World Journal of Urology

, Volume 37, Issue 4, pp 667–690 | Cite as

Comparative sensitivity and specificity of imaging modalities in staging bladder cancer prior to radical cystectomy: a systematic review and meta-analysis

  • Jack CrozierEmail author
  • Nathan Papa
  • Marlon Perera
  • Brian Ngo
  • Damien Bolton
  • Shomik Sengupta
  • Nathan Lawrentschuk
Uninvited Review



The detection of lymph node metastases in bladder cancer has a significant impact on treatment decisions. Multiple imaging modalities are available to clinicians including magnetic resonance imaging, computed tomography and positron emission tomography. We aimed to investigate the utility of alternate imaging modalities on pre-cystectomy imaging in bladder cancer for the detection of lymph node metastases.


We performed systematic search of Web of Science (including MEDLINE), EMBASE and Cochrane libraries in accordance with the PRISMA statement. Studies comparing lymph node imaging findings with final histopathology were included in our analysis. Sensitivity and specificity data were quantified using patient-based analysis. A true positive was defined as a node-positive patient on imaging and node positive on histopathology. Meta-analysis of studies was performed using a mixed-effects, hierarchical logistic regression model.


Our systematic search identified 35 articles suitable for inclusion. MRI and PET have a higher sensitivity than CT while the specificity of all modalities was similar. The summary MRI sensitivity = 0.60 (95% CI 0.44–0.74) and specificity = 0.91 (95% CI 0.82–0.96). Summary PET/CT sensitivity = 0.56 (95% CI 0.49–0.63) and specificity = 0.92 (95% CI 0.86–0.95). Summary CT sensitivity = 0.40 (95% CI 0.33–0.49) and specificity = 0.92 (95% CI 0.86–0.95).


MRI and PET/CT provides superior sensitivity compared to CT for detection of positive lymph nodes in bladder cancer prior to cystectomy. There is variability in the accuracy that current imaging modalities achieve across different studies. A number of other factors impact on detection accuracy and these must be considered.


Bladder cancer Transitional cell carcinoma Positron emission tomography Magnetic resonance imaging Computed tomography 


Author contributions

JC: project development, data collection, data analysis, manuscript writing/editing; NP: project development, data collection, data analysis, manuscript writing/editing; MP: data collection, data analysis, manuscript writing/editing; BN: data collection, data analysis; DB: manuscript editing; SS: manuscript editing; NL: project development, manuscript editing.


This project received no funding.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest. This project did not require formal ethics committee approval.

Ethical approval

For this type of study formal ethics approval is not required.


  1. 1.
    Alfred Witjes J, Lebret T, Comperat EM, Cowan NC, De Santis M, Bruins HM, Hernandez V, Espinos EL, Dunn J, Rouanne M, Neuzillet Y, Veskimae E, van der Heijden AG, Gakis G, Ribal MJ (2017) Updated 2016 EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol 71(3):462–475CrossRefGoogle Scholar
  2. 2.
    Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, Skinner E, Bochner B, Thangathurai D, Mikhail M, Raghavan D, Skinner DG (2001) Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 19(3):666–675CrossRefGoogle Scholar
  3. 3.
    Gschwend JDP, Fair W (2002) Disease specific survival as endpoint of outcome for bladder cancer patients following radical cystectomy. Eur Urol 41:440–448CrossRefGoogle Scholar
  4. 4.
    Zehnder P, Studer UE, Skinner EC, Dorin RP, Cai J, Roth B, Miranda G, Birkhauser F, Stein J, Burkhard FC, Daneshmand S, Thalmann GN, Gill IS, Skinner DG (2011) Super extended versus extended pelvic lymph node dissection in patients undergoing radical cystectomy for bladder cancer: a comparative study. J Urol 186(4):1261–1268CrossRefGoogle Scholar
  5. 5.
    Yang Z, Cheng J, Pan L, Hu S, Xu J, Zhang Y, Wang M, Zhang J, Ye D, Zhang Y (2012) Is whole-body fluorine-18 fluorodeoxyglucose PET/CT plus additional pelvic images (oral hydration-voiding-refilling) useful for detecting recurrent bladder cancer? Ann Nucl Med 26(7):571–577CrossRefGoogle Scholar
  6. 6.
    Maurer T, Souvatzoglou M, Kubler H, Opercan K, Schmidt S, Herrmann K, Stollfuss J, Weirich G, Haller B, Gschwend JE, Schwaiger M, Krause BJ, Treiber U (2012) Diagnostic efficacy of 11C-choline positron emission tomography/computed tomography compared with conventional computed tomography in lymph node staging of patients with bladder cancer prior to radical cystectomy. Eur Urol 61(5):1031–1038CrossRefGoogle Scholar
  7. 7.
    Thoeny HC, Triantafyllou M, Birkhaeuser FD, Froehlich JM, Tshering DW, Binser T, Fleischmann A, Vermathen P, Studer UE (2009) Combined ultrasmall superparamagnetic particles of iron oxide-enhanced and diffusion-weighted magnetic resonance imaging reliably detect pelvic lymph node metastases in normal-sized nodes of bladder and prostate cancer patients. Eur Urol 55(4):761–769CrossRefGoogle Scholar
  8. 8.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700CrossRefGoogle Scholar
  9. 9.
    Higgins JP, Green S (2008) Cochrane handbook for systematic reviews of interventions. Wiley, West Sussex, EnglandCrossRefGoogle Scholar
  10. 10.
    Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM (2011) QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155(8):529–536CrossRefGoogle Scholar
  11. 11.
    Harbord RM, Deeks JJ, Egger M, Whiting P, Sterne JA (2007) A unification of models for meta-analysis of diagnostic accuracy studies. Biostatistics 8(2):239–251CrossRefGoogle Scholar
  12. 12.
    Aljabery F, Lindblom G, Skoog S, Shabo I, Olsson H, Rosell J, Jahnson S (2015) PET/CT versus conventional CT for detection of lymph node metastases in patients with locally advanced bladder cancer. BMC Urol 15:87CrossRefGoogle Scholar
  13. 13.
    Rais-Bahrami S, Pietryga JA, Nix JW (2016) Contemporary role of advanced imaging for bladder cancer staging. Urol Oncol 34(3):124–133CrossRefGoogle Scholar
  14. 14.
    Soubra A, Hayward D, Dahm P, Goldfarb R, Froehlich J, Jha G, Konety BR (2016) The diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography and computed tomography in staging bladder cancer: a single-institution study and a systematic review with meta-analysis. World J Urol 34(9):1229–1237CrossRefGoogle Scholar
  15. 15.
    Vargas HA, Akin O, Schoder H, Olgac S, Dalbagni G, Hricak H, Bochner BH (2012) Prospective evaluation of MRI, 11C-acetate PET/CT and contrast-enhanced CT for staging of bladder cancer. Eur J Radiol 81(12):4131–4137CrossRefGoogle Scholar
  16. 16.
    Orevi M, Klein M, Mishani E, Chisin R, Freedman N, Gofrit ON (2012) 11C-acetate PET/CT in bladder urothelial carcinoma: intraindividual comparison with 11C-choline. Clin Nucl Med 37(4):e67–e72CrossRefGoogle Scholar
  17. 17.
    Ceci F, Bianchi L, Graziani T, Castellucci P, Pultrone C, Eugenio B, Martorana G, Colletti PM, Rubello D, Fanti S, Schiavina R (2015) 11C-choline PET/CT and bladder cancer: lymph node metastasis assessment with pathological specimens as reference standard. Clin Nucl Med 40(2):e124–e128CrossRefGoogle Scholar
  18. 18.
    Brunocilla E, Ceci F, Schiavina R, Castellucci P, Maffione AM, Cevenini M, Bianchi L, Borghesi M, Giunchi F, Fiorentino M, Chondrogiannis S, Colletti PM, Fanti S, Martorana G (2014) Diagnostic accuracy of 11C-choline PET/CT in preoperative lymph node staging of bladder cancer: a systematic comparison with contrast-enhanced CT and histologic findings. Clin Nucl Med 39(5):e308–e312CrossRefGoogle Scholar
  19. 19.
    Grossman HB, Natale RB, Tangen CM, Speights VO, Vogelzang NJ, Trump DL, deVere White RW, Sarosdy MF, Wood DP, Raghavan D, Crawford ED (2003) Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med 349(9):859–866CrossRefGoogle Scholar
  20. 20.
    Burger M, Mulders P, Witjes W (2012) Use of neoadjuvant chemotherapy for muscle-invasive bladder cancer is low among major European centres: results of a feasibility questionnaire. Eur Urol 61(5):1070–1071CrossRefGoogle Scholar
  21. 21.
    Chang SS, Bochner BH, Chou R, Dreicer R, Kamat AM, Lerner SP, Lotan Y, Meeks JJ, Michalski JM, Morgan TM, Quale DZ, Rosenberg JE, Zietman AL, Holzbeierlein JM (2017) Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/ASTRO/SUO Guideline. J Urol 198(3):552–559CrossRefGoogle Scholar
  22. 22.
    Amendola MA, Glazer GM, Grossman HB, Aisen AM, Francis IR (1986) Staging of bladder carcinoma: MRI–CT-surgical correlation. Am J Roentgenol 146(6):1179–1183CrossRefGoogle Scholar
  23. 23.
    Tritschler S, Mosler C, Tilki D, Buchner A, Stief C, Graser A (2012) Interobserver variability limits exact preoperative staging by computed tomography in bladder cancer. Urology 79(6):1317–1321CrossRefGoogle Scholar
  24. 24.
    Baltaci S, Resorlu B, Yagci C, Turkolmez K, Gogus C, Beduk Y (2008) Computerized tomography for detecting perivesical infiltration and lymph node metastasis in invasive bladder carcinoma. Urol Int 81(4):399–402CrossRefGoogle Scholar
  25. 25.
    Barentsz JO, Jager G, Mugler JP, Oosterhof G, Peters H, Vanerning L, Ruijs SHJ (1995) Staging urinary-bladder cancer-value of T1-weighted 3-dimensional magnetization prepared-rapid gradient-echo and 2-dimensional spin-echo sequences. Am J Roentgenol 164(1):109–115CrossRefGoogle Scholar
  26. 26.
    Chakraborty D, Mittal BR, Kashyap R, Mete UK, Narang V, Das A, Bhattacharya A, Khandelwal N, Mandal AK (2014) Role of fluorodeoxyglucose positron emission tomography/computed tomography in diagnostic evaluation of carcinoma urinary bladder: comparison with computed tomography. World J Nucl Med 13(1):34–39CrossRefGoogle Scholar
  27. 27.
    Chen J, Cui Y, Liu L, Li C, Tang Y, Zhou X, Qi L, Zu X (2016) CCR7 as a predictive biomarker associated with computed tomography for the diagnosis of lymph node metastasis in bladder carcinoma. Oncol Lett 11(1):735–740CrossRefGoogle Scholar
  28. 28.
    Daneshmand S, Ahmadi H, Huynh LN, Dobos N (2012) Preoperative staging of invasive bladder cancer with dynamic gadolinium-enhanced magnetic resonance imaging: results from a prospective study. Urology 80(6):1313–1318CrossRefGoogle Scholar
  29. 29.
    Ficarra V, Dalpiaz O, Alrabi N, Novara G, Galfano A, Artibani W (2005) Correlation between clinical and pathological staging in a series of radical cystectomies for bladder carcinoma. BJU Int 95(6):786–790CrossRefGoogle Scholar
  30. 30.
    Gofrit ON, Mishani E, Orevi M, Klein M, Freedman N, Pode D, Shapiro A, Katz R, Libson E, Chisin R (2006) Contribution of C-11-choline positron emission tomography/computerized tomography to preoperative staging of advanced transitional cell carcinoma. J Urol 176(3):940–944CrossRefGoogle Scholar
  31. 31.
    Goodfellow H, Viney Z, Hughes P, Rankin S, Rottenberg G, Hughes S, Evison F, Dasgupta P, O’Brien T, Khan MS (2014) Role of fluorodeoxyglucose positron emission tomography (FDG PET)-computed tomography (CT) in the staging of bladder cancer. BJU Int 114(3):389–395Google Scholar
  32. 32.
    Heicappell R, Muller-Mattheis V, Reinhardt M, Vosberg H, Gerharz CD, Muller-Gartner HW, Ackermann R (1999) Staging of pelvic lymph nodes in neoplasms of the bladder and prostate by positron emission tomography with 2-F-18-2-deoxy-d-glucose. Eur Urol 36(6):582–587CrossRefGoogle Scholar
  33. 33.
    Hitier-Berthault M, Ansquer C, Branchereau J, Renaudin K, Bodere F, Bouchot O, Rigaud J (2013) F-18-fluorodeoxyglucose positron emission tomography-computed tomography for preoperative lymph node staging in patients undergoing radical cystectomy for bladder cancer: a prospective study. Int J Urol 20(8):788–796CrossRefGoogle Scholar
  34. 34.
    Horn T, Zahel T, Adt N, Schmid SC, Heck MM, Thalgott MK, Hatzichristodoulou G, Haller B, Autenrieth M, Kubler HR, Gschwend JE, Holzapfel K, Maurer T (2016) Evaluation of computed tomography for lymph node staging in bladder cancer prior to radical cystectomy. Urol Int 96(1):51–56CrossRefGoogle Scholar
  35. 35.
    Jensen TK, Holt P, Gerke O, Riehmann M, Svolgaard B, Marcussen N, Bouchelouche K (2011) Preoperative lymph-node staging of invasive urothelial bladder cancer with F-18-fluorodeoxyglucose positron emission tomography/computed axial tomography and magnetic resonance imaging: correlation with histopathology. Scand J Urol Nephrol 45(2):122–128CrossRefGoogle Scholar
  36. 36.
    Jeong IG, Hong S, You D, Hong JH, Ahn H, Kim CS (2015) FDG PET-CT for lymph node staging of bladder cancer: a prospective study of patients with extended pelvic lymphadenectomy. Ann Surg Oncol 22(9):3150–3156CrossRefGoogle Scholar
  37. 37.
    Kibel AS, Dehdashti F, Katz MD, Klim AP, Grubb RL, Humphrey PA, Siegel C, Cao D, Gao F, Siegel BA (2009) Prospective study of [18F] fluorodeoxyglucose positron emission tomography/computed tomography for staging of muscle-invasive bladder carcinoma. J Clin Oncol 27(26):4314–4320CrossRefGoogle Scholar
  38. 38.
    Li Z, Qi F, Miao J, Zu X, He W, Wang L, Qi L (2010) Vascular endothelial growth Factor-C associated with computed tomography used in the diagnosis of lymph node metastasis of bladder carcinoma. Arch Med Res 41(8):606–610CrossRefGoogle Scholar
  39. 39.
    Liedberg F, Bendahl PO, Davidsson T, Gudjonsson S, Holmer M, Mansson W, Wallengren NO (2013) Preoperative staging of locally advanced bladder cancer before radical cystectomy using 3 tesla magnetic resonance imaging with a standardized protocol. Scand J Urol 47(2):108–112CrossRefGoogle Scholar
  40. 40.
    Lista F, Andres G, Caceres F, Ramon de Fata F, Rodriguez-Barbero JM, Angulo JC (2013) Evaluation of risk of muscle invasion, perivesical and/or lymph node affectation by diffusion-weighted magnetic nuclear resonance in the patient who is a candidate for radical cystectomy. Actas Urol Esp 37(7):419–424CrossRefGoogle Scholar
  41. 41.
    Lodde M, Lacombe L, Friede J, Morin F, Saourine A, Fradet Y (2010) Evaluation of fluorodeoxyglucose positron-emission tomography with computed tomography for staging of urothelial carcinoma. BJU Int 106(5):658–663CrossRefGoogle Scholar
  42. 42.
    Paik ML, Scolieri MJ, Brown SL, Spirnak JP, Resnick MI (2000) Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy. J Urol 163(6):1693–1696CrossRefGoogle Scholar
  43. 43.
    Persad R, Kabala J, Gillatt D, Penry B, Gingell JC, Smith PJB (1993) Magnetic-resonance-imaging in the staging of bladder cancer. Br J Urol 71(5):566–573CrossRefGoogle Scholar
  44. 44.
    Picchio M, Treiber U, Beer AJ, Metz S, Bössner P, Randenborgh H, Paul R, Weirich G, Souvatzoglou M, Hartung R, Schwaiger M, Piert M (2006) Value of 11C-choline PET and contrast-enhanced CT for staging of bladder cancer: correlation with histopathologic findings. J Nucl Med 47(6):938–944Google Scholar
  45. 45.
    Rouanne M, Girma A, Neuzillet Y, Vilain D, Radulescu C, Letang N, Yonneau L, Herve JM, Botto H, Le Stanc E, Lebret T (2014) Potential impact of F-18-FDG PET/CT on patients selection for neoadjuvant chemotherapy before radical cystectomy. Eur J Surg Oncol 40(12):1724–1730CrossRefGoogle Scholar
  46. 46.
    Swinnen G, Maes A, Pottel H, Vanneste A, Billiet I, Lesage K, Werbrouck P (2010) FDG-PET/CT for the preoperative lymph node staging of invasive bladder cancer. Eur Urol 57(4):641–647CrossRefGoogle Scholar
  47. 47.
    Tritschler S, Mosler C, Straub J, Buchner A, Karl A, Graser A, Stief C, Tilki D (2012) Staging of muscle-invasive bladder cancer: can computerized tomography help us to decide on local treatment? World J Urol 30(6):827–831CrossRefGoogle Scholar
  48. 48.
    Uttam M, Pravin N, Anish B, Nandita K, Arup M (2016) Is F-18 -fluorodeoxyglucose FDG-PET/CT better than ct alone for the preoperative lymph node staging of muscle invasive bladder cancer? Int Braz J Urol 42(2):234–241CrossRefGoogle Scholar
  49. 49.
    Wollin DA, Deng FM, Huang WC, Babb JS, Rosenkrantz AB (2014) Conventional and diffusion-weighted MRI features in diagnosis of metastatic lymphadenopathy in bladder cancer. Can J Urol 21(5):7454–7459Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryAustin HealthHeidelbergAustralia
  2. 2.The University of MelbourneParkvilleAustralia
  3. 3.Division of Cancer SurgeryPeter MacCallum Cancer CentreMelbourneAustralia

Personalised recommendations