Visible haematuria — suspected urothelial cancer

ACR AC Hematuria

Painless visible haematuria in an adult is urothelial cancer until proven otherwise, and the study that excludes it is a CT urogram. The classic vetting failure is the request arriving as a stone protocol: an unenhanced CT KUB looks superficially like the right scan and cannot see a urothelial tumour at all.

Adult with visible haematuria, or non-visible haematuria with risk factors, referred for upper tract imaging alongside cystoscopy.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

CT Urogram — Split Bolus

CT Urogram

What we'd amend, and why

An upper tract urothelial tumour is a soft-tissue lesion inside a collapsed, fluid-filled tube. It is invisible on an unenhanced scan and barely distinguishable from urine on a venous-phase scan; it becomes visible only as a filling defect once excreted contrast opacifies the system around it. That is the entire reason the excretory phase exists. The unenhanced series is retained so that stones can still be identified, and the nephrographic component covers the parenchyma for a renal mass. Hydration and ureteric distension are part of the technique, because a collapsed ureter hides small lesions.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwaystandard — Adults — visible haematuria
rulerule-contrast-reaction-premed — Prior contrast reaction and elective premedication; checked by Nurse before the scan
rulerule-metformin — Metformin and iodinated contrast; checked by Radiographer at the scanner
rulerule-paeds-dose — Child-sized technique and contrast dose; checked by Radiographer at the scanner
rulerule-pregnancy-ionising — Pregnancy status before an ionising exposure; checked by Radiographer at the scanner
rulerule-renal-iodinated — Kidney function and intravenous iodinated contrast; checked by Radiographer at the scanner
rulerule-iv-access — Intravenous access adequate for the planned injection; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(4)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

Metformin and iodinated contrast
Confirm whether the patient takes metformin or a metformin-containing combination, and if so whether ACR Category II applies (eGFR below 30, known or suspected AKI, or an arterial catheter study likely to cause renal embolisation). If Category I — that is, no AKI and eGFR at or above 30 — no action of any kind is needed.
Radiographer at the scannerAt the scanner
Flags back if: The patient takes metformin AND meets ACR Category II — eGFR below 30 mL/min/1.73 m2, known or suspected acute kidney injury, or an arterial catheter procedure with likely renal arterial embolisation. Metformin plus a normal or mildly reduced eGFR is explicitly NOT a flag-back: there is no need to stop metformin before or after intravenous iodinated contrast in Category I patients, and no need to re-check creatinine afterwards.
Child-sized technique and contrast dose
Confirm that a size- or weight-based protocol is selected — child-sized kV and mAs against size-based diagnostic reference ranges — and that contrast volume is calculated by weight rather than taken from an adult default. Weight-based iodinated contrast volumes of roughly 1.5–2.0 mL/kg are widely used in paediatric CT.
Radiographer at the scannerAt the scanner
Flags back if: No paediatric or size-based protocol exists on the scanner for the requested examination, or the requested coverage or number of phases exceeds what the clinical question needs — for example a multiphase study where a single phase answers it, or whole-body coverage for a focal question.
Pregnancy status before an ionising exposure
Make the pregnancy enquiry immediately before the exposure and record the answer. In the UK this is a statutory operator duty discharged at the time of exposure under the employer’s written procedures required by IR(ME)R 2017 — it is not something the vetting radiologist can perform or pre-empt, and a request is complete without it.
Radiographer at the scannerAt the scanner
Flags back if: The patient states that she is, or may be, pregnant AND the uterus is in or near the primary beam. The exposure is then paused for re-justification by the IR(ME)R practitioner before it proceeds.
Intravenous access adequate for the planned injection
Site and test a cannula that supports the protocol flow rate, preferring an antecubital or large forearm vein, and observe the injection for extravasation. A 20-gauge or larger cannula is preferred for flow rates of 3 mL/s or more.
Radiographer at the scannerAt the scanner
Flags back if: No cannula can be sited that supports the protocol flow rate — for example only a 22-gauge hand or foot cannula for a CT angiogram needing 4–5 mL/s; or the only available access is a central line or port that is not labelled power-injectable; or an extravasation occurs.

Worth asking the referrer (1)

None of these hold the request up. They sharpen the protocol or the plan that follows.

Is the haematuria visible to the patient, or detected on dipstick only?
Visible haematuria carries a far higher cancer yield and warrants full urographic imaging; the pathway for non-visible haematuria is more selective.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Pregnant

Role	Study & protocol	Why this answers the question
First line	Ultrasound renal tract Ultrasound renal tract	Ultrasound carries no radiation and no contrast and answers the questions that matter acutely — obstruction, a renal mass, bladder abnormality. Urothelial malignancy is rare at this age, so the yield lost by deferring urographic imaging is small and the exposure avoided is real.
Second line	MRI abdomen and pelvis MRI abdomen/pelvis — non-contrast rapid protocol	Unenhanced MR urography with heavily T2-weighted sequences shows the collecting systems as fluid without gadolinium and without ionising radiation, which is the right escalation when ultrasound is inconclusive and the question cannot wait until after delivery.

Adults — visible haematuria

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	CT Urogram CT Urogram — Split Bolus usually appropriate	An upper tract urothelial tumour is a soft-tissue lesion inside a collapsed, fluid-filled tube. It is invisible on an unenhanced scan and barely distinguishable from urine on a venous-phase scan; it becomes visible only as a filling defect once excreted contrast opacifies the system around it. That is the entire reason the excretory phase exists. The unenhanced series is retained so that stones can still be identified, and the nephrographic component covers the parenchyma for a renal mass. Hydration and ureteric distension are part of the technique, because a collapsed ureter hides small lesions.
Reasonable alternative	Ultrasound renal tract Ultrasound renal tract	Reasonable as the first test in a younger patient with non-visible haematuria and no risk factors, where the yield from full urographic imaging is low and the dose is not justified. It detects hydronephrosis and renal masses but is insensitive to urothelial disease, and that limitation must be stated rather than implied.

Pitfalls

Vetting this request as a stone protocol. An unenhanced low-dose CT KUB is the single commonest wrong answer to painless visible haematuria, and it reads as a negative scan.
Stopping the work-up when a stone is found. A stone in an older patient with painless visible haematuria may be entirely incidental.
Incomplete ureteric opacification reported as a normal ureter — a non-opacified segment is unassessed.
Calling a study a urogram when the delayed acquisition was taken too early to opacify and distend the ureters. Eight to fifteen minutes and a distension technique are what make it a urogram; three minutes makes it a nephrographic scan of the kidneys.
Assuming a normal CT urogram excludes bladder cancer. Bladder assessment is cystoscopic, and layering dense contrast in the bladder can hide a tumour.
Very dense excreted contrast causing streak that obscures small filling defects; dilution by hydration is part of the protocol rather than an afterthought.

Priors — what to pull first

Check whether a CT KUB has already been done for this episode. It is very often the study that was performed, and it does not answer this question — repeating imaging correctly is the right call, not a duplicate.
Previous urological history, including prior urothelial tumours, changes both the pre-test probability and the surveillance interval.

What makes a good request

For visible haematuria, CT urography without and with contrast is the appropriate initial study; MR urography is the alternative where iodinated contrast or radiation must be avoided.
Imaging assesses the upper tracts. The bladder is assessed by cystoscopy, and a normal CT urogram does not remove the need for it.
Age and risk factors shift the pre-test probability substantially, but a stone found on a haematuria scan does not explain visible haematuria in an older smoker and should not stop the work-up.
The unenhanced series is part of the urogram and must not be dropped: without it, a stone within an opacified collecting system cannot be distinguished from excreted contrast.
The excretory timing is the technical detail people quietly drop. Opacification of the whole collecting system needs roughly 8-15 minutes after injection — or the appropriate delay after the first bolus of a split-bolus injection — together with hydration and a distension technique such as supine and prone acquisitions or abdominal compression, because a collapsed ureter hides a small filling defect. A "urogram" acquired three minutes after injection is a nephrographic study with a name it has not earned, and reporting the ureters from it is reporting an unassessed structure.
Age changes the dose calculus as much as the yield. CT urography is a multiphase study and its dose is not trivial. In an adult under about 40 with visible haematuria and no smoking, occupational, analgesic or prior urothelial risk factor, renal tract ultrasound alongside cystoscopy is a reasonable opening, with urography reserved for a negative work-up or persistent bleeding. From 40 upwards, and at any age with risk factors, urography is the study and the dose is justified.

Scoring this once it is done

The classification and risk tools this question ends in.

VI-RADS (Bladder Cancer Muscle Invasion, mpMRI)

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

Ultrasound renal tract MRI abdomen/pelvis — non-contrast rapid protocol CT Urogram — Split Bolus

Confirm locally

CT Urogram — Split Bolus: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.