VIRTUAL CYSTOSCOPY

The recent introduction of virtual endoscopy adds to the imaging armamentarium for use
in bladder evaluation.

The volumetric data obtained with helical CT or MR imaging are computer rendered to
generate three-dimensional images, and with commercially available software,
intraluminal navigation through any hollow viscus is possible.

Of the different three-dimensional rendering techniques available, perspective

volume rendering provides the most information because the entire data set is
incorporated .

Requires a more powerful computer than do other three-dimensional techniques, such as

Shaded - surface display or Maximum intensity projection.

Virtual endoscopy has been most widely applied to imaging of the colon (virtual
colonoscopy), virtual cystoscopy is a feasible technique for use in the detection of bladder
lesions larger than 5 mm.

Technique :
 Begin with the placement of a 12-F Foley catheter into the bladder to drain residual
urine.
 The bladder was then insufflated with 300–500 mL of carbon dioxide through
the Foley catheter, according to patient tolerance.
 After a scout view was obtained with the patient in the supine position to locate
the bladder and confirm its adequate distention, single–breath-hold helical CT
was performed .
 Images were reconstructed at 1-mm intervals by using the minimal field of view
measured from the inner aspect of the middle of the pelvis.
 The patient was then turned to the prone position, and helical CT of the bladder was
repeated with use of the same parameters after a repeat scout view was obtained.
 Additional bladder distention with approximately 100 mL of CO2 was necessary in
about half of the patients, since repositioning led to leakage of some of the insufflated gas
from the bladder.
 Virtual cystoscopy time, including catheter placement, was approximately 30 minutes.
 The data were downloaded to an independent workstation equipped
with software for interactive intraluminal navigation with a surface-rendering algorithm.
 The threshold was optimized at 2500 HU.

Two factors that could optimize lesion detection.

 Type of view :
Transverse and virtual views are complementary in lesion detection and
characterization; therefore, sets of both of these images should be used for accurate
lesion detection.
 Patient position :
Imaging in both positions - supine and prone is necessary for
visualization of the entire mucosal surface without obscuration caused by
residual urine.

As a minimally invasive procedure, virtual cystoscopy provides many Advantages:

 It allows accurate localization of a lesion due to its wide field of view and
depiction of extravesical anatomic landmarks.

 The size of a tumor is measured objectively, and virtual cystoscopy can

be used to monitor treatment response in a patient with a
non resectable tumor.

 Patients with a severe ureteral stricture or marked prostatic hypertrophy,

who may be poor candidates for conventional cystoscopy, can safely
 undergo CT cystoscopy, since a small ureteral catheter can be used to instill
air in to the bladder .

 Use of the transverse images during CT cystoscopy also allows for

comprehensive pelvic imaging to assess extravesical metastases.

Important limitations
 A major limitation -- Unable to depict flat lesions (carcinoma in situ),
which appear as subtle mucosal color changes at conventional cystoscopy.

 The current resolution of helical CT does not allow reliable and consistent
visualization of small (< 5 mm) lesions.

 Mucosal thickening secondary to fibrosis cannot be distinguished from a

neoplasm. ( Similar with conventional cystoscopy)
Biopsy is often required to determine whether a bladder lesion is
inflammatory, fibrotic, or neoplastic.

 Lacks the ability to provide tissue for histologic evaluation, an ability that is
possible with conventional cystoscopy and biopsy.

In conclusion, CT virtual cystoscopy is a promising technique for use in the detection of

bladder lesions larger than 5 mm.

Adequate bladder distention and analysis of both transverse and virtual images obtained
with the patient in both supine and prone positions are required for optimal evaluation.