive distension may cause discomfort for the patient who could moves determining movement artifact or asks to interrupt the examination if not more able to hold urine.

Generally, taking under evaluation a 1.5 T MRI scanner, the examination is performed at the patient in a supine position and the set of sequences necessary for a proper evaluation of the bladder are: T1W Fast Spin Echo (FSE) on the axial plane; T2W sequences with high resolution and narrow FoV on axial, sagittal or coronal and with fat suppression; DWI and ADC; and finally DCE-MRI with the T1W three-dimensional Gradient Echo (3D) and the Dixon Three Point method.

In female patients, the images have to include the urinary bladder but also the uterus, ovaries, and vagina, while in male patients have to include also the prostate (5).

Applications

The main application of MRI in the BCa evaluation is local tumor staging as it allows to distinguish the presence or absence of muscular infiltration, resulting in a differentiation between NMIBC and MIBC, as well as stages ranging from T1 to greater than T2.

The bladder wall is multilayered with the urothelium and lamina propria appearing as a hyperintense line only after contrast agent administration, in the early phase of the DCE-MRI sequences; the muscular layer appears as a low-intensity line on T2W, medium intensity line in DWI and ADC sequences, and with a late and gradual enhancement in DCE-MRI (5).

The development of the Vesical Imaging-Reporting and Data System (VI-RADS) score helps standardize the approach to MRI acquisition, interpretation, and reporting in patients diagnosed with BCa through TURBT. It ranges from 1 to 5 and expresses the progressive increasing risk of invasion of the detrusor muscle (6). The sequences to accurately examine are the T2W, the DWI/ADC, and the DCE with each sequence generating a score of 1 to 5.

At first, it is necessary to analyze the structural information in the T2W, evaluating the integrity of the muscular layer in the T2W that should appear homogeneously hypointense in contrast with the hyperintense signal of the bladder content. The presence of a lesion appears as an interruption of this line with an intermediate signal of a vegetating formation with a maximum size of 1cm, suggesting a score of 1 and an NMIBC form. If the lesion is sessile, associated with the presence of edema because of the thickening of the hyperintense line the probability of an invasion increases. A score of 2 is assigned when the diameter is superior to 1cm but there is no sign of invasion. A score of 3 expresses a doubt. A certain invasion of the muscular layer is expressed with a score of 4, which becomes 5 when there is the involvement of the adipose tissue nearby. The second step concerns the evaluation of the signal on DWI/ADC and DCE sequences. In the case of a tumor, the signal would appear hyperintense on DWI and hypointense on the ADC map, and there is an early enhancement of the inner layer. Following the information obtained from each sequence, the combination of the different scores is compared to obtain the final VI-RADS score. In case of a discrepancy in results, the DWI/ADC map and DCE will prevail to downgrade and upgrade lesions (5).

MRI also has a role in post therapeutic approach in BCa, concerning patient evaluation after neoadjuvant chemotherapy and immunotherapy, which is the last revolution in the treatment of MIBC forms. The purpose is the assessment of the lesion after treatment taking under examination the T2W, DWI/ADC, and DCE sequences, and the establishment of the response to the therapy, which can be partial, complete, or absent. In this context, also the VI-RADS scoring system has shown promising results (23).

In conclusion, MRI is rapidly becoming a leading imaging modality in BCa diagnostic workup, assessment of response to therapies, and longitudinal surveillance, and plays an important role in BCa surgical and radiation therapy treatment planning. Nevertheless, transurethral resection biopsy is required for tumor grading and cannot be replaced by MRI (Figure 5, Figure 6).

Conclusion

The role of imaging is crucial in the evaluation of BCa and has an essential role in the detection and staging. Conventional technologies such as the US and especially CTU are nowadays flanked by the MRI which is acquiring its importance as it allows the differentiation between NMIBC and MIBC through the VI-RADS score system. Emerging modalities such as CEUS and DECT are not included in the typical diagnostic and staging process but have their applications in particular conditions and can provide useful information that both clinicians and radiologists should know to guarantee the proper approach to the oncological patient with a future eye on increasingly personalized medicine. 

Авторлар туралы

Federica Masino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: federicamasino@gmail.com
ORCID iD: 0009-0004-4289-3289
Италия, Viale L. Pinto 1, 71122, Foggia (FG), Italy.

Laura Eusebi

Radiology Unit, “Carlo Urbani” Hospital.

Email: lauraeu@virgilio.it
ORCID iD: 0000-0002-4172-5126
Италия, Via Aldo Moro 52, 60035, Jesi (AN), Italy.

Gianmichele Muscatella

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: muscatella94@gmail.com
Италия, Viale L. Pinto 1, 71122, Foggia (FG).

Manuela Montatore

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: manuela.montatore@unifg.it
Италия, Viale L. Pinto 1, 71122, Foggia (FG), Italy.

Giuseppe Sortino

Urology Unit, “Carlo Urbani” Hospital

Email: giuseppesortino@live.it
Италия, Via Aldo Moro 52, 60035, Jesi (AN), Italy.

Willy Giannubilo

Urology Unit, “Civitanova Marche” Hospital.

Email: willygiannubilo@virgilio.it
Италия, Via Pietro Ginevri 1, 62012, Civitanova Marche (MC), Italy;

Giuseppe Guglielmi

Department of Clinical and Experimental Medicine, Foggia University School of Medicine;
Radiology Unit, “Dimiccoli” Hospital;
Radiology Unit, “IRCCS Casa Sollievo della Sofferenza” Hospital.

Хат алмасуға жауапты Автор.
Email: giuseppe.guglielmi@unifg.it
ORCID iD: 0000-0002-4325-8330

Medical Doctor, Full Professor of Radiology.

Department of Clinical and Experimental Medicine.

Италия, Viale L. Pinto 1, 71122, Foggia (FG), Italy; Viale Ippocrate 15, 70051, Barletta (BT), Italy; Viale Cappuccini 1,71013, San Giovanni Rotondo (FG), Italy.

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