Which imaging modality is used to evaluate suspected urothelial cancer in gross painless hematuria?

• A. Abdominal X-ray
• B. CT urography
• C. Ultrasound of the scrotum
• D. PET-CT

Answer: (B)

The main idea is that when someone has gross painless hematuria, you want imaging that can visualize the entire urinary tract in detail to detect urothelial tumors wherever they may be (kidneys, ureters, bladder) and to assess surrounding anatomy.

CT urography provides high-resolution images of the kidneys, collecting system, ureters, and bladder with multiphase imaging (usually noncontrast, nephrographic, and excretory phases). This combination lets you see enhancing lesions, filling defects, or thickening of the urothelium, as well as stones or other causes of bleeding. It’s fast, widely available, and has high sensitivity for both upper and lower tract urothelial cancers, making it the preferred initial test in suspected urothelial cancer presenting with gross hematuria.

Other options don’t fit as well. An abdominal X-ray mainly shows calcifications and gives limited soft-tissue detail, so it’s poor for detecting urothelial tumors. Scrotal ultrasound focuses on testicular pathology and doesn’t evaluate the upper urinary tract or bladder well. PET-CT is more suited for staging and detecting metastasis rather than initial detection of a primary urothelial tumor in the setting of hematuria, and it lacks the detailed urothelial visualization that CT urography provides.