Julia R. Fielding, M.D. Brigham and Women's Hospital, Harvard Medical School Boston, Massachusetts

This elderly woman presented to the emergency ward with gross hematuria. She denied flank pain. A helical, unenhanced CT of the kidneys and ureters was performed.

Answer: (Figure 1) shows mild left hydronephrosis and hydroureter. (Figure 2) and (Figure 3) show a dilated left ureter passing adjacent of a phlebolith. One clue that the calcification is a phlebolith and not an obstructing stone is that the ureter remains dilated to the level of the ureterovesical junction. (Figure 4) demonstrates a mass at the left ureterovesical junction. Upon biopsy performed during cystoscopy, this was found to be a transitional cell carcinoma.

This case demonstrates the care that must be taken when interpreting unenhanced CT scans, now routinely obtained to diagnose obstructing ureteral stones.

References:

1. Fielding JR, Steele G, Fox LA, Heller H and Loughlin KR. Spiral computerized tomography in the evaluation of acute flank pain: a replacement for excretory urography. J Urol 1997; 157:2071-2073.