Virtual cystoscopy, computed tomography urography and optical cystoscopy for the detection and follow-up for bladder cancer

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A) Correlación con lesión adyacente al cuello vesical de la <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> (flecha). B) Ejemplo de UCO en un paciente diferente con otra lesión papilomatosa (flecha) y dos lesiones planas visibles como cambios eritematosos en la mucosa (asterisco)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Ibáñez Muñoz, I. Quintana Martínez, A. Fernández Militino, D. Sánchez Zalabardo, L. Sarria Octavio de Toledo, R. Cozcolluela Cabrejas" "autores" => array:6 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Ibáñez Muñoz" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Quintana Martínez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Fernández Militino" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Sánchez Zalabardo" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Sarria Octavio de Toledo" ] 5 => array:2 [ "nombre" => "R." 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(A) and (B) MRI study with hepatospecific contrast (gadoxetic acid) in the hepatocellular phase showing one lesion in the left liver lobe (LLL) that happens to be compatible with focal nodular hyperplasia. (C) Biopsy study showing ductular proliferation in the fibrous septa-liver trabeculae junction. (D) and (F) Arteriography and final findings after selective embolization with 500–700μm PAPs leading to the devascularization of the lesion. (G) Surgical piece. The surgical intervention took place 5 days later without any complications." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.D. Ferrer Puchol, C. La Parra Casado, A. Cervera Araez, R. Sala López, E. Esteban Hernández, A. Cremades Mira, R. Ramiro Gandia" "autores" => array:7 [ 0 => array:2 [ "nombre" => "M.D." "apellidos" => "Ferrer Puchol" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "La Parra Casado" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Cervera Araez" ] 3 => array:2 [ "nombre" => "R." 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"apellidos" => "Ramiro Gandia" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833817300693" "doi" => "10.1016/j.rx.2017.04.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833817300693?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510717300526?idApp=UINPBA00004N" "url" => "/21735107/0000005900000005/v1_201709230142/S2173510717300526/v1_201709230142/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Virtual cystoscopy, computed tomography urography and optical cystoscopy for the detection and follow-up for bladder cancer" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "422" "paginaFinal" => "430" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Ibáñez Muñoz, I. Quintana Martínez, A. Fernández Militino, D. Sánchez Zalabardo, L. Sarria Octavio de Toledo, R. Cozcolluela Cabrejas" "autores" => array:6 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Ibáñez Muñoz" "email" => array:1 [ 0 => "david_ibi@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Quintana Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Fernández Militino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "D." "apellidos" => "Sánchez Zalabardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "L." "apellidos" => "Sarria Octavio de Toledo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Cozcolluela Cabrejas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Sección de Radiodiagnóstico, Hospital Reina Sofía, Tudela, Navarra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Estadística, Universidad Pública de Navarra (UPNA), Pamplona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sección de Urología, Hospital Reina Sofía, Tudela, Navarra, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cistoscopia virtual, urografía por tomografía computarizada y uretrocistoscopia óptica en el diagnóstico y el seguimiento del cáncer de vejiga" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 700 "Ancho" => 1400 "Tamanyo" => 97338 ] ] "descripcion" => array:1 [ "en" => "Examples of OUC images. (A) Correlation with lesion adjacent to the vesical neck from <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> (arrow). (B) Example of OUC in a different patient with another papillomatous lesion (arrow) and two visible planar lesions as erythematous changes in the mucosa (asterisk)." ] ] ] "textoCompleto" => "IntroductionThe urothelial bladder cancer is the seventh most common type of cancer in males and the eighteenth most common type of cancer in females around the world<a class="elsevierStyleCrossRef" href="#bib0095">1</a>; it is also the most common superficial urothelial and papillary carcinoma of all.<a class="elsevierStyleCrossRefs" href="#bib0100">2,3</a>The economic cost of this type of cancer is high due to its long average survival and the follow-up and management techniques needed, with an average cost of $15,000,000 dollars per patient in the United States.<a class="elsevierStyleCrossRefs" href="#bib0110">4,5</a> Such cost justifies the search for diagnostic techniques that may reduce the economic cost derived from the follow-up of these patients. The presence of macroscopic hematuria in patients who are smokers or have a history of chronic irritation due to lithiasis or amine exposure are all fundamental factors that may lead to suspect of this type of cancer.When it comes to the diagnosis of bladder cancer, the first test to be performed is an ultrasound that will let us to see any protruding masses. Compared to the ultrasound, the computed tomography urography (CTU) has similar specificity and higher sensitivity (90 per cent versus 69 per cent from the ultrasound).<a class="elsevierStyleCrossRef" href="#bib0120">6</a> The main limitation of the ultrasound and the CTU is their zero utility in the diagnosis of in situ carcinomas, and the same thing happens with the magnetic resonance imaging (MRI).<a class="elsevierStyleCrossRefs" href="#bib0125">7,8</a>The optical urethral-cystoscopy (OUC) is still the reference modality in the detection and follow-up of bladder cancer. It may be rigid or flexible, usually flexible, with similar diagnostic accuracy than the rigid OUC, and even higher diagnostic accuracy in lesions located in the anterior vesical neck.<a class="elsevierStyleCrossRef" href="#bib0135">9</a> Although the morbidity of this modality is low, it is associated with a risk of urinary tract infections in 3 per cent of the cases, a risk of transient hemorrhages in 19 per cent of the cases, pollakiuria in 37 per cent, and dysuria in 50 per cent of the cases.<a class="elsevierStyleCrossRefs" href="#bib0140">10,11</a> Also cases of vesical perforation and uretheral stenosis due to lesions occurring while the urethral-cytoscope is inserted and is passing by have been reported in the medical literature. There are also contraindications when performing OUCs such as the existence of acute cystitis, prostatitis, or urethritis, significant prostate hypertrophy, or vesical tears.<a class="elsevierStyleCrossRef" href="#bib0150">12</a> On the other hand, some regions are blind to the cytoscope, even the flexible one, such as the inside of diverticuli, and the vesical neck. These cases triggered the development of a new imaging modality–the virtual cystoscopy (VC) that associates the capacity of performing one abdominal multidetector computer tomography (MDCT) scan plus computing post-processing in order to make a virtual reconstruction of visceral lumen in a similar way to how we perform virtual colonoscopies today. The greatest advantage of VC according to the medical literature is that it is less invasive, it may be performed in cases when the OUC is contraindicated and allows us to establish if there is extravesical invasion. However, its main limitations are the use of ionizing radiation and the difficulty of detecting planar lesions,<a class="elsevierStyleCrossRef" href="#bib0155">13</a> although the risk of infection is lower than that of the OUC (between 1 per cent and 2 per cent).<a class="elsevierStyleCrossRef" href="#bib0150">12</a>The goal of this paper is to assess the utility of the VC performed together with the CTU in patients studied due to macroscopic hematuria or being followed for having a history of already treated bladder cancer, and then compare these findings with the ones obtained from the reference modality (the OUC).MethodsSelection of the sampleWe present a retrospective study including all patients referred from the emergency room or primary care to the urology practice in a period of one year due to suspicion of vesical neoplasm due to macroscopic hematuria with associated risk factors (age of the smoker ≥45 years old, no urinary tract infection, no history of pelvic radiotherapy due to tumors of non-vesical origin, or no presence of intravesical lithiasis), or due to a previous ultrasound with suspicious findings. Also all patients who were referred to the urology practice during that year to follow-up of their bladder cancer were included. Patients were selected in the urology practice based on these criteria and then referred to the unit of radio-diagnosis for the performance of VC and CTU modalities before handing their written informed consents for their inclusion in the study approved by the hospital ethics committee. The patients’ refusal to participate in the study, and the presence of microscopic hematuria were considered exclusion criteria.Exploratory techniqueSince the goal of this paper was to compare the results obtained with the VC and CTU imaging modalities, and the OUC, the maximum interval between the radiological and the urological tests were seven days, while the participating physicians from the different units were blinded and were not aware of the findings made in other studies.When it comes to the technique used to perform the VC and CTU modalities, after complete micturition, the patient was transferred to the tomography unit (Toshiba Aquilion™ 64-MDCT, with a 0.5mm cutting thickness, 120kv, 163mA, and 1000ms, using the same parameters in all sequences) and, once the patient was lying flat on the examination table, the nurses from the unit of radiodiagnosis proceeded, after local asepsy, to introduce one Foley 14-French catheter in order to drain any residual urine. The catheter balloon was filled up with air so that it would not intercede with the 3D reconstruction. Then 300 and 500 cc of room air were injected (based on the capacity of the bladder and the patient's tolerance) using a 60ml syringe, the catheter was not removed, and remained closed until the study was over (since it allowed filling up the bladder when necessary and avoided air content escape).When doing the initial scouting in the anterior–posterior and sagittal planes, the radiologist studied if bladder distension was adequate by measuring its maximum transverse and craniocaudal diameters, respectively, while using the following intervals already established as references in Amin and Abd El Hamid's study<a class="elsevierStyleCrossRef" href="#bib0165">15</a>: >15cm, optimal; 10–15cm, satisfactory; <10cm, poor. In case of mismatch between both intervals, the highest measurement was taken as the reference.One first series of abdominal-pelvic CT scans without contrast was performed (that allowed assessing the presence of hematuria-induced lithiasis), and then another acquisition 75s after the administration of IV contrast (Visipaque™, 320mg/ml, introducing 120ml at 3ml/s through peripheral venous access with an initial bolus of 20ml of physiological saline solution) was performed with the patient lying flat in the decubitus supine position, and volume was obtained for post-processing purposes. Then the patient was immediately placed in the decubitus prone position in order to perform a third acquisition from the pelvic region (from the iliac crests to the pubic symphysis) with additional fillings of 80–120ml of air when distension was not large enough. Lastly, and after emptying the bladder through the catheter, a fourth abdominal-pelvic acquisition was performed with the patient in the decubitus prone position in the excretory phase 8min after the administration of contrast in order to rule out upper urinary tract disease that may lead to macroscopic hematuria or distension of a former bladder carcinoma that would affect such tract. Once its validity was checked, the nurses were told to remove the catheter and dismiss the patient.Image interpretationThe studies were transferred to the working station (Vitrea® 2 Ver. 4.1.14.0, Vital Imaging Inc., CA, USA) using interactive intraluminal navigation software with a volume-rendering algorithm.The bladder assessment through the VC was always carried out by two radiologists with a similar experience who were not aware of the findings made. They assessed the VC and the CTU separately each one of them started with the VC. The study of the bladder started from an observation point at the centre of the bladder, and the different quadrants or segments were assessed in an orderly fashion (anterior, posterior, superior, inferior, right, and left, trigone, urethral orifices, internal urethral orifice and diverticuli) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Whenever any vesical lesions would be detected, the following parameters were studied: number, size, location, morphology (sessile/infiltrating, papillary/superficial, or areas of thickened wall), parietal mucosal thickening, trabeculation, diverticuli, and other intraluminal conditions (mainly lithiasis).True positives were cases of lesions in both the VC and the OUC; false positives were those where the lesion could be seen in the VC but not in the OUC; and false negatives were those where the lesion could be seen in the OUC but not in the VC.The OUC was performed using one flexible catheter. The study was carried out in an outpatient setting with asepsy, working in a sterile field, with iodinated povidone and urological lubricant using the flexible Storz® 19 Charriers cytoscope. The CTU was performed by assistant physicians from the urology unit, all of them with a similar experience. The parameters established were the degree of vesical distension; in the presence of lesions, the same parameters used in the VC were established; and the presence of diverticuli, or trabeculations.When it comes to the study of radiation induced by VC+CTU modalities and right after the analysis of doses in the individual studies of patients, the unit of radiophysics estimated the average dose length product (DLP) and effective dose by taking all abdominal-pelvic phases of the study into consideration since the DLP had not been stratified, which is why one complete abdominal-pelvic mathematical phantom was implemented. Data were collected using the dosage calculation sheets ImPACT, ImPACT CT patient dosimetry calculator, version 1.0.4 (27/5/2011).Statistical analysisThe data were statistically analyzed by personnel from the department of statistics using the R version 3.2.1 (18-6-2015) statistical software, and the IBM® SPSS® Statistics version 20.0.0 software. The most adequate statistical contrasts were performed using 5 per cent significance levels in order to make inferences about population parameters. The intervals used by consensus for Pearson's correlation coefficient were: values <0.20 were indicative of no match at all, values from 0.20 to 0.39 were indicative of a poor match, values from 0.40 to 0.59 were indicative of a regular match, values from 0.60 to 0.79 were indicative of a good match, and values from 0–80 to 1 were indicative of an excellent match.ResultsOne hundred and seventeen (117) patients were included in the study, among which 79 per cent were males and 21 per cent females with average ages of 66 and 68 years old, respectively. Of these 117 patients, seven men and one woman refused undergoing the study, two men and one woman did not attend, and in two men the necessary catheter for the VC could not be used, so they were all excluded from the study. On the other hand, two patients were referred due to microhematuria and were excluded, and in four patients with macroscopic hematuria the OUC could not be performed (one patient did not attend, another one refused, another one passed away before performing the OUC due to severe anemia, and in another patient the clinical manifestation were due to lithiasis, the CTU was not considered necessary and therefore was not requested). In sum, 102 patients (41 with macroscopic hematuria and 61 tumor controls) were assessed through VC/CTU, among which 98 underwent OUCs too. The first radiologist observer detected tumors in 22 patients, and the second radiologist observer in 24, with good matches in a positive sense between them (Pearson's correlation coefficient: 0.748).The air insufflated in the bladder using the catheter was, on average, 357cc in men and 355cc in women, without any statistically significant differences.The average time elapsed between the VC and the OUC was 5 days, with a minimum of 2 days and a maximum of 90 days (in one case only as we will be talking about later in the paper).When it comes to the size of the lesion, the VC confirmed a minimal dimension of 2mm, and a maximal dimension of 54mm (an average 13.25mm). The OUC confirmed an average of 3.05mm, with a minimal dimension of 2mm and a maximal dimension of 40mm, and a positive correlation between such measurements (Pearson's correlation coefficient: 0.011).Taking the findings of both populations altogether (macroscopic hematuria and controls) in the detection of intravesical tumors with VC versus OUC showed a 81.8 per cent sensitivity and a 92.1 per cent specificity, with a positive predictive value (PPV) of 75 per cent, and a negative predictive value (NPV) of 94.6 per cent. Among the 18 cases of true positives, there was only one case with non-tumor anatomopathological (AP) findings. Out of the four cases of false negatives, one case showed multiple papillary lesions >5mm in the OUC (almost three months passed between both imaging modalities, but the question of why this delay happened remains unanswered, and after treating the patient, the control study performed after three months showed new multiple papillary lesions of similar size) while in the remaining four cases, the size of the lesions was <5mm (two cases with inflammatory AP findings and one case with AP findings of carcinoma).On the other hand, if we take into consideration patients whose AP finding after the performance of the optical urethral-cytoscopy was carcinoma (that is, the capacity of the VC to detect cancer), only three biopsied cases happened not to be tumors (among which two cases were consistent with lesions <5mm in size, being VC false negatives, and only one case could be identified in the VC and the OUC–one true positive, but with atypical non-specific AP findings which is why it was also excluded). In this case, sensitivity was 89.5 per cent, and specificity, 91.1 per cent, with a PPV of 70.8 per cent, and a NPV of 97.3 per cent.However, when taking into account lesions ≤5mm only, the overall sensitivity was 80 per cent, and specificity, 96 per cent. Only three cases of lesions ≤5mm were identified in the OUC but not in the VC; out of these three lesions, two turned out to be chronic/follicullary based on the AP findings and one lesion a T1G2 infiltrating urothelial carcinoma. The PPV was 75 per cent, and the NPV, 96 per cent. The use of contrast in the standard CT study did not detect these lesions or other VC false negatives.When it comes to the number of lesions detected, there was a good positive correlation between both imaging modalities (Pearson's correlation coefficient: 0.846). However, when it comes to the size of lesions, no good correlations were obtained (Pearson's correlation coefficient: 0.011, −0.363 and −0.264 for the first, second, and third measured lesions, respectively).<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows all data assessed in the overall sample, and <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> show each and every one of the populations making up the sample.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Also the detection of lesions through VC versus CTU was compared with blinded assessors unaware of the findings made by the other imaging modality. The tests of statistical significance did not show any differences between both imaging modalities in the axial or the coronal planes. As a matter of fact, more cases were detected through the VC than through the conventional CT scan: nine in the axial plane and eight in the coronal plane, among which five cases were not consistent with lesions in the OUC (three were false images from imprints of the pubic symphysis or urachal remains [<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>]) while four images did show lesions in the OUC – three of them with AP findings of carcinoma. The series in the excretory phase did not provide any additional information to the information already provided by the conventional CT scan in any of the cases. In the assessment of collateral findings detected through VC-associated CTUs in 102 patients, 13 cases of high clinical significance could be identified (12.7 per cent of all VC+CTU studies conducted): two cases of pulmonary nodules suspicious of malignancy, five cases of aortic disease (among them one chronic dissection), two cases of urethral neoplasms, one case of hepatic metastasis due to rectal carcinoma, and three cases of abdominal adenopathies suspicious of being malignant too. Also, renal lithiasis, postoperative changes with air reflux in the ureters, or air bubbles simulating lesions were detected, among other non-critical findings made (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>As additional data from the study, the complications derived from using both imaging modalities were recorded (VC and OUC). Only three men suffered from complications after the VC (two urinary tract infections and one vasovagal syncope due to catheterization), compared to five patients who suffered from complications after the OUC.When it comes to the doses of radiation obtained, the average DLP was 2942.8mGy/cm and the effective dose, 45mSv.DiscussionIn our study we analyzed 98 patients who underwent VC/CTU and OUC imaging modalities and found a good interobserver correlation, and when it comes to the reference imaging modality (the OUC) in the capacity to detect lesions through VC, high sensitivity and specificity percentages for both the overall population and every one of the subgroups (macroscopic hematuria and tumor controls) were reached. These numbers were also high for cases studied through VC and OUC whose AP findings were neoplasms. When it comes to quantifying the number of lesions, we saw a good correlation between the VC and the OUC that was close to 1 in a positive sense and that was statistically significant, although this was not the case of tumor sizes determined by each imaging modality. In a controversial issue of medical literature such as the capacity to detect lesions <5mm, sensitivity was 80 per cent, and specificity, 96 per cent, with a high NPV, for all patients (out of the three cases of false negatives, only one case turned out to be a carcinoma in the AP findings)–numbers slightly lower in cases with macroscopic hematuria (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1–3</a>). The use of IV contrast in the CTU, or other VC false negatives did not contribute to the detection of such lesions either. Only one lesion in the axial study was seen compared to the VC, remaining this lesion unidentified in the OUC, meaning it was a false image. The tests of statistical significance did not show any significant differences between the existence of visible lesions through the VC and the axial or coronal CT scan study. Nevertheless, nine more lesions were detected through the VC than through the CT scan in the axial plane, among which five lesions were not consistent with the lesions found in the OUC (three were false images from imprints of the pubic symphysis), but four were positive lesions found in the OUC–three of them with final AP findings of carcinoma. The percentage of CTU studies with collateral critical findings was 12.7 per cent, but the use of one series in the excretory phase did not provide any additional information that would justify its use, since the incidental findings were detected in the series in the portal phase or, otherwise, in the series in the vacuum phase.If we make a comparison between our findings and the medical literature, Vining et al.<a class="elsevierStyleCrossRef" href="#bib0160">14</a> happened to be the first authors to use the VC in a study where they described the technique used in three patients. However, one of the very first studies to use 16-MDCT was Tsampoulas et al.’s study,<a class="elsevierStyleCrossRef" href="#bib0150">12</a> where they detected 55 out of 57 tumor lesions identified through the OUC, including 18 tumor lesions <5mm. The combination of multiplanar and virtual reconstructions allowed the detection of 11 tumors <5mm that were non visible in the axial plane. However, the main limitation of this study was that it only included patients with very high clinical suspicion of vesicle tumor, meaning that the study sensitivity increased. In 2013, Amin and Abd El Hamid<a class="elsevierStyleCrossRef" href="#bib0165">15</a> recorded 35 patients with macroscopic hematuria, and a total of 67 and 71 lesions detected in the VC and the OUC, respectively. Sensitivity was 85.7 per cent for lesions <5mm and 94.36 per cent for lesions >5mm, and specificity, 71.42 per cent. Finally, in Kalokairinou et al.’s study,<a class="elsevierStyleCrossRef" href="#bib0170">16</a> published in 2014, 25 patients were diagnosed with vesicle tumor through OUC and VC. The time elapsed between the OUC and the VC was 1 or 2 days. The radiologist responsible knew, with respect to the OUC findings in each case, that at least there was one vesical lesion. The probe technique used and the sequences obtained in the VC were similar to the samples, even though the study conducted in the decubitus prone position was only limited to the vesical region and without the administration of IV contrast. The MDCT scan and the virtual reconstruction software used were similar to the machine we used (Toshiba Aquilion 64®, and Vitrea 5.2©). When it comes to the findings, they claim that there were not any false positives or negatives in the VC, and that the OUC and the VC detected a total of 44 lesions of between 3 and 80mm in size (15 of which had sizes ≤5mm). However, in the OUC, no planar lesions or color changes in the mucosa were detected, which may explain the excellent results achieved.There are not too many recent papers showing the sensitivity and specificity values of the OUC imaging modality in the overall detection of vesicle tumors (not even considering the detection of superficial tumors only) compared to AP, although it is widely accepted that these values are close to100 per cent (although they drop to lower values in the case of non-invasive carcinomas). One of the very few papers on this regard is Gonzalo et al.’s paper<a class="elsevierStyleCrossRef" href="#bib0175">17</a> that reported 100 per cent sensitivity and specificity for the cystoscopy compared to the 81.8 per cent sensitivity and 92 per cent high specificity found in our study of the VC (due to the large number of cases where no lesions are detected through VC or OUC). However, when it comes to the size of lesions there is not such a thing as a good correlation between the VC and the OUC. This is due to the difficulties that urologists have when it comes to determining the size of the lesion, giving approximate visual measurements and not using an appropriate metric system.One of the largest series on incidental findings on the CTU is Liu et al.’s series<a class="elsevierStyleCrossRef" href="#bib0180">18</a> that recorded data from 344 patients with CTUs due to a history of hematuria–147 of macroscopic nature. There were 568 extraurinary findings, 71 of which were of high clinical significance (12.5 per cent), 222 of intermediate clinical significance, and 275 of low clinical significance. In our case, we had a similar percentage of critical findings. Although they are findings of clinical relevance, the dose of radiation doubled compared to the standard abdominal-pelvic study as we can see in the section where the findings are exhibited.We could not confirm one of the benefits according to the medical literature that derives from VCs is that they are easier to use for the detection of intradiverticular tumors, especially when they have a narrow neck, or urethral stenosis because we did not have cases in such situations.The medical literature also talks about higher or lower rates of complications derived from using VCs, or OUCs that may justify the use of one imaging modality over the other, but there are no precise data on this regard. In our study, patients tolerated the VC adequately and without any major complications. Only three patients suffered from one complication after the VC (one urinary tract infection), and five patients suffered from complications after the OUC (three patients suffered from urinary tract infections and two suffered from acute urinary retention), but, on the big picture, there were not significant differences between both imaging modalities.Our work has the largest series of patients ever published so far and, unlike most former studies already published, the radiologists were blinded and were not aware of the results from the OUCs since they were performed right after the VCs. One of the main limitations of this study was the patients’ refusal, or the impossibility of probing them, but no study was left undone due to allergies to the contrast medium. On the other hand, although the number of patients included is fairly high, only in 22/24 patients the lesions were detected through VC; a very different scenario to the one proposed by the medical literature where the studies take into account the number of lesions but not the number of patients; yet despite this fact, the correlation between the number of lesions detected through VC and OUC was good.In sum, the VC is a good alternative to diagnose bladder cancer, especially when there are contraindications or it is not possible to perform the OUC. In the follow-up of bladder cancer, this modality may be an alternative imaging modality to the OUC, since it has a lower rate of complications and more accurate measurements of the tumors. In cases where the use of VC is indicated, we need more comprehensive studies on the repercussion of use associated with the CTU. Although there were statistically significant differences in the cases detected through VC and CTU, more cases were detected through VC, and some of them with AP findings of neoplasms, which is the reason why studies with larger samples should be conducted in the future in order to clear this out.Authors contribution<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Manager of the integrity of the study: DI, RC, and LS.</li><li class="elsevierStyleListItem" id="lsti0010">2.Study idea: DI, RC, and LS.</li><li class="elsevierStyleListItem" id="lsti0015">3.Study design: AM.</li><li class="elsevierStyleListItem" id="lsti0020">4.Data mining: DI, IQ, RC, and DS.</li><li class="elsevierStyleListItem" id="lsti0025">5.Data analysis and interpretation: AM, DI, IQ, DS, RC, and LS.</li><li class="elsevierStyleListItem" id="lsti0030">6.Statistical analysis: AM, and DI.</li><li class="elsevierStyleListItem" id="lsti0035">7.Reference: DI, IQ, RC, LS, and DS.</li><li class="elsevierStyleListItem" id="lsti0040">8.Writing: DI, IQ, DS, RC, and LS.</li><li class="elsevierStyleListItem" id="lsti0045">9.Critical review of the manuscript with intellectually relevant remarks: AM, DS, RC, and LS.</li><li class="elsevierStyleListItem" id="lsti0050">10.Approval of final version: AM, DI, IQ, DS, RC, and LS.</li></ul>Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed abide by the ethics and regulations of the Human Research Committee, the World Health Organization and the Declaration of Helsinki.Confidentiality of dataThe authors declare that they have followed the protocols from their centers on the disclosure of data from patients.Right to privacy and informed consentThe authors have obtained prior written informed consent from the aforementioned patients. This document belongs to the corresponding author.Conflicts of interestsThe authors declare no conflict of interests associated with this article whatsoever." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres905082" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec885519" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres905083" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec885518" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Selection of the sample" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Exploratory technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Image interpretation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Authors contribution" ] 9 => array:3 [ "identificador" => "sec0050" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-24" "fechaAceptado" => "2017-04-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec885519" "palabras" => array:5 [ 0 => "Cystoscopy" 1 => "Urography" 2 => "Computed tomography" 3 => "Bladder cancer" 4 => "Hematuria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec885518" "palabras" => array:4 [ 0 => "Cistoscopia" 1 => "Tomografía computarizada" 2 => "Cáncer de vejiga" 3 => "Hematuria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo evaluate the utility of virtual cystoscopy (VC) performed with CT urography in patients being studied under gross hematuria or patients being followed-up after a previous bladder cancer and compare the results with those obtained with gold standard technique (optical cystoscopy). MethodsRetrospective study of 117 patients who were referred for VC by the Urology Department between May 2014 and May 2015. Those patients presented with gross hematuria or they were previously treated patients from bladder cancer being followed up. These patients were evaluated with MDCT and virtual cystoscopy after distending the bladder with air. The results were compared with those obtained with optical cystoscopy which was performed no more than a week after. ResultsThe global sensitivity and specificity of VC were 81.8 and 92.1 per cent. Additional findings detected in CT urography were an aortic dissection, urinary lithiasis and colonic metastasis. ConclusionVC seems an useful technique in the diagnosis and follow-up for bladder cancer with a good correlation with OC. The main limitations are the impossibility of biopsy during the procedure and the detection of erythematous lesions. Collateral findings can be detected performed with CT urography although the high radiation exposure does not recommend their combined use." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosEvaluar la utilidad de la cistoscopia virtual (CV) realizada junto con la urografía por tomografía computarizada (URO-TC) en pacientes en estudio por hematuria macroscópica o en seguimiento por antecedente de cáncer de vejiga tratado, y comparar los resultados con los obtenidos con la técnica de referencia (uretrocistoscopia óptica [UCO]). Material y métodosEstudio retrospectivo de 117 pacientes derivados para realización de CV y URO-TC desde el Departamento de Urología entre mayo de 2014 y mayo de 2015. Dichos pacientes presentaban hematuria macroscópica o habían sido tratados previamente por cáncer de vejiga y estaban bajo seguimiento periódico. Fueron sometidos a CV tras la distensión de la vejiga con aire. Los resultados obtenidos fueron comparados con los de la UCO realizada no más de una semana después. ResultadosLa sensibilidad y la especificidad global de la CV fueron del 81,8% y el 92,1%, respectivamente. La tasa de hallazgos críticos (que comprometían la vida del paciente) detectados en la URO-TC realizada junto a la CV fue del 12%, similar a la de otros estudios. ConclusiónLa CV es una técnica útil en el diagnóstico y el seguimiento del cáncer de vejiga, con buena correlación con la UCO. Sus principales limitaciones son la imposibilidad de toma de biopsia y la capacidad para detectar lesiones eritematosas de mucosa. El empleo concomitante de la URO-TC aporta hallazgos incidentales críticos, pero el incremento en la dosis de radiación no justifica el empleo combinado de ambas." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ibáñez Muñoz D, Quintana Martínez I, Fernández Militino A, Sánchez Zalabardo D, Sarria Octavio de Toledo L, Cozcolluela Cabrejas R. Cistoscopia virtual, urografía por tomografía computarizada y uretrocistoscopia óptica en el diagnóstico y el seguimiento del cáncer de vejiga. Radiología. 2017;59:422–430." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1273 "Ancho" => 1700 "Tamanyo" => 229068 ] ] "descripcion" => array:1 [ "en" => "Example of VC in one patient with macroscopic hematuria. (A) Presence of two tumor lesions, one larger lesion adjacent to the vesical probe (asterisk) and another millimetric lesion (asterisk). (B) Same lesions seen in the axial CT scan. (C) In the axial cut we can see one millimetric lesion (arrow) unseen in the VC and unconfirmed by the OUC. (D) Using the airways multiplanar reconstruction the dominant lesion (asterisk) may be identified." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 700 "Ancho" => 1400 "Tamanyo" => 97338 ] ] "descripcion" => array:1 [ "en" => "Examples of OUC images. (A) Correlation with lesion adjacent to the vesical neck from <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> (arrow). (B) Example of OUC in a different patient with another papillomatous lesion (arrow) and two visible planar lesions as erythematous changes in the mucosa (asterisk)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1200 "Ancho" => 1600 "Tamanyo" => 151285 ] ] "descripcion" => array:1 [ "en" => "Bilateral air reflux touching the renal pelvis – visible both in the airways multiplanar reconstruction (A), and in the MiniIP coronal reconstruction (B). The axial CT scan (C) shows one dilated right ureter with air inside–this makes it possible to perform one virtual ureteroscopy (D)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1200 "Ancho" => 1600 "Tamanyo" => 194784 ] ] "descripcion" => array:1 [ "en" => "Visible pseudotumors in VC (A and C) consistent with air bubbles (B), and impring of urachal remains (D)" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SS: statistically significant; Spe.: specificity; Sens.: sensitivity; Sig.: statistical significance; NPV: negative predictive value; PPV: positive predictive value; /: non-applicable." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sens. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spe. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pearson \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sig. \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Presence of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81.8 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92.1 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.6 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tumor lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">89.5 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.1 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70.8 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.3 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">≤5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Number of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.735–0.846 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.363 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.264 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1522030.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of VC–OUC findings in patients with macroscopic hematuria and followed due to history of tumors." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SS: statistically significant; Spe.: specificity; Sens.: sensitivity; Sig.: statistical significance; NPV: negative predictive value; PPV: positive predictive value; /: non-applicable." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sens. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spe. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pearson \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sig. \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Presence of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81.8 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80.8 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64.3 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.3 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tumor lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88.9 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80.8 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61.5 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">≤5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71.4 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87.5 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.5 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Number of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.769–0.719 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.964 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.366 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.977 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1522032.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of VC-OUC findings in patients with macroscopic hematuria." ] ] 6 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SS: statistically significant; Spe.: specificity; Sens.: sensitivity; Sig.: statistical significance; NPV: negative predictive value; PPV: positive predictive value; /: non-applicable." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sens. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spe. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pearson \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sig. \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Presence of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81.8 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96.1 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tumor lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">≤5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87.5 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87.5 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98 per cent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Number of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.700–0.915 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.298 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.615 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Size of lesion #3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">−0.953 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-SS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1522031.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of VC-OUC findings in patients followed due to history of vesical neoplasms." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: http://globocan.iarc.fr (accessed 09.06.14)" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GLOBOCAN 2012 v1.0, cancer incidence and mortality worldwide: IARC CancerBase No. 11" "autores" => array:1 [ 0 => array:2 [ "etal" => 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Cistoscopia virtual, urografía por tomografía computarizada y uretrocistoscopia óptica en el diagnóstico y el seguimiento del cáncer de vejiga

D. Ibáñez Muñoza,

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david_ibi@hotmail.com

Corresponding author.

, I. Quintana Martínezb, A. Fernández Militinoc, D. Sánchez Zalabardod, L. Sarria Octavio de Toledob, R. Cozcolluela Cabrejasa

a Sección de Radiodiagnóstico, Hospital Reina Sofía, Tudela, Navarra, Spain

b Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain

c Departamento de Estadística, Universidad Pública de Navarra (UPNA), Pamplona, Spain

d Sección de Urología, Hospital Reina Sofía, Tudela, Navarra, Spain

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The presence of macroscopic hematuria in patients who are smokers or have a history of chronic irritation due to lithiasis or amine exposure are all fundamental factors that may lead to suspect of this type of cancer&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">When it comes to the diagnosis of bladder cancer&#44; the first test to be performed is an ultrasound that will let us to see any protruding masses&#46; Compared to the ultrasound&#44; the computed tomography urography &#40;CTU&#41; has similar specificity and higher sensitivity &#40;90 per cent versus 69 per cent from the ultrasound&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> The main limitation of the ultrasound and the CTU is their zero utility in the diagnosis of in situ carcinomas&#44; and the same thing happens with the magnetic resonance imaging &#40;MRI&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The optical urethral-cystoscopy &#40;OUC&#41; is still the reference modality in the detection and follow-up of bladder cancer&#46; It may be rigid or flexible&#44; usually flexible&#44; with similar diagnostic accuracy than the rigid OUC&#44; and even higher diagnostic accuracy in lesions located in the anterior vesical neck&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> Although the morbidity of this modality is low&#44; it is associated with a risk of urinary tract infections in 3 per cent of the cases&#44; a risk of transient hemorrhages in 19 per cent of the cases&#44; pollakiuria in 37 per cent&#44; and dysuria in 50 per cent of the cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">10&#44;11</span></a> Also cases of vesical perforation and uretheral stenosis due to lesions occurring while the urethral-cytoscope is inserted and is passing by have been reported in the medical literature&#46; There are also contraindications when performing OUCs such as the existence of acute cystitis&#44; prostatitis&#44; or urethritis&#44; significant prostate hypertrophy&#44; or vesical tears&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> On the other hand&#44; some regions are blind to the cytoscope&#44; even the flexible one&#44; such as the inside of diverticuli&#44; and the vesical neck&#46; These cases triggered the development of a new imaging modality&#8211;the virtual cystoscopy &#40;VC&#41; that associates the capacity of performing one abdominal multidetector computer tomography &#40;MDCT&#41; scan plus computing post-processing in order to make a virtual reconstruction of visceral lumen in a similar way to how we perform virtual colonoscopies today&#46; The greatest advantage of VC according to the medical literature is that it is less invasive&#44; it may be performed in cases when the OUC is contraindicated and allows us to establish if there is extravesical invasion&#46; However&#44; its main limitations are the use of ionizing radiation and the difficulty of detecting planar lesions&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> although the risk of infection is lower than that of the OUC &#40;between 1 per cent and 2 per cent&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The goal of this paper is to assess the utility of the VC performed together with the CTU in patients studied due to macroscopic hematuria or being followed for having a history of already treated bladder cancer&#44; and then compare these findings with the ones obtained from the reference modality &#40;the OUC&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Selection of the sample</span><p id="par0030" class="elsevierStylePara elsevierViewall">We present a retrospective study including all patients referred from the emergency room or primary care to the urology practice in a period of one year due to suspicion of vesical neoplasm due to macroscopic hematuria with associated risk factors &#40;age of the smoker &#8805;45 years old&#44; no urinary tract infection&#44; no history of pelvic radiotherapy due to tumors of non-vesical origin&#44; or no presence of intravesical lithiasis&#41;&#44; or due to a previous ultrasound with suspicious findings&#46; Also all patients who were referred to the urology practice during that year to follow-up of their bladder cancer were included&#46; Patients were selected in the urology practice based on these criteria and then referred to the unit of radio-diagnosis for the performance of VC and CTU modalities before handing their written informed consents for their inclusion in the study approved by the hospital ethics committee&#46; The patients&#8217; refusal to participate in the study&#44; and the presence of microscopic hematuria were considered exclusion criteria&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Exploratory technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">Since the goal of this paper was to compare the results obtained with the VC and CTU imaging modalities&#44; and the OUC&#44; the maximum interval between the radiological and the urological tests were seven days&#44; while the participating physicians from the different units were blinded and were not aware of the findings made in other studies&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">When it comes to the technique used to perform the VC and CTU modalities&#44; 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and then another acquisition 75<span class="elsevierStyleHsp" style=""></span>s after the administration of IV contrast &#40;Visipaque&#8482;&#44; 320<span class="elsevierStyleHsp" style=""></span>mg&#47;ml&#44; introducing 120<span class="elsevierStyleHsp" style=""></span>ml at 3<span class="elsevierStyleHsp" style=""></span>ml&#47;s through peripheral venous access with an initial bolus of 20<span class="elsevierStyleHsp" style=""></span>ml of physiological saline solution&#41; was performed with the patient lying flat in the decubitus supine position&#44; and volume was obtained for post-processing purposes&#46; Then the patient was immediately placed in the decubitus prone position in order to perform a third acquisition from the pelvic region &#40;from the iliac crests to the pubic symphysis&#41; with additional fillings of 80&#8211;120<span class="elsevierStyleHsp" style=""></span>ml of air when distension was not large enough&#46; Lastly&#44; and after emptying the bladder through the catheter&#44; a fourth abdominal-pelvic acquisition was performed with the patient in the decubitus prone position in the excretory phase 8<span class="elsevierStyleHsp" style=""></span>min after the administration of contrast in order to rule out upper urinary tract disease that may lead to macroscopic hematuria or distension of a former bladder carcinoma that would affect such tract&#46; Once its validity was checked&#44; the nurses were told to remove the catheter and dismiss the patient&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Image interpretation</span><p id="par0055" class="elsevierStylePara elsevierViewall">The studies were transferred to the working station &#40;Vitrea<span class="elsevierStyleSup">&#174;</span> 2 Ver&#46; 4&#46;1&#46;14&#46;0&#44; Vital Imaging Inc&#46;&#44; CA&#44; USA&#41; using interactive intraluminal navigation software with a volume-rendering algorithm&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The bladder assessment through the VC was always carried out by two radiologists with a similar experience who were not aware of the findings made&#46; They assessed the VC and the CTU separately each one of them started with the VC&#46; The study of the bladder started from an observation point at the centre of the bladder&#44; and the different quadrants or segments were assessed in an orderly fashion &#40;anterior&#44; posterior&#44; superior&#44; inferior&#44; right&#44; and left&#44; trigone&#44; urethral orifices&#44; internal urethral orifice and diverticuli&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Whenever any vesical lesions would be detected&#44; the following parameters were studied&#58; number&#44; size&#44; location&#44; morphology &#40;sessile&#47;infiltrating&#44; papillary&#47;superficial&#44; or areas of thickened wall&#41;&#44; parietal mucosal thickening&#44; trabeculation&#44; diverticuli&#44; and other intraluminal conditions &#40;mainly lithiasis&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">True positives were cases of lesions in both the VC and the OUC&#59; false positives were those where the lesion could be seen in the VC but not in the OUC&#59; and false negatives were those where the lesion could be seen in the OUC but not in the VC&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The OUC was performed using one flexible catheter&#46; The study was carried out in an outpatient setting with asepsy&#44; working in a sterile field&#44; with iodinated povidone and urological lubricant using the flexible Storz<span class="elsevierStyleSup">&#174;</span> 19 Charriers cytoscope&#46; The CTU was performed by assistant physicians from the urology unit&#44; all of them with a similar experience&#46; The parameters established were the degree of vesical distension&#59; in the presence of lesions&#44; the same parameters used in the VC were established&#59; and the presence of diverticuli&#44; or trabeculations&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">When it comes to the study of radiation induced by VC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CTU modalities and right after the analysis of doses in the individual studies of patients&#44; the unit of radiophysics estimated the average dose length product &#40;DLP&#41; and effective dose by taking all abdominal-pelvic phases of the study into consideration since the DLP had not been stratified&#44; which is why one complete abdominal-pelvic mathematical phantom was implemented&#46; Data were collected using the dosage calculation sheets ImPACT&#44; ImPACT CT patient dosimetry calculator&#44; version 1&#46;0&#46;4 &#40;27&#47;5&#47;2011&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">The data were statistically analyzed by personnel from the department of statistics using the R version 3&#46;2&#46;1 &#40;18-6-2015&#41; statistical software&#44; and the IBM<span class="elsevierStyleSup">&#174;</span> SPSS<span class="elsevierStyleSup">&#174;</span> Statistics version 20&#46;0&#46;0 software&#46; The most adequate statistical contrasts were performed using 5 per cent significance levels in order to make inferences about population parameters&#46; The intervals used by consensus for Pearson&#39;s correlation coefficient were&#58; values &#60;0&#46;20 were indicative of no match at all&#44; values from 0&#46;20 to 0&#46;39 were indicative of a poor match&#44; values from 0&#46;40 to 0&#46;59 were indicative of a regular match&#44; values from 0&#46;60 to 0&#46;79 were indicative of a good match&#44; and values from 0&#8211;80 to 1 were indicative of an excellent match&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">One hundred and seventeen &#40;117&#41; patients were included in the study&#44; among which 79 per cent were males and 21 per cent females with average ages of 66 and 68 years old&#44; respectively&#46; Of these 117 patients&#44; seven men and one woman refused undergoing the study&#44; two men and one woman did not attend&#44; and in two men the necessary catheter for the VC could not be used&#44; so they were all excluded from the study&#46; On the other hand&#44; two patients were referred due to microhematuria and were excluded&#44; and in four patients with macroscopic hematuria the OUC could not be performed &#40;one patient did not attend&#44; another one refused&#44; another one passed away before performing the OUC due to severe anemia&#44; and in another patient the clinical manifestation were due to lithiasis&#44; the CTU was not considered necessary and therefore was not requested&#41;&#46; In sum&#44; 102 patients &#40;41 with macroscopic hematuria and 61 tumor controls&#41; were assessed through VC&#47;CTU&#44; among which 98 underwent OUCs too&#46; The first radiologist observer detected tumors in 22 patients&#44; and the second radiologist observer in 24&#44; with good matches in a positive sense between them &#40;Pearson&#39;s correlation coefficient&#58; 0&#46;748&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The air insufflated in the bladder using the catheter was&#44; on average&#44; 357<span class="elsevierStyleHsp" style=""></span>cc in men and 355<span class="elsevierStyleHsp" style=""></span>cc in women&#44; without any statistically significant differences&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The average time elapsed between the VC and the OUC was 5 days&#44; with a minimum of 2 days and a maximum of 90 days &#40;in one case only as we will be talking about later in the paper&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">When it comes to the size of the lesion&#44; the VC confirmed a minimal dimension of 2<span class="elsevierStyleHsp" style=""></span>mm&#44; and a maximal dimension of 54<span class="elsevierStyleHsp" style=""></span>mm &#40;an average 13&#46;25<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The OUC confirmed an average of 3&#46;05<span class="elsevierStyleHsp" style=""></span>mm&#44; with a minimal dimension of 2<span class="elsevierStyleHsp" style=""></span>mm and a maximal dimension of 40<span class="elsevierStyleHsp" style=""></span>mm&#44; and a positive correlation between such measurements &#40;Pearson&#39;s correlation coefficient&#58; 0&#46;011&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Taking the findings of both populations altogether &#40;macroscopic hematuria and controls&#41; in the detection of intravesical tumors with VC versus OUC showed a 81&#46;8 per cent sensitivity and a 92&#46;1 per cent specificity&#44; with a positive predictive value &#40;PPV&#41; of 75 per cent&#44; and a negative predictive value &#40;NPV&#41; of 94&#46;6 per cent&#46; Among the 18 cases of true positives&#44; there was only one case with non-tumor anatomopathological &#40;AP&#41; findings&#46; Out of the four cases of false negatives&#44; one case showed multiple papillary lesions &#62;5<span class="elsevierStyleHsp" style=""></span>mm in the OUC &#40;almost three months passed between both imaging modalities&#44; but the question of why this delay happened remains unanswered&#44; and after treating the patient&#44; the control study performed after three months showed new multiple papillary lesions of similar size&#41; while in the remaining four cases&#44; the size of the lesions was &#60;5<span class="elsevierStyleHsp" style=""></span>mm &#40;two cases with inflammatory AP findings and one case with AP findings of carcinoma&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">On the other hand&#44; if we take into consideration patients whose AP finding after the performance of the optical urethral-cytoscopy was carcinoma &#40;that is&#44; the capacity of the VC to detect cancer&#41;&#44; only three biopsied cases happened not to be tumors &#40;among which two cases were consistent with lesions &#60;5<span class="elsevierStyleHsp" style=""></span>mm in size&#44; being VC false negatives&#44; and only one case could be identified in the VC and the OUC&#8211;one true positive&#44; but with atypical non-specific AP findings which is why it was also excluded&#41;&#46; In this case&#44; sensitivity was 89&#46;5 per cent&#44; and specificity&#44; 91&#46;1 per cent&#44; with a PPV of 70&#46;8 per cent&#44; and a NPV of 97&#46;3 per cent&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">However&#44; when taking into account lesions &#8804;5<span class="elsevierStyleHsp" style=""></span>mm only&#44; the overall sensitivity was 80 per cent&#44; and specificity&#44; 96 per cent&#46; Only three cases of lesions &#8804;5<span class="elsevierStyleHsp" style=""></span>mm were identified in the OUC but not in the VC&#59; out of these three lesions&#44; two turned out to be chronic&#47;follicullary based on the AP findings and one lesion a T1G2 infiltrating urothelial carcinoma&#46; The PPV was 75 per cent&#44; and the NPV&#44; 96 per cent&#46; The use of contrast in the standard CT study did not detect these lesions or other VC false negatives&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">When it comes to the number of lesions detected&#44; there was a good positive correlation between both imaging modalities &#40;Pearson&#39;s correlation coefficient&#58; 0&#46;846&#41;&#46; However&#44; when it comes to the size of lesions&#44; no good correlations were obtained &#40;Pearson&#39;s correlation coefficient&#58; 0&#46;011&#44; &#8722;0&#46;363 and &#8722;0&#46;264 for the first&#44; second&#44; and third measured lesions&#44; respectively&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows all data assessed in the overall sample&#44; and <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> show each and every one of the populations making up the sample&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Also the detection of lesions through VC versus CTU was compared with blinded assessors unaware of the findings made by the other imaging modality&#46; The tests of statistical significance did not show any differences between both imaging modalities in the axial or the coronal planes&#46; As a matter of fact&#44; more cases were detected through the VC than through the conventional CT scan&#58; nine in the axial plane and eight in the coronal plane&#44; among which five cases were not consistent with lesions in the OUC &#40;three were false images from imprints of the pubic symphysis or urachal remains &#91;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#93;&#41; while four images did show lesions in the OUC &#8211; three of them with AP findings of carcinoma&#46; The series in the excretory phase did not provide any additional information to the information already provided by the conventional CT scan in any of the cases&#46; In the assessment of collateral findings detected through VC-associated CTUs in 102 patients&#44; 13 cases of high clinical significance could be identified &#40;12&#46;7 per cent of all VC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CTU studies conducted&#41;&#58; two cases of pulmonary nodules suspicious of malignancy&#44; five cases of aortic disease &#40;among them one chronic dissection&#41;&#44; two cases of urethral neoplasms&#44; one case of hepatic metastasis due to rectal carcinoma&#44; and three cases of abdominal adenopathies suspicious of being malignant too&#46; Also&#44; renal lithiasis&#44; postoperative changes with air reflux in the ureters&#44; or air bubbles simulating lesions were detected&#44; among other non-critical findings made &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">As additional data from the study&#44; the complications derived from using both imaging modalities were recorded &#40;VC and OUC&#41;&#46; Only three men suffered from complications after the VC &#40;two urinary tract infections and one vasovagal syncope due to catheterization&#41;&#44; compared to five patients who suffered from complications after the OUC&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">When it comes to the doses of radiation obtained&#44; the average DLP was 2942&#46;8<span class="elsevierStyleHsp" style=""></span>mGy&#47;cm and the effective dose&#44; 45<span class="elsevierStyleHsp" style=""></span>mSv&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In our study we analyzed 98 patients who underwent VC&#47;CTU and OUC imaging modalities and found a good interobserver correlation&#44; and when it comes to the reference imaging modality &#40;the OUC&#41; in the capacity to detect lesions through VC&#44; high sensitivity and specificity percentages for both the overall population and every one of the subgroups &#40;macroscopic hematuria and tumor controls&#41; were reached&#46; These numbers were also high for cases studied through VC and OUC whose AP findings were neoplasms&#46; When it comes to quantifying the number of lesions&#44; we saw a good correlation between the VC and the OUC that was close to 1 in a positive sense and that was statistically significant&#44; although this was not the case of tumor sizes determined by each imaging modality&#46; In a controversial issue of medical literature such as the capacity to detect lesions &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#44; sensitivity was 80 per cent&#44; and specificity&#44; 96 per cent&#44; with a high NPV&#44; for all patients &#40;out of the three cases of false negatives&#44; only one case turned out to be a carcinoma in the AP findings&#41;&#8211;numbers slightly lower in cases with macroscopic hematuria &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1&#8211;3</a>&#41;&#46; The use of IV contrast in the CTU&#44; or other VC false negatives did not contribute to the detection of such lesions either&#46; Only one lesion in the axial study was seen compared to the VC&#44; remaining this lesion unidentified in the OUC&#44; meaning it was a false image&#46; The tests of statistical significance did not show any significant differences between the existence of visible lesions through the VC and the axial or coronal CT scan study&#46; Nevertheless&#44; nine more lesions were detected through the VC than through the CT scan in the axial plane&#44; among which five lesions were not consistent with the lesions found in the OUC &#40;three were false images from imprints of the pubic symphysis&#41;&#44; but four were positive lesions found in the OUC&#8211;three of them with final AP findings of carcinoma&#46; The percentage of CTU studies with collateral critical findings was 12&#46;7 per cent&#44; but the use of one series in the excretory phase did not provide any additional information that would justify its use&#44; since the incidental findings were detected in the series in the portal phase or&#44; otherwise&#44; in the series in the vacuum phase&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">If we make a comparison between our findings and the medical literature&#44; Vining et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> happened to be the first authors to use the VC in a study where they described the technique used in three patients&#46; However&#44; one of the very first studies to use 16-MDCT was Tsampoulas et al&#46;&#8217;s study&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> where they detected 55 out of 57 tumor lesions identified through the OUC&#44; including 18 tumor lesions &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#46; The combination of multiplanar and virtual reconstructions allowed the detection of 11 tumors &#60;5<span class="elsevierStyleHsp" style=""></span>mm that were non visible in the axial plane&#46; However&#44; the main limitation of this study was that it only included patients with very high clinical suspicion of vesicle tumor&#44; meaning that the study sensitivity increased&#46; In 2013&#44; Amin and Abd El Hamid<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> recorded 35 patients with macroscopic hematuria&#44; and a total of 67 and 71 lesions detected in the VC and the OUC&#44; respectively&#46; Sensitivity was 85&#46;7 per cent for lesions &#60;5<span class="elsevierStyleHsp" style=""></span>mm and 94&#46;36 per cent for lesions &#62;5<span class="elsevierStyleHsp" style=""></span>mm&#44; and specificity&#44; 71&#46;42 per cent&#46; Finally&#44; in Kalokairinou et al&#46;&#8217;s study&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> published in 2014&#44; 25 patients were diagnosed with vesicle tumor through OUC and VC&#46; The time elapsed between the OUC and the VC was 1 or 2 days&#46; The radiologist responsible knew&#44; with respect to the OUC findings in each case&#44; that at least there was one vesical lesion&#46; The probe technique used and the sequences obtained in the VC were similar to the samples&#44; even though the study conducted in the decubitus prone position was only limited to the vesical region and without the administration of IV contrast&#46; The MDCT scan and the virtual reconstruction software used were similar to the machine we used &#40;Toshiba Aquilion 64<span class="elsevierStyleSup">&#174;</span>&#44; and Vitrea 5&#46;2<span class="elsevierStyleSup">&#169;</span>&#41;&#46; When it comes to the findings&#44; they claim that there were not any false positives or negatives in the VC&#44; and that the OUC and the VC detected a total of 44 lesions of between 3 and 80<span class="elsevierStyleHsp" style=""></span>mm in size &#40;15 of which had sizes &#8804;5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; However&#44; in the OUC&#44; no planar lesions or color changes in the mucosa were detected&#44; which may explain the excellent results achieved&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">There are not too many recent papers showing the sensitivity and specificity values of the OUC imaging modality in the overall detection of vesicle tumors &#40;not even considering the detection of superficial tumors only&#41; compared to AP&#44; although it is widely accepted that these values are close to100 per cent &#40;although they drop to lower values in the case of non-invasive carcinomas&#41;&#46; One of the very few papers on this regard is Gonzalo et al&#46;&#8217;s paper<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> that reported 100 per cent sensitivity and specificity for the cystoscopy compared to the 81&#46;8 per cent sensitivity and 92 per cent high specificity found in our study of the VC &#40;due to the large number of cases where no lesions are detected through VC or OUC&#41;&#46; However&#44; when it comes to the size of lesions there is not such a thing as a good correlation between the VC and the OUC&#46; This is due to the difficulties that urologists have when it comes to determining the size of the lesion&#44; giving approximate visual measurements and not using an appropriate metric system&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">One of the largest series on incidental findings on the CTU is Liu et al&#46;&#8217;s series<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> that recorded data from 344 patients with CTUs due to a history of hematuria&#8211;147 of macroscopic nature&#46; There were 568 extraurinary findings&#44; 71 of which were of high clinical significance &#40;12&#46;5 per cent&#41;&#44; 222 of intermediate clinical significance&#44; and 275 of low clinical significance&#46; In our case&#44; we had a similar percentage of critical findings&#46; Although they are findings of clinical relevance&#44; the dose of radiation doubled compared to the standard abdominal-pelvic study as we can see in the section where the findings are exhibited&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">We could not confirm one of the benefits according to the medical literature that derives from VCs is that they are easier to use for the detection of intradiverticular tumors&#44; especially when they have a narrow neck&#44; or urethral stenosis because we did not have cases in such situations&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The medical literature also talks about higher or lower rates of complications derived from using VCs&#44; or OUCs that may justify the use of one imaging modality over the other&#44; but there are no precise data on this regard&#46; In our study&#44; patients tolerated the VC adequately and without any major complications&#46; Only three patients suffered from one complication after the VC &#40;one urinary tract infection&#41;&#44; and five patients suffered from complications after the OUC &#40;three patients suffered from urinary tract infections and two suffered from acute urinary retention&#41;&#44; but&#44; on the big picture&#44; there were not significant differences between both imaging modalities&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Our work has the largest series of patients ever published so far and&#44; unlike most former studies already published&#44; the radiologists were blinded and were not aware of the results from the OUCs since they were performed right after the VCs&#46; One of the main limitations of this study was the patients&#8217; refusal&#44; or the impossibility of probing them&#44; but no study was left undone due to allergies to the contrast medium&#46; On the other hand&#44; although the number of patients included is fairly high&#44; only in 22&#47;24 patients the lesions were detected through VC&#59; a very different scenario to the one proposed by the medical literature where the studies take into account the number of lesions but not the number of patients&#59; yet despite this fact&#44; the correlation between the number of lesions detected through VC and OUC was good&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In sum&#44; the VC is a good alternative to diagnose bladder cancer&#44; especially when there are contraindications or it is not possible to perform the OUC&#46; In the follow-up of bladder cancer&#44; this modality may be an alternative imaging modality to the OUC&#44; since it has a lower rate of complications and more accurate measurements of the tumors&#46; In cases where the use of VC is indicated&#44; we need more comprehensive studies on the repercussion of use associated with the CTU&#46; Although there were statistically significant differences in the cases detected through VC and CTU&#44; more cases were detected through VC&#44; and some of them with AP findings of neoplasms&#44; which is the reason why studies with larger samples should be conducted in the future in order to clear this out&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors contribution</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; DI&#44; RC&#44; and LS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Study idea&#58; DI&#44; RC&#44; and LS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Study design&#58; AM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Data mining&#58; DI&#44; IQ&#44; RC&#44; and DS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; AM&#44; DI&#44; IQ&#44; DS&#44; RC&#44; and LS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Statistical analysis&#58; AM&#44; and DI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Reference&#58; DI&#44; IQ&#44; RC&#44; LS&#44; and DS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Writing&#58; DI&#44; IQ&#44; DS&#44; RC&#44; and LS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; AM&#44; DS&#44; RC&#44; and LS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Approval of final version&#58; AM&#44; DI&#44; IQ&#44; DS&#44; RC&#44; and LS&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of human and animal subjects</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed abide by the ethics and regulations of the Human Research Committee&#44; the World Health Organization and the Declaration of Helsinki&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols from their centers on the disclosure of data from patients&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have obtained prior written informed consent from the aforementioned patients&#46; This document belongs to the corresponding author&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever&#46;</p></span></span>"
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          "identificador" => "xres905083"
          "titulo" => "Resumen"
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              "titulo" => "Material y m&#233;todos"
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            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
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            3 => array:2 [
              "identificador" => "abst0040"
              "titulo" => "Conclusi&#243;n"
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          "identificador" => "xpalclavsec885518"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:3 [
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          "titulo" => "Methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Selection of the sample"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Exploratory technique"
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              "identificador" => "sec0025"
              "titulo" => "Image interpretation"
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              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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          "identificador" => "sec0035"
          "titulo" => "Results"
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          "titulo" => "Discussion"
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          "identificador" => "sec0045"
          "titulo" => "Authors contribution"
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          "titulo" => "Ethical disclosures"
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            0 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Protection of human and animal subjects"
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            1 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Confidentiality of data"
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            2 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Right to privacy and informed consent"
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          ]
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        10 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of interests"
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        11 => array:1 [
          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-05-24"
    "fechaAceptado" => "2017-04-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec885519"
          "palabras" => array:5 [
            0 => "Cystoscopy"
            1 => "Urography"
            2 => "Computed tomography"
            3 => "Bladder cancer"
            4 => "Hematuria"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec885518"
          "palabras" => array:4 [
            0 => "Cistoscopia"
            1 => "Tomograf&#237;a computarizada"
            2 => "C&#225;ncer de vejiga"
            3 => "Hematuria"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the utility of virtual cystoscopy &#40;VC&#41; performed with CT urography in patients being studied under gross hematuria or patients being followed-up after a previous bladder cancer and compare the results with those obtained with gold standard technique &#40;optical cystoscopy&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 117 patients who were referred for VC by the Urology Department between May 2014 and May 2015&#46; Those patients presented with gross hematuria or they were previously treated patients from bladder cancer being followed up&#46; These patients were evaluated with MDCT and virtual cystoscopy after distending the bladder with air&#46; The results were compared with those obtained with optical cystoscopy which was performed no more than a week after&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The global sensitivity and specificity of VC were 81&#46;8 and 92&#46;1 per cent&#46; Additional findings detected in CT urography were an aortic dissection&#44; urinary lithiasis and colonic metastasis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">VC seems an useful technique in the diagnosis and follow-up for bladder cancer with a good correlation with OC&#46; The main limitations are the impossibility of biopsy during the procedure and the detection of erythematous lesions&#46; Collateral findings can be detected performed with CT urography although the high radiation exposure does not recommend their combined use&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la utilidad de la cistoscopia virtual &#40;<span class="elsevierStyleSmallCaps">CV</span>&#41; realizada junto con la urograf&#237;a por tomograf&#237;a computarizada &#40;URO-TC&#41; en pacientes en estudio por hematuria macrosc&#243;pica o en seguimiento por antecedente de c&#225;ncer de vejiga tratado&#44; y comparar los resultados con los obtenidos con la t&#233;cnica de referencia &#40;uretrocistoscopia &#243;ptica &#91;UCO&#93;&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 117 pacientes derivados para realizaci&#243;n de CV y URO-TC desde el Departamento de Urolog&#237;a entre mayo de 2014 y mayo de 2015&#46; Dichos pacientes presentaban hematuria macrosc&#243;pica o hab&#237;an sido tratados previamente por c&#225;ncer de vejiga y estaban bajo seguimiento peri&#243;dico&#46; Fueron sometidos a CV tras la distensi&#243;n de la vejiga con aire&#46; Los resultados obtenidos fueron comparados con los de la UCO realizada no m&#225;s de una semana despu&#233;s&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La sensibilidad y la especificidad global de la CV fueron del 81&#44;8&#37; y el 92&#44;1&#37;&#44; respectivamente&#46; La tasa de hallazgos cr&#237;ticos &#40;que compromet&#237;an la vida del paciente&#41; detectados en la URO-TC realizada junto a la CV fue del 12&#37;&#44; similar a la de otros estudios&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La CV es una t&#233;cnica &#250;til en el diagn&#243;stico y el seguimiento del c&#225;ncer de vejiga&#44; con buena correlaci&#243;n con la UCO&#46; Sus principales limitaciones son la imposibilidad de toma de biopsia y la capacidad para detectar lesiones eritematosas de mucosa&#46; El empleo concomitante de la URO-TC aporta hallazgos incidentales cr&#237;ticos&#44; pero el incremento en la dosis de radiaci&#243;n no justifica el empleo combinado de ambas&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
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            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ib&#225;&#241;ez Mu&#241;oz D&#44; Quintana Mart&#237;nez I&#44; Fern&#225;ndez Militino A&#44; S&#225;nchez Zalabardo D&#44; Sarria Octavio de Toledo L&#44; Cozcolluela Cabrejas R&#46; Cistoscopia virtual&#44; urograf&#237;a por tomograf&#237;a computarizada y uretrocistoscopia &#243;ptica en el diagn&#243;stico y el seguimiento del c&#225;ncer de vejiga&#46; Radiolog&#237;a&#46; 2017&#59;59&#58;422&#8211;430&#46;</p>"
      ]
    ]
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      0 => array:7 [
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        "figura" => array:1 [
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Example of VC in one patient with macroscopic hematuria&#46; &#40;A&#41; Presence of two tumor lesions&#44; one larger lesion adjacent to the vesical probe &#40;asterisk&#41; and another millimetric lesion &#40;asterisk&#41;&#46; &#40;B&#41; Same lesions seen in the axial CT scan&#46; &#40;C&#41; In the axial cut we can see one millimetric lesion &#40;arrow&#41; unseen in the VC and unconfirmed by the OUC&#46; &#40;D&#41; Using the airways multiplanar reconstruction the dominant lesion &#40;asterisk&#41; may be identified&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Examples of OUC images&#46; &#40;A&#41; Correlation with lesion adjacent to the vesical neck from <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> &#40;arrow&#41;&#46; &#40;B&#41; Example of OUC in a different patient with another papillomatous lesion &#40;arrow&#41; and two visible planar lesions as erythematous changes in the mucosa &#40;asterisk&#41;&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
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        "mostrarFloat" => true
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            "Tamanyo" => 151285
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bilateral air reflux touching the renal pelvis &#8211; visible both in the airways multiplanar reconstruction &#40;A&#41;&#44; and in the MiniIP coronal reconstruction &#40;B&#41;&#46; The axial CT scan &#40;C&#41; shows one dilated right ureter with air inside&#8211;this makes it possible to perform one virtual ureteroscopy &#40;D&#41;&#46;</p>"
        ]
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        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Visible pseudotumors in VC &#40;A and C&#41; consistent with air bubbles &#40;B&#41;&#44; and impring of urachal remains &#40;D&#41;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">SS&#58; statistically significant&#59; Spe&#46;&#58; specificity&#59; Sens&#46;&#58; sensitivity&#59; Sig&#46;&#58; statistical significance&#59; NPV&#58; negative predictive value&#59; PPV&#58; positive predictive value&#59; &#47;&#58; non-applicable&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sens&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spe&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pearson&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sig&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Presence of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#46;8 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&#46;1 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#46;6 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tumor lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&#46;5 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;1 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#46;8 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#46;3 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8804;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Number of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;735&#8211;0&#46;846&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;363&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;264&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Summary of VC&#8211;OUC findings in patients with macroscopic hematuria and followed due to history of tumors&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">SS&#58; statistically significant&#59; Spe&#46;&#58; specificity&#59; Sens&#46;&#58; sensitivity&#59; Sig&#46;&#58; statistical significance&#59; NPV&#58; negative predictive value&#59; PPV&#58; positive predictive value&#59; &#47;&#58; non-applicable&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sens&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spe&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pearson&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sig&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Presence of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#46;8 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#46;8 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;3 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&#46;3 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tumor lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#46;9 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#46;8 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;5 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8804;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#46;4 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#46;5 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;5 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Number of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;769&#8211;0&#46;719&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;964&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;366&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;977&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Summary of VC-OUC findings in patients with macroscopic hematuria&#46;</p>"
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">SS&#58; statistically significant&#59; Spe&#46;&#58; specificity&#59; Sens&#46;&#58; sensitivity&#59; Sig&#46;&#58; statistical significance&#59; NPV&#58; negative predictive value&#59; PPV&#58; positive predictive value&#59; &#47;&#58; non-applicable&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sens&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spe&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pearson&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sig&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Presence of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#46;8 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#46;1 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tumor lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8804;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#46;5 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#46;5 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98 per cent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Number of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;700&#8211;0&#46;915&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;298&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;615&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Size of lesion &#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;953&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Summary of VC-OUC findings in patients followed due to history of vesical neoplasms&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <span class="elsevierStyleInterRef" id="intr0010" href="http://globocan.iarc.fr/">http&#58;&#47;&#47;globocan&#46;iarc&#46;fr</span> &#40;accessed 09&#46;06&#46;14&#41;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GLOBOCAN 2012 v1&#46;0&#44; cancer incidence and mortality worldwide&#58; IARC CancerBase No&#46; 11"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;S&#46;I&#46; Ferlay"
                            1 => "M&#46; Ervik"
                            2 => "R&#46; Dikshit"
                            3 => "S&#46; Eser"
                            4 => "C&#46; Mathers"
                            5 => "M&#46; Rebelo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2014"
                        "editorial" => "International Agency for Research on Cancer"
                        "editorialLocalizacion" => "Lyon&#44; France"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Malignant non-urothelial neoplasms of the urinary bladder&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Dahm"
                            1 => "J&#46;E&#46; Gschwend"
                          ]
                        ]
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2017.07.005

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