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Hannemann A, Pessoa RR, Flaig T, Kuna EM, Warren A, Robin T, Kim SP, Ballon-Landa E. Cost of upper tract imaging obtained during hematuria evaluation: Analysis of a national claims database. Urol Oncol 2024; 42:246.e1-246.e5. [PMID: 38679529 DOI: 10.1016/j.urolonc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/14/2023] [Accepted: 03/10/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION To investigate the actual cost of hematuria evaluation using nationally representative claims data, given that the workup for hematuria burdens the healthcare system with significant associated costs. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US). METHODS Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient factors associated with total healthcare costs. RESULTS We identified 318,680 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $362 overall, $504 for CT with contrast, $163 for US, $680 for magnetic resonance imaging (MRI), $283 for CT without contrast, and $294 for retrograde pyelogram. Median cystoscopy cost was $283. Total healthcare costs per patient were highest when utilizing MRI and CT imaging. When adjusted for comorbidities, the use of any imaging other than ultrasound was associated with higher costs. CONCLUSIONS In this nationally representative analysis, hematuria evaluation confers a significant cost burden, while the primary factor associated with higher costs of screening was imaging type. Based upon reduced cost of US-based strategies, further investigation should delineate its cost-effectiveness in the diagnosis of urological disease.
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Affiliation(s)
| | | | | | - Elizabeth Molina Kuna
- CU Anschutz School of Medicine, Aurora, CO; University of Colorado Cancer Center, Population Health Shared Resource, Aurora, CO
| | - Adam Warren
- University of Colorado Cancer Center, Population Health Shared Resource, Aurora, CO
| | | | | | - Eric Ballon-Landa
- CU Anschutz School of Medicine, Aurora, CO; Rocky Mountain Regional VA Medical Center, Aurora, CO.
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Brooks ER, Siriruchatanon M, Prabhu V, Charytan DM, Huang WC, Chen Y, Kang SK. Chronic kidney disease and risk of kidney or urothelial malignancy: systematic review and meta-analysis. Nephrol Dial Transplant 2024; 39:1023-1033. [PMID: 38037426 PMCID: PMC11139511 DOI: 10.1093/ndt/gfad249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is highly prevalent, affecting approximately 11% of US adults. Multiple studies have evaluated a potential association between CKD and urinary tract malignancies. Summary estimates of urinary tract malignancy risk in CKD patients with and without common co-existing conditions may guide clinical practice recommendations. METHODS Four electronic databases were searched for original cohort studies evaluating the association between CKD and urinary tract cancers (kidney cancer and urothelial carcinoma) through 25 May 2023, in persons with at least moderate CKD and no dialysis or kidney transplantation. Quality assessment was performed for studies meeting inclusion criteria using the Newcastle-Ottawa Scale. Meta-analysis with a random-effects model was performed for unadjusted incidence rate ratios (IRR) as well as adjusted hazard ratios (aHR) for confounding conditions (diabetes, hypertension and/or tobacco use), shown to have association with kidney cancer and urothelial carcinoma. Sub-analysis was conducted for estimates associated with CKD stages separately. RESULTS Six cohort studies with 8 617 563 persons were included. Overall, the methodological quality of the studies was good. CKD was associated with both higher unadjusted incidence and adjusted hazard of kidney cancer (IRR 3.36, 95% confidence interval (CI) 2.32-4.88; aHR 2.04, 95% CI 1.77-2.36) and urothelial cancer (IRR 3.96, 95% CI 2.44-6.40; aHR 1.35, 95% CI 1.22-1.50) compared with persons without CKD. Examining incident urinary tract cancers by CKD severity, risks were elevated in stage 3 CKD (kidney aHR 1.89, 95% CI 1.56-2.30; urothelial carcinoma aHR 1.35, 95% CI 1.20-1.52) as well as in stages 4/5 CKD (kidney cancer aHR 2.30, 95% CI 2.00-2.66; urothelial carcinoma aHR 1.24, 95% CI 1.04-1.49). CONCLUSIONS Even moderate CKD is associated with elevated risk of kidney cancer and urothelial carcinoma. Providers should consider these elevated risks when managing individuals with CKD, particularly when considering evaluation for the presence and etiology of hematuria.
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Affiliation(s)
- Emily R Brooks
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Vinay Prabhu
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - David M Charytan
- Department of Medicine, Division of Nephrology, NYU Grossman School of Medicine, New York, NY, USA
| | - William C Huang
- Department of Urology, NYU Grossman School of Medicine, New York, NY, USA
| | - Yu Chen
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Stella K Kang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
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Tan WS, Ahmad A, Zhou Y, Nathan A, Ogunbo A, Gbolahan O, Kallam N, Smith R, Khalifeh M, Tan WP, Cohen D, Volanis D, Walter FM, Sasieni P, Kamat AM, Kelly JD. Hematuria Cancer Risk Score with Ultrasound Informs Cystoscopy Use in Patients with Hematuria. Eur Urol Oncol 2024:S2588-9311(24)00134-2. [PMID: 38811250 DOI: 10.1016/j.euo.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/04/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Hematuria is a cardinal symptom of urinary tract cancer and would require further investigations. OBJECTIVE To determine the ability of renal bladder ultrasound (RBUS) with the Hematuria Cancer Risk Score (HCRS) to inform cystoscopy use in patients with hematuria. DESIGN, SETTING, AND PARTICIPANTS The development cohort comprised 1984 patients with hematuria from 40 UK hospitals (DETECT 1; ClinicalTrials.gov: NCT02676180) who received RBUS. An independent validation cohort comprised 500 consecutive patients referred to secondary care for a suspicion of bladder cancer. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Sensitivity and true negative of the HCRS and RBUS were assessed. RESULTS AND LIMITATIONS A total of 134 (7%) and 36 (8%) patients in the development and validation cohorts, respectively, had a diagnosis of urinary tract cancer. Validation of the HCRS achieves good discrimination with an area under the receiver operating characteristic curve of 0.727 (95% confidence interval 0.648-0.800) in the validation cohort with sensitivity of 95% for the identification of cancer. Utilizing the cutoff of 4.500 derived from the HCRS in combination with RBUS in the development cohort, 680 (34%) patients would have been spared cystoscopy at the cost of missing a G1 Ta bladder cancer and a urinary tract cancer patient, while 117 (25%) patients would have avoided cystoscopy at the cost of missing a single patient of G1 Ta bladder cancer with sensitivity for the identification of cancer of 97% in the validation cohort. CONCLUSIONS The HCRS with RBUS offers good discriminatory ability in identifying patients who would benefit from cystoscopy, sparing selected patient cohorts from an invasive procedure. PATIENT SUMMARY The hematuria cancer risk score with renal bladder ultrasound allows for the triage of patients with hematuria who would benefit from visual examination of the bladder (cystoscopy). This resulted in 25% of patients safely omitting cystoscopy, which is an invasive procedure, and would lead to health care cost savings.
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Affiliation(s)
- Wei Shen Tan
- Department of Urology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Division of Surgery and Interventional Science, University College London, London, UK.
| | - Amar Ahmad
- Division of Surgery and Interventional Science, University College London, London, UK; Cancer Intelligence, Cancer Research UK, London, UK
| | - Yin Zhou
- Department of Public health and Primary Care, University of Cambridge, Cambridge, UK; Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Arjun Nathan
- Department of Urology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Department of Urology, Royal Free Hospital, London, UK
| | | | | | - Neha Kallam
- Department of Urology, Royal Free Hospital, London, UK
| | - Rebecca Smith
- Department of Urology, Royal Free Hospital, London, UK
| | - Maen Khalifeh
- Department of Urology, Royal Free Hospital, London, UK
| | - Wei Phin Tan
- Department of Urology, New York University Langone Health, New York City, NY, USA
| | - Daniel Cohen
- Department of Urology, Royal Free Hospital, London, UK
| | | | - Fiona M Walter
- Department of Public health and Primary Care, University of Cambridge, Cambridge, UK; Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Peter Sasieni
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Innovation Hub, Guys Cancer Centre, Guys Hospital, King's College London, London, UK
| | - Ashish M Kamat
- Division of Surgery and Interventional Science, University College London, London, UK
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals, London, UK
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Hyman MJ, Skolarus TA, Cabral J, Shewmon K, Bedziner M, Agarwal PK, Modi PK. Utilization and Timing of Cystoscopy for Hematuria Evaluation by Advanced Practice Providers and Urologists. Urology 2024:S0090-4295(24)00291-7. [PMID: 38663584 DOI: 10.1016/j.urology.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To characterize differences between urologists and advanced practice providers (APPs) in the utilization of cystoscopy for hematuria. METHODS We identified patients initially evaluated for hematuria by a urologist or urology APP between 2015 and 2020 in the MarketScan Research Databases. We determined whether they received a cystoscopy within 6 months of their urology visit and the number of days until cystoscopy. We used multivariable regression to analyze the association between these outcomes and whether the urology clinician was an advanced practice registered nurse (APRN), physician assistant (PA), or urologist. RESULTS We identified 34,470 patients with microscopic hematuria and 17,328 patients with gross hematuria. Patients evaluated by urologists more often received a same-day cystoscopy than those evaluated by APPs (13% vs 5.8%). The odds that patients evaluated for microscopic and gross hematuria received a cystoscopy were 46.2% and 26.2% lower, respectively, if they were evaluated by an APRN vs a urologist. Patients seeing an APRN for microscopic and gross hematuria also waited approximately 7 and 14 days longer for their cystoscopy, respectively. No differences were observed for patients evaluated by PAs vs urologists. CONCLUSION Patients evaluated for hematuria by an APRN were less likely to receive a cystoscopy and had a longer wait until the procedure compared to those evaluated by a urologist; however, no differences were observed between PAs and urologists. Better understanding APP integration into urology clinics is warranted.
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Affiliation(s)
- Max J Hyman
- The Center for Health and the Social Sciences, The University of Chicago, Chicago, IL
| | - Ted A Skolarus
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Joshua Cabral
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Kate Shewmon
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Moshe Bedziner
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Piyush K Agarwal
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL
| | - Parth K Modi
- Section of Urology, Department of Surgery, The University of Chicago, Chicago, IL.
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Gercek O, Ulusoy K, Yazar VM, Topal K. Effects of delayed diagnosis on tumor size, stage and grade in bladder cancer. Int Urol Nephrol 2024; 56:935-940. [PMID: 37847325 DOI: 10.1007/s11255-023-03829-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE This study is planned based on the hypothesis that if bladder cancer is detected early, the disease would be less advanced and the possibility of treatment will increase, at least the recurrence-free survival will be longer. Regarding this hypothesis, it is aimed to investigate the effect of delayed diagnosis primarily on the disease factors. MATERIALS AND METHODS The study included 169 patients, who underwent TUR-BT with the suspicion of bladder cancer in the urology clinic of Afyonkarahisar Faculty of Medicine between April 2018 and April 2023. Demographic and clinical data of the patients were recorded and compared. RESULTS It was observed that the delay in diagnosis was significantly longer in patients with tumors larger than 3 cm compared to patients with tumors smaller than 3 cm (p < 0.001). In the correlation analysis between tumor size, duration of diagnosis delay, age, T stage, and tumor grade, a low level of positive correlation was observed between tumor size and duration of diagnosis delay, and it was statistically significant (r = 0.215, p = 0.005). CONCLUSION In our study, it was shown that the tumor size increases as the duration of diagnosis delay increases and this increase causes an increase of 0.088 mm in the pathological size of the tumor in the 1-day delay period. Considering that tumor size changes the risk group of the disease in bladder tumors, and relatedly the follow-up and treatment process changes, we believe that these data will be valuable in the management of bladder cancer.
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Affiliation(s)
- O Gercek
- Department of Urology, Afyonkarahisar Health Sciences University, 03100, Afyonkarahisar, Turkey.
| | - K Ulusoy
- Department of Urology, Afyonkarahisar Health Sciences University, 03100, Afyonkarahisar, Turkey
| | - V M Yazar
- Department of Urology, Afyonkarahisar Health Sciences University, 03100, Afyonkarahisar, Turkey
| | - K Topal
- Department of Urology, Afyonkarahisar State Hospital, Afyonkarahisar, Turkey
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Zhang HP, Liang RX, Lin XY, Xue ES, Ye Q, Zhu YF. Application of contrast-enhanced ultrasound in diagnosis and grading of bladder urothelial carcinoma. BMC Med Imaging 2024; 24:26. [PMID: 38273224 PMCID: PMC10809509 DOI: 10.1186/s12880-024-01199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
PURPOSE To explore the application of contrast-enhanced ultrasound (CEUS) for the diagnosis and grading of bladder urothelial carcinoma (BUC). METHODS The results of a two-dimensional ultrasound, color Doppler ultrasound and CEUS, were analyzed in 173 bladder lesion cases. The ultrasound and surgical pathology results were compared, and their diagnostic efficacy was analyzed. RESULTS There were statistically significant differences between BUC and benign lesions in terms of color blood flow distribution intensity and CEUS enhancement intensity (both P < 0.05). The area under the time-intensity curve (AUC), rising slope, and peak intensity of BUC were significantly higher than those of benign lesions (all P < 0.05). The H/T (height H / basal width T)value of 0.63 was the critical value for distinguishing high- and low-grade BUC, had a diagnostic sensitivity of 80.0% and a specificity of 60.0%. CONCLUSION The combination of CEUS and TIC can help improve the diagnostic accuracy of BUC. There is a statistically significant difference between high- and low-grade BUC in contrast enhancement intensity (P < 0.05); The decrease of H/T value indicates the possible increase of the BUC grade.
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Affiliation(s)
- Hui-Ping Zhang
- Department of Ultrasound, Fujian Medical University Union Hospital, Antai Street & Xin Quan Road 29, Fuzhou, Fujian Province, China
| | - Rong-Xi Liang
- Department of Ultrasound, Fujian Medical University Union Hospital, Antai Street & Xin Quan Road 29, Fuzhou, Fujian Province, China
| | - Xue-Ying Lin
- Department of Ultrasound, Fujian Medical University Union Hospital, Antai Street & Xin Quan Road 29, Fuzhou, Fujian Province, China
| | - En-Sheng Xue
- Department of Ultrasound, Fujian Medical University Union Hospital, Antai Street & Xin Quan Road 29, Fuzhou, Fujian Province, China
| | - Qin Ye
- Department of Ultrasound, Fujian Medical University Union Hospital, Antai Street & Xin Quan Road 29, Fuzhou, Fujian Province, China.
| | - Yi-Fan Zhu
- Department of Ultrasound, Fujian Medical University Union Hospital, Antai Street & Xin Quan Road 29, Fuzhou, Fujian Province, China
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7
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Alfred Witjes J, Max Bruins H, Carrión A, Cathomas R, Compérat E, Efstathiou JA, Fietkau R, Gakis G, Lorch A, Martini A, Mertens LS, Meijer RP, Milowsky MI, Neuzillet Y, Panebianco V, Redlef J, Rink M, Rouanne M, Thalmann GN, Sæbjørnsen S, Veskimäe E, van der Heijden AG. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines. Eur Urol 2024; 85:17-31. [PMID: 37858453 DOI: 10.1016/j.eururo.2023.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/18/2023] [Indexed: 10/21/2023]
Abstract
CONTEXT We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). OBJECTIVE To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022. EVIDENCE SYNTHESIS Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences. CONCLUSIONS This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Harman Max Bruins
- Department of Urology, Zuyderland Medisch Centrum, Sittard/Heerlen, The Netherlands
| | - Albert Carrión
- Department of Urology, Vall Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Richard Cathomas
- Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Eva Compérat
- Department of Pathology, Medical University Vienna General Hospital, Vienna, Austria
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Rainer Fietkau
- Department of Radiation Therapy, University of Erlangen, Erlangen, Germany
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany
| | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Alberto Martini
- Department of Urology, Institut Universitaire du Cancer-Toulouse-Oncopole, Toulouse, France; Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Laura S Mertens
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthew I Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - John Redlef
- Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Michael Rink
- Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany
| | - Mathieu Rouanne
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - George N Thalmann
- Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sæbjørn Sæbjørnsen
- Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
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Brown TA, Tse JR. Discrepant guidelines in the evaluation of hematuria. Abdom Radiol (NY) 2024; 49:202-208. [PMID: 37971572 DOI: 10.1007/s00261-023-04091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 08/24/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To assess discrepancies in current imaging recommendations for hematuria among North American societies: American College of Radiology (ACR), American Urological Association (AUA), and Canadian Urological Association (CUA). METHODS The latest available ACR Appropriateness Recommendations, AUA guidelines, and CUA guidelines were reviewed. AUA and CUA guidelines imaging recommendations by variants and level of appropriateness were converted to match the style of ACR. Imaging recommendations including modality, anatomy, and requirement for contrast were recorded. RESULTS Clinical variants included microhematuria without risk factors, microhematuria with risk factors, gross hematuria, and microhematuria during pregnancy. CUA recommends ultrasound kidneys as the first-line imaging study in the first 3 variants; pregnancy is not explicitly addressed. For hematuria without risk factors, ACR does not routinely recommend imaging, while AUA recommends shared decision-making to decide repeat urinalysis versus cystoscopy with ultrasound kidneys. For hematuria with risk factors and gross hematuria, ACR recommends CT urography; MR urography can also be considered in gross hematuria. AUA further stratifies intermediate- and high-risk patients, for which ultrasound kidneys and CT urography are recommended, respectively. For pregnancy, ACR and AUA both recommend ultrasound kidneys, though AUA additionally recommends consideration of CT or MR urography after delivery. CONCLUSION There is no universally agreed upon algorithm for diagnostic evaluation. Discrepancies centered on the role of upper tract imaging with ultrasound versus CT. Prospective studies and/or repeat simulation studies that apply newly updated guidelines are needed to further clarify the role of imaging, particularly for patients with microhematuria with no and intermediate risk factors.
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Affiliation(s)
- Terrell A Brown
- School of Medicine, Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA, 30310, USA
| | - Justin R Tse
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Devlies W, de Jong JJ, Hofmann F, Bruins HM, Zuiverloon TCM, Smith EJ, Yuan Y, van Rhijn BWG, Mostafid H, Santesso N, Violette P, Omar MI. The Diagnostic Accuracy of Cystoscopy for Detecting Bladder Cancer in Adults Presenting with Haematuria: A Systematic Review from the European Association of Urology Guidelines Office. Eur Urol Focus 2024; 10:115-122. [PMID: 37633791 DOI: 10.1016/j.euf.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/28/2023] [Accepted: 08/11/2023] [Indexed: 08/28/2023]
Abstract
CONTEXT Haematuria can be macroscopic (visible haematuria [VH]) or microscopic (nonvisible haematuria [NVH]), and may be caused by a number of underlying aetiologies. Currently, in case of haematuria, cystoscopy is the standard diagnostic tool to screen the entire bladder for malignancy. OBJECTIVE The objective of this systematic review is to determine the diagnostic test accuracy of cystoscopy (compared with other tests, eg, computed tomography, urine biomarkers, and urine cytology) for detecting bladder cancer in adults. EVIDENCE ACQUISITION A systematic review of the literature was performed according to the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for diagnostic test accuracy studies' checklist. The MEDLINE, Embase, Cochrane CENTRAL, and Cochrane CDSR databases (via Ovid) were searched up to July 13, 2022. The population comprises patients presenting with either VH or NVH, without previous urological cancers. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). EVIDENCE SYNTHESIS Overall, nine studies were included in the qualitative analysis. Seven out of nine included trials covered the use of cystoscopy in comparison with radiological imaging. Overall, sensitivity of cystoscopy ranged from 87% to 100%, specificity from 64% to 100%, positive predictive value from 79% to 98%, and negative predictive values between 98% and 100%. Two trials compared enhanced or air cystoscopy versus conventional cystoscopy. Overall sensitivity of conventional white light cystoscopy ranged from 47% to 100% and specificity from 93.4% to 100%. CONCLUSIONS The true accuracy of cystoscopy for the detection of bladder cancer within the context of haematuria has not been studied extensively, resulting in inconsistent data regarding its performance for patients with haematuria. In comparison with imaging modalities, a few trials have prospectively assessed the diagnostic performance of cystoscopy, confirming very high accuracy for cystoscopy, exceeding the diagnostic value of any other imaging test. PATIENT SUMMARY Evidence of tests for detecting bladder cancer in adults presenting with haematuria (blood in urine) was reviewed. The most common test used was cystoscopy, which remains the current standard for diagnosing bladder cancer.
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Affiliation(s)
- Wout Devlies
- Department of Urology, UZ Leuven, Leuven, Belgium
| | - Joep J de Jong
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Harman Max Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen/Heerlen, The Netherlands
| | | | | | - Yuhong Yuan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Hugh Mostafid
- Department of Urology, Royal Surrey Hospital, Guildford, UK
| | - Nancy Santesso
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Phil Violette
- Department of Surgery, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Flores Monar GV, Reynolds T, Gordon M, Moon D, Moon C. Molecular Markers for Bladder Cancer Screening: An Insight into Bladder Cancer and FDA-Approved Biomarkers. Int J Mol Sci 2023; 24:14374. [PMID: 37762677 PMCID: PMC10531979 DOI: 10.3390/ijms241814374] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/10/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Bladder cancer is one of the most financially burdensome cancers globally, from its diagnostic to its terminal stages. The impact it imposes on patients and the medical community is substantial, exacerbated by the absence of disease-specific characteristics and limited disease-free spans. Frequent recurrences, impacting nearly half of the diagnosed population, require frequent and invasive monitoring. Given the advancing comprehension of its etiology and attributes, bladder cancer is an appealing candidate for screening strategies. Cystoscopy is the current gold standard for bladder cancer detection, but it is invasive and has the potential for undesired complications and elevated costs. Although urine cytology is a supplementary tool in select instances, its efficacy is limited due to its restricted sensitivity, mainly when targeting low-grade tumors. Although most of these assays exhibit higher sensitivity than urine cytology, clinical guidelines do not currently incorporate them. Consequently, it is necessary to explore novel screening assays to identify distinctive alterations exclusive to bladder cancer. Thus, integrating potential molecular assays requires further investigation through more extensive validation studies. Within this article, we offer a comprehensive overview of the critical features of bladder cancer while conducting a thorough analysis of the FDA-approved assays designed to diagnose and monitor its recurrences.
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Affiliation(s)
| | - Thomas Reynolds
- NEXT Bio-Research Services, LLC, 11601 Ironbridge Road, Suite 101, Chester, VA 23831, USA;
| | - Maxie Gordon
- BCD Innovations USA, 10606 Candlewick Road, Lutherville, MD 2109, USA
| | - David Moon
- HJM Cancer Research Foundation Corporation, 10606 Candlewick Road, Lutherville, MD 2109, USA
| | - Chulso Moon
- HJM Cancer Research Foundation Corporation, 10606 Candlewick Road, Lutherville, MD 2109, USA
- BCD Innovations USA, 10606 Candlewick Road, Lutherville, MD 2109, USA
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins Medical Institution, Cancer Research Building II, 5M3, 1550 Orleans Street, Baltimore, MD 21205, USA
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11
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Jeong SH, Ku JH. Clinical guidelines for diagnosis of hematuria. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2023; 66:343-347. [DOI: 10.5124/jkma.2023.66.6.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/27/2023] [Indexed: 09/20/2023] Open
Abstract
Background: Hematuria is a common condition caused by various factors, including infections, inflammations, stone diseases, and anatomical abnormalities. While hematuria can be mistaken for other conditions, its significance should not be overlooked, as studies have shown that some patients with hematuria are diagnosed with urological cancers.Current Concepts: Experts agree on the need for specific diagnostic tests such as cystoscopy, upper urinary tract imaging, and urine cytology for visible hematuria. However, opinions differ when it comes to microscopic hematuria. Delays in diagnosing bladder cancer can significantly impact mortality rates. Therefore, objective diagnostic criteria, as well as guidelines to reduce excessive evaluations, costs, and side effects, are required. As of 2020, the American Urological Association has released new guidelines for the diagnosis and management of microscopic hematuria, that focus on assessing the risk of urological malignancies in individual patients and recommend tailored evaluations based on risk levels. This article provides an overview of these guidelines, discussing diagnostic criteria, initial evaluations, risk stratification, and recommended evaluations of the urinary tract.Discussion and Conclusion: Guidelines on hematuria aim to reduce unnecessary invasive procedures, provide appropriate follow-up strategies to patients with persistent or recurrent microscopic hematuria, and improve patient outcomes while minimizing unnecessary tests and procedures.
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12
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Awad M, Harraz AM, Farg H, Gabr HS, Sharaf DE, Abou-El-Ghar M, El-Hefnawy AS, Osman Y. Microscopic hematuria and pelvic ultrasonography could rule out flexible cystoscopy during surveillance for T1-low grade non-muscle invasive bladder cancer. Arab J Urol 2023; 21:150-155. [PMID: 37521447 PMCID: PMC10373612 DOI: 10.1080/2090598x.2023.2202930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/09/2023] [Indexed: 08/01/2023] Open
Abstract
Purpose Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC. Methods Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology. Results In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, p = 0.1) or the combination of MH, US, and UC (94.9%) (difference = 0.03, p = 0.2). The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations (90.4% and 92.3%; differences: 0.038 and 0.019; p = 0.4 and 0.7, respectively). Conclusions During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients.
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Affiliation(s)
- Mohamed Awad
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Ahmed M. Harraz
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Hashim Farg
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Hady S. Gabr
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Doaa E. Sharaf
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | | | | | - Yasser Osman
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
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13
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Koterazawa S, Somiya S, Ito K, Haitani T, Makino Y, Arakaki R, Kawase N, Higashi Y, Yamada H, Kanno T. The efficacy of ultrasonography for the detection of upper tract urothelial carcinoma. J Med Ultrason (2001) 2023; 50:197-203. [PMID: 36930378 DOI: 10.1007/s10396-023-01299-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/16/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE Ultrasonography and computed tomography urography are two commonly used modalities to image the upper tracts for the evaluation of hematuria. This study evaluated the efficacy of ultrasonography for the detection of upper tract urothelial carcinoma compared to computed tomography urography as a standard reference. METHODS This retrospective study included patients with urothelial carcinoma of the renal pelvis and/or ureter who were diagnosed using computed tomography urography and underwent surgical treatment. We calculated the sensitivity of ultrasonography in upper tract urothelial carcinoma diagnosis, further classified the degree of hydronephrosis on ultrasonography, and analyzed the relationship between the sensitivity and the degree of hydronephrosis and tumor location. Additionally, the usefulness of the combination of the screening ultrasonography findings, the presence of gross hematuria, and/or urine cytology was analyzed. RESULTS This study included 136 patients with upper urothelial carcinoma. Ultrasonography in the diagnosis had 45.6% sensitivity, and ultrasonography findings, including the detection of hydronephrosis, were present in 72.8%. The presence of hydronephrosis and tumor location were associated with detection by ultrasonography. The tumor was identified in a total of 134 (98.5%) patients by combining tumor detection and hydronephrosis using ultrasonography with gross hematuria and positive urine cytology as screening. CONCLUSION Ultrasonography showed acceptable sensitivity for upper tract urothelial carcinoma diagnosis. Considering the hydronephrosis findings, ultrasonography is a useful screening tool for upper tract urothelial carcinoma. Additionally, excessive computed tomography examinations can be reduced by adding gross hematuria and positive urine cytology.
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Affiliation(s)
- Shigeki Koterazawa
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Shinya Somiya
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Katsuhiro Ito
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Takao Haitani
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Yuki Makino
- Department of Urology, Kosekai Takeda Hospital, Kyoto, Japan
| | | | - Norio Kawase
- Department of Urology, Kosekai Takeda Hospital, Kyoto, Japan
| | - Yoshihito Higashi
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Hitoshi Yamada
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan
| | - Toru Kanno
- Department of Urology, Ijinkai Takeda General Hospital, 28-1 Moriminami-Cho, Ishida Fushimi-Ku, Kyoto, 601-1495, Japan.
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14
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Reply to Suman Sahoo, Abhishek Pandy, Swarnendu Mandal, Manoj Kumar Das, and Prasant Nayak's Letter to the Editor re: Wei Shen Tan, Aaron Pendergast, Charlotte Ackerman, et al. Adjuvant Intravesical Chemohyperthermia Versus Passive Chemotherapy in Patients with Intermediate-risk Non-muscle-invasive Bladder Cancer (HIVEC-II): A Phase 2, Open-label, Randomised Controlled Trial. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2022.08.003. Eur Urol 2023; 83:e48-e49. [PMID: 36456403 DOI: 10.1016/j.eururo.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 11/29/2022]
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15
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Sarier M, Demir M, Emek M, Özgen A, Turgut H, Özdemir C. Association between selective serotonin and serotonin-noradrenaline reuptake inhibitor therapy and hematuria. Nord J Psychiatry 2023; 77:31-35. [PMID: 35243962 DOI: 10.1080/08039488.2022.2047224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are used as first-line treatment for many psychiatric diseases, especially major depressive disorder. However, an important side effect of these drugs is the risk of bleeding due to platelet dysfunction. The aim of this study was to determine the frequency of hematuria in patients using SSRI/SNRIs and to compare with a control group. METHODS This study included patients who were followed up and treated with SSRI/SNRI in the psychiatric outpatient clinic of the Antalya Medical Park Hospital between 1 January 2021 and 31 March 2021 and a control group comprising patients who presented to the medical check-up outpatient clinic between the same dates. Complete urinalysis was performed for all patients and the results were compared between the groups. RESULTS Each group included 100 patients with a female/male ratio of 1. The mean age was 41.45 ± 13.47 (16-74) years in the study group and 40.51 ± 13.75 (20-70) years in the control group (p = 0.519). Mean duration of SSRI/SNRI use in the study group was 13.35 ± 1.32 (1-64) months. The prevalence of hematuria was 17% in the SSRI/SNRI group and 6% in the control group (p = 0.015). All cases of hematuria were microscopic hematuria. CONCLUSION Hematuria is significantly more common in patients receiving SSRI/SNRI treatment. The use of SSRI/SNRI should also be taken into account when investigating the etiology of hematuria.
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Affiliation(s)
- Mehmet Sarier
- Department of Urology, Istinye University, Istanbul, Turkey.,Department of Urology, Medical Park Hospital, Antalya, Turkey
| | - Meltem Demir
- Vocational School of Health Services, Antalya Bilim University, Turkey
| | - Mestan Emek
- Department of Public Health, Akdeniz University, Antalya, Turkey
| | - Ali Özgen
- Department of Pschiatry, Medical Park Hospital, Antalya, Turkey
| | - Hasan Turgut
- Faculty of Health Science, Avrasya University, Trabzon, Turkey
| | - Candan Özdemir
- Department of Neurology, Medical park Hospital, Antalya, Turkey
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16
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de Jong JJ, Pijpers OM, van Kessel KEM, Boormans JL, Van Criekinge W, Zwarthoff EC, Lotan Y. A Urine-based Genomic Assay Improves Risk Stratification for Patients with High-risk Hematuria Stratified According to the American Urological Association Guidelines. Eur Urol Oncol 2022; 6:183-189. [PMID: 36089502 DOI: 10.1016/j.euo.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/28/2022] [Accepted: 08/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND According to the recent American Urological Association (AUA) guideline on hematuria, patients are stratified into groups with low, intermediate, and high risk of urothelial carcinoma (UC). These risk groups are based on clinical factors and do not incorporate urine-based tumor markers. OBJECTIVE To evaluate whether a urine-based genomic assay improves the redefined AUA risk stratification for hematuria. DESIGN, SETTING, AND PARTICIPANTS We selected patients with complete biomarker status, as assessed on urinary DNA, from a previously collected prospective Dutch hematuria cohort (n = 838). Patients were stratified into the AUA risk categories on the basis of sex, age, and type of hematuria. Biomarker status included mutation status for the FGFR3, TERT, and HRAS genes, and methylation status for the OTX1, ONECUT2, and TWIST1 genes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was the diagnostic model performance for different hematuria risk groups. Further analyses assessed the pretest and post-test UC probability in the hematuria subgroups using a Fagan nomogram. RESULTS AND LIMITATIONS Overall, 65 patients (7.8%) were classified as low risk, 106 (12.6%) as intermediate risk, and 667 (79.6%) as high risk. The UC incidence differed significantly between the gross hematuria (21%, 98/457) and microscopic hematuria (4%, 14/381) groups (p < 0.001). All cancer cases were in the high-risk group, which had UC incidence of 16.8% (112/667). Application of the diagnostic model revealed robust performance among all risk groups (area under the receiver operating characteristic curve 0.929-0.971). Depending on the risk group evaluated, a negative urine assay was associated with post-test UC probability of 0.3-2%, whereas a positive urine assay was associated with post-test UC probability of 31-42%. CONCLUSIONS This study shows the value that a urine-based genomic assay adds to the AUA guideline stratification for patients with hematuria. It seems justified to safely withhold cystoscopy for patients with AUA low risk who have a negative urine assay. In addition, evaluation should be expedited for patients with AUA intermediate or high risk and a positive urine assay. PATIENT SUMMARY Patients who have blood in their urine (hematuria) can be classified as having low, intermediate, or high risk of having cancer in their urinary tract. We found that use of a urine-based genetic test improves the accuracy of predicting which patients are most likely to have cancer. Patients with a negative test may be able to avoid invasive tests, while further tests could be prioritized for patients with a positive test.
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Affiliation(s)
- Joep J de Jong
- Department of Urology, Erasmus MC Urothelial Cancer Research Group, Rotterdam, The Netherlands.
| | - Olga M Pijpers
- Department of Urology, Erasmus MC Urothelial Cancer Research Group, Rotterdam, The Netherlands
| | - Kim E M van Kessel
- Department of Urology, Erasmus MC Urothelial Cancer Research Group, Rotterdam, The Netherlands
| | - Joost L Boormans
- Department of Urology, Erasmus MC Urothelial Cancer Research Group, Rotterdam, The Netherlands
| | - Wim Van Criekinge
- Laboratory of Bioinformatics and Computational Genomics, Ghent University, Ghent, Belgium
| | - Ellen C Zwarthoff
- Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA
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17
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Teoh JYC, Kamat AM, Black PC, Grivas P, Shariat SF, Babjuk M. Recurrence mechanisms of non-muscle-invasive bladder cancer - a clinical perspective. Nat Rev Urol 2022; 19:280-294. [PMID: 35361927 DOI: 10.1038/s41585-022-00578-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/24/2022]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) is an early-stage cancer without invasion into the detrusor muscle layer. Transurethral resection of bladder tumour (TURBT) is a diagnostic and potentially curative procedure for NMIBC, but has some limitations, including difficulties in ascertaining complete tumour removal upon piecemeal resection and the possibility of tumour re-implantation after the procedure. The oncological control of NMIBC is far from satisfactory, with a 1-year recurrence rate of 15-61%, and a 5-year recurrence rate of 31-78%. Various recurrence mechanisms have been described for NMIBC, such as undetected tumours upon cystoscopy, incomplete resection during TURBT, tumour re-implantation after TURBT, drop metastasis from upper tract urothelial carcinoma and field change cancerization. Understanding the recurrence mechanisms from a clinical perspective has strong implications for the optimization of NMIBC oncological outcomes, as a cure for patients with NMIBC can only be achieved by tackling all possible recurrence mechanisms in a comprehensive manner.
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Affiliation(s)
- Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China. .,European Association of Urology-Young Academic Urologists (EAU-YAU) Urothelial Cancer Working Group, Amsterdam, Netherlands.
| | - Ashish M Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, Weill Cornell Medical College, New York, NY, USA.,Department of Urology, University of Texas Southwestern, Dallas, TX, USA.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan.,Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
| | - Marek Babjuk
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
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18
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Sarier M, Demir M, Emek M, Turgut H. Hematuria frequency and association with abnormal urological findings in medical check-up patients. Niger J Clin Pract 2022; 25:310-314. [PMID: 35295054 DOI: 10.4103/njcp.njcp_1509_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aims and Background Hematuria is one of the most common findings in urology. The management of hematuria detected in routine medical check-ups is also important in this respect. The aim of this study was to determine the frequency of hematuria in patients undergoing medical check-ups and evaluate its association with abnormal urological findings in laboratory tests and imaging. Patients and Methods Asymptomatic patients who presented to the check-up clinic between January 1 and December 31, 2020, were included. All patients underwent a complete laboratory workup and total abdominal ultrasound (TAUS). The distribution of hematuria by sex and age and the relationship between hematuria and abnormal urological findings in the laboratory tests and TAUS were calculated. Results The mean age of the 2,077 check-up patients was 45.8 ± 12.8 years. The female to male ratio was 1.07:1, and there was no significant difference in age between the sexes (P = 0.655). Microscopic hematuria was detected in 15.9% of the patients. The frequency of hematuria was 10.8% in men and 20.7% in women (P < 0.001). Men with hematuria were significantly older than men without hematuria (P = 0.033), whereas hematuria was not associated with age in women (P = 0.521). When its relationship between abnormal urological findings was evaluated, hematuria had a sensitivity of 21.70% (95% confidence interval [CI]: 18.84, 24.86) and a specificity of 87.11% (95% CI: 85.23, 88.79). Conclusion The frequency of hematuria in check-up patients was remarkable, at 15.9%. Hematuria in women is more common and unrelated to age, unlike in men. Hematuria had a high specificity but low sensitivity for urological abnormal findings.
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Affiliation(s)
- M Sarier
- Department of Urology, Istinye University, Istanbul; Department of Urology, Medical Park Hospital, Antalya, Turkey
| | - M Demir
- Faculty of Health Sciences, Bilim University, Antalya, Turkey
| | - M Emek
- Department of Public Health, Akdeniz University, Antalya, Turkey
| | - H Turgut
- Faculty of Health Science, Avrasya University, Trabzon, Turkey
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19
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Büttner T, Ritter M. Sonographie von Nieren, Retroperitoneum und Harnblase. Urologe A 2022; 61:357-364. [DOI: 10.1007/s00120-022-01791-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 10/18/2022]
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20
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Sancı A, Özkaya MF, Kubilay E, Gokce Mİ, Süer E, Gülpinar O, Baltacı S, Turkolmez K. Individual-risk-score for urinary tract malignancy in patients with microscopic hematuria. Int J Clin Pract 2021; 75:e14662. [PMID: 34322953 DOI: 10.1111/ijcp.14662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Abstract
AIM To determine the patients who can be safely exempted from undergoing unnecessary diagnostic procedures for microscopic hematuria (MH) evaluation by using the developed individual-risk-scoring system. MATERIALS AND METHODS The patients who underwent a complete urological evaluation for MH were identified retrospectively. The risk factors for urinary malignancy which defined in the 2020 American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction guidelines were recorded for each patient. Multivariable logistic regression was performed to establish a predictive risk-scoring system. The odds ratios obtained as a result of the logistic regression analysis were scored. RESULTS A total of 1461 patients who had undergone a complete urological evaluation for MH were identified. The urinary malignancy rate was 3.4% (50 of the 1461 patients). According to the odds ratios, age >40 was calculated as 1 point; male gender, 2 points; smoking history, 4 points; presence of occupational risk factor, 1 point; and presence of macroscopic hematuria, 2 points. For the cut-off risk score, 5 points was found to be the most appropriate score according to the sensitivity and specificity levels. The patients with risk scores of 5 points or lower were considered to be in the low-risk group for urinary tract malignancy. CONCLUSION The patients with a risk score of 5 points or above require complete urological evaluation. The results of the present study may reduce the number of patients undergoing unnecessary urological evaluation.
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Affiliation(s)
- Adem Sancı
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
| | | | - Eralp Kubilay
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
| | - Mehmet İlker Gokce
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
| | - Evren Süer
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
| | - Omer Gülpinar
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
| | - Sumer Baltacı
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
| | - Kadir Turkolmez
- Faculty of Medicine, Urology Department, Ankara University, Ankara, Turkey
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21
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Yap LC, McNicholas DP, Walsh AL, Rauf A, Patterson K, Power R. Upper tract imaging modality to investigate haematuria: cancer detection rates and changing guidelines. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00179-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To assess the imaging modalities used to investigate both visible haematuria and non-visible haematuria along with their detection rate of malignancy at two hospitals and the corresponding radiological workload produced.
Methods
A retrospective study was conducted across two hospitals. All CT urograms and ultrasound scans investigating haematuria in the outpatient setting over a 12-month period were evaluated.
Results
The detection rate for upper tract urothelial cancer with visible haematuria was 0.97% and for renal cell carcinoma was 0.64%. Of all the CT urograms performed for non-visible haematuria 4.9% had suspicious findings but none of these represents an underlying malignancy. Of all the ultrasound scans performed for either visible or non-visible haematuria, none were shown to have an underlying malignancy. The detection rate was thus zero for an upper tract urinary cancer or renal cell carcinoma in the non-visible haematuria group. A CT urogram was performed in 27% and 67% of cases in each respective hospital to further investigate non-visible haematuria. CT urography makes up 2.3% and 5.2% of each hospitals overall respective workload in the CT department. CT urography to investigate non-visible haematuria could be replaced by ultrasound in low-risk patients.
Conclusions
Radiological investigations are a limited resource and better rationalisation of upper tract imaging is needed in the setting of haematuria. Risk stratification of patients would be of benefit to help prevent a significant delay in timely diagnostics for higher risk individuals presenting with haematuria.
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22
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Judge C, Cifu AS, Faris S. Management of Patients With Microhematuria. JAMA 2021; 326:563-564. [PMID: 34374732 DOI: 10.1001/jama.2021.4770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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23
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Tohi Y, Miyauchi Y, Yamasaki M, Fujiwara K, Harada S, Matsuda I, Ito A, Matsuoka Y, Kato T, Taoka R, Tsunemori H, Ueda N, Sugimoto M. Incidental Bladder Cancer Found on Cystoscopy during Prostate Biopsy: Prevalence, Pathological Findings, and Oncological Outcome. Urol Int 2021; 106:791-797. [PMID: 34352796 DOI: 10.1159/000517895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/04/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We examined the prevalence, pathological findings, and oncological outcomes of incidental bladder cancer found on cystoscopy among patients eligible for prostate biopsy (PB). METHODS We retrospectively reviewed 803 patients who underwent cystoscopy prior to PB between January 2010 and September 2020. In cases of bladder tumor-like findings on cystoscopy, biopsy or transurethral resection of the bladder tumor was performed. The primary and secondary outcomes were the prevalence of incidental bladder cancer and pathological and oncological outcomes of incidental bladder cancer, respectively. RESULTS Incidental findings were observed in 31/803 patients (3.9%). Bladder tumor-like findings were found in 24/803 patients (3%), while 9/803 patients (1.1%) were pathologically diagnosed with urothelial carcinoma. The stage and grade of incidental bladder cancer were pTa in 8/9 patients and pT1 in 1/9 and low grade in 8/9 and high in 1/9, respectively. The median tumor size of the papillary pedunculated type was 0.5 cm. At 26-month median follow-up, no recurrence was observed. CONCLUSION Cystoscopy during PB may yield incidental bladder cancer findings, although the prevalence is very low. Incidental bladder cancer was of low stage and grade, which seemed unrelated to survival. Moreover, performing routine cystoscopy in conjunction with PB is not recommended as it may lead to overdiagnosis of low-risk bladder cancer.
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Affiliation(s)
- Yoichiro Tohi
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yasuyuki Miyauchi
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Mari Yamasaki
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kengo Fujiwara
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Satoshi Harada
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Iori Matsuda
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Ayako Ito
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yuki Matsuoka
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takuma Kato
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Rikiya Taoka
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hiroyuki Tsunemori
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Nobufumi Ueda
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Mikio Sugimoto
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Sancı A, Oktar A, Gokce MI, Süer E, Gülpinar O, Gögüs C, Baltacı S, Turkolmez K. Comparison of Microscopic Hematuria Guidelines as Applied in 1018 Patients With Microscopic Hematuria. Urology 2021; 154:28-32. [PMID: 33971192 DOI: 10.1016/j.urology.2021.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/03/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the 2012 American Urological Association (AUA) and 2020 AUA/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) microscopic hematuria (MH) guidelines as applied in 1,018 patients with MH, to confirm of risk groups and to investigate the natural history of patients with MH. MATERIALS AND METHODS Patients who had undergone a complete urological evaluation for MH according to the 2012 AUA MH guidelines were identified retrospectively. All the patients were then classified into low-, intermediate-, or high-risk for urinary tract malignancy according to the updated 2020 AUA/SUFU MH guidelines, for a second evaluation. The results of the first and second evaluations using the previous 2012 AUA and updated 2020 AUA/SUFU MH guidelines, respectively, were then compared. RESULTS A total of 1018 patients with MH were identified. The urinary tract malignancy rate was 3.3% (34 of the 1,018 patients). According to the 2020 AUA/SUFU MH guidelines, there were 218 patients (21.4%) in the low-risk group, 447 patients (43.9%) in the intermediate-risk group, and 353 patients (34.6%) in the high-risk group. All the 34 patients with malignancy were from the intermediate- or high-risk group who require further urological evaluation. There was no patient with newly developed urinary tract malignancy at the median follow-up time of 28 months (12-58). CONCLUSION The use of the updated 2020 AUA/SUFU MH guidelines may reduce the number of diagnostic procedures without compromising the diagnosis of life-threatening malignant lesions.
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Affiliation(s)
- Adem Sancı
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
| | - Alkan Oktar
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
| | - Mehmet I Gokce
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
| | - Evren Süer
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey.
| | - Omer Gülpinar
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
| | - Cagatay Gögüs
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
| | - Sumer Baltacı
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
| | - Kadir Turkolmez
- Urology department, Ankara University Faculty of Medicine, Altindag, Ankara, Turkey
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Waisbrod S, Natsos A, Wettstein MS, Saba K, Hermanns T, Fankhauser CD, Müller A. Assessment of Diagnostic Yield of Cystoscopy and Computed Tomographic Urography for Urinary Tract Cancers in Patients Evaluated for Microhematuria: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e218409. [PMID: 33970257 PMCID: PMC8111485 DOI: 10.1001/jamanetworkopen.2021.8409] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Microhematuria (MH) is a common finding that often leads to further evaluation for urinary tract cancers. There is ongoing debate about the extent to which patients with MH should be evaluated for cancer. OBJECTIVE To assess the diagnostic yield for detection of urinary tract cancers, specifically bladder cancer, upper tract urothelial carcinoma (UTUC), and kidney cell carcinoma, among patients evaluated for MH using cystoscopy and computed tomographic (CT) urography. DATA SOURCES MEDLINE, Scopus, and Embase were systematically searched for eligible studies published between January 1, 2009, and December 31, 2019. STUDY SELECTION Original prospective and retrospective studies reporting the prevalence of cancer among patients evaluated for MH were eligible. Two authors independently screened the titles and abstracts to select studies that met the eligibility criteria and reached consensus about which studies to include. Among 5802 records identified, 5802 articles were screened using titles and abstracts. After exclusions, 55 full-text articles were assessed for eligibility, with 39 studies selected for systematic review. DATA EXTRACTION AND SYNTHESIS This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Studies were quantitatively synthesized using a random-intercept logistic regression model. MAIN OUTCOMES AND MEASURES The primary outcome was diagnostic yield, defined as the proportion of patients with a diagnosis of urinary tract cancer (bladder cancer, UTUC, or kidney cell carcinoma) after presentation with MH. Studies were stratified by the percentage of cystoscopy and CT urography use and by high-risk cohorts. The diagnostic yields of CT urography and cystoscopy were calculated for each cancer type. RESULTS A total of 30 studies comprising 24 366 patients evaluated for MH were included in the meta-analysis. The pooled diagnostic yield among all patients was 2.00% (95% CI, 1.30%-3.09%) for bladder cancer, 0.02% (95% CI, 0.0%-0.15%) for UTUC, and 0.18% (95% CI, 0.09%-0.36%) for kidney cell carcinoma. Stratification of studies that used cystoscopy and/or CT urography for 95% or more of the cohort produced diagnostic yields of 2.74% (95% CI, 1.81%-4.12%) for bladder cancer, 0.09% (95% CI, 0.01%-0.75%) for UTUC, and 0.10% (95% CI, 0.04%-0.23%) for kidney cell carcinoma. In high-risk cohorts, the diagnostic yields increased to 4.61% (95% CI, 2.34%-8.90%) for bladder cancer and 0.45% (95% CI, 0.22%-0.95%) for UTUC. CONCLUSIONS AND RELEVANCE This study's findings suggest that, given the low diagnostic yield of CT urography and the associated risks and costs, limiting its use to high-risk patients older than 50 years is warranted. Risk stratification, as recommended by the recent American Urology Association guidelines on MH, may be a better approach to tailor further evaluation.
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Affiliation(s)
- Sharon Waisbrod
- Department of Urology, Spital-Limmattal, Schlieren, Switzerland
| | | | | | - Karim Saba
- Department of Urology, Kantonsspital Graubünden, Chur, Switzerland
| | - Thomas Hermanns
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Laboratory Reporting Parameters of Microhematuria: Implications for Interpreting the 2020 AUA Guideline. Urology 2021; 154:24-27. [PMID: 33895203 DOI: 10.1016/j.urology.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/28/2021] [Accepted: 04/09/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To explore how laboratories in the United States (U.S.) report red blood cell per high powered field (RBC/HPF) counts on urinalysis and to evaluate whether this methodology permits effective risk stratification in accordance with the 2020 AUA/SUFU microhematuria guidelines. MATERIALS AND METHODS Reporting methods for RBC/HPF counts (ranges, or actual counts) were collected by querying urologists in U.S. academic medical institutions or commercial laboratories. We explore whether (1) the reporting schemes were concordant with the risk strata in the new microhematuria guideline (3-10 [low risk], 11-25 [intermediate risk], and more than 25 [high risk]), and (2) evaluate the potential for risk group misclassification based on reporting methodology. RESULTS Data were available for 141 laboratories. Seventy-two (51%) use RBC/HPF ranges, while the remainder use actual counts (or counts to a threshold). Sixty (42%) report range cutoffs which are not concordant with the microhematuria guidelines risk groups. Furthermore, fifty-six (40%) do not include the cutoff of 25 RBC/HPF which could potentially misclassify intermediate and high risk groups. Finally, sixteen (11%) do not include the cut-off of 3 RBC/HPF that defines the presence of microhematuria. CONCLUSION A significant number of laboratories report RBC/HPF counts in ranges that differ from thresholds in the 2020 AUA/SUFU guideline. The implication is potential misclassification of microhematuria both at minimum threshold diagnosis (3 RBC/HPF), and additionally between intermediate and high risk groups. Standardization of reporting schemes to actual RBC/HPF counts may allow improved adherence to guidelines while providing data for future guideline development.
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Lucocq J, Ali A, Harrison W, Khalil T, Powar G, Raza K, Nandwani G. Does non-visible haematuria require urgent assessment? A retrospective cohort study from a university teaching hospital. World J Urol 2021; 39:3393-3397. [PMID: 33760946 PMCID: PMC8510922 DOI: 10.1007/s00345-021-03670-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/13/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES It is not certain from current evidence which patient groups with non-visible haematuria (NVH) require urgent investigation and which investigations are sufficient. We report referral outcomes data from Scotland to identify patient groups who will benefit from urgent assessment to rule out urological cancer (UC) and whether full set of investigations are necessary in all referred patients. MATERIALS AND METHODS Data were collected from electronic patient records for patients referred with NVH to secondary care urology services between July 2017 and May 2020. The correlations between risk factors and final diagnosis were assessed using categorical variables in a multivariate logistic regression analysis and using chi-squared models. Statistical analysis was performed using IBM SPSS data editor version 25. RESULTS Our study cohort comprised 525 patients (43.4% males; median age 66 years), in which UC was diagnosed in 25 patients (4.8%). Age > 60 years had sensitivity and NPV for UC of 92% and 99%, respectively. Univariate and multivariate analysis showed male sex, age ≥ 60 years and smoking were significant predictors of UC in patients with NVH (p < 0.05). There was no significant difference in UC in patients with history of LUTS, anticoagulation and previous UC. CONCLUSION The risk of urologic cancer in NVH patients is significant and male gender, age ≥ 60 years and smoking are significant predictors of UC. Patients with risk factors of UC require complete assessment of both the upper and lower urinary tract; however, in the absence of risk factors, patients do not require urgent or complete assessment.
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Affiliation(s)
- James Lucocq
- Department of Urology, Ninewells Hospital, Dundee, Scotland.
| | - Adnan Ali
- Department of Urology, Ninewells Hospital, Dundee, Scotland
| | | | - Tarek Khalil
- Department of Urology, Ninewells Hospital, Dundee, Scotland
| | - Gursunil Powar
- Department of Urology, Ninewells Hospital, Dundee, Scotland
| | - Kamran Raza
- Department of Urology, Ninewells Hospital, Dundee, Scotland
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Cancer Prevalence and Risk Stratification in Adults Presenting With Hematuria: A Population-Based Cohort Study. Mayo Clin Proc Innov Qual Outcomes 2021; 5:308-319. [PMID: 33997630 PMCID: PMC8105499 DOI: 10.1016/j.mayocpiqo.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To calculate the prevalence of renal cell carcinoma (RCC), upper urinary tract urothelial carcinoma (UT-UC), and lower urinary tract urothelial carcinoma (LT-UC) in patients with gross asymptomatic microhematuria (AMH) and symptomatic microhematuria (SMH). Patients and Methods This study was a population-based retrospective descriptive study. The study was approved by both the Mayo Clinic Institutional Review Board and the Olmsted Medical Center Institutional Review Board, and the population used was Olmsted County residents. A total of 4453 patients who presented with an initial episode of hematuria from January 1, 2000, through December 30, 2010, were included. Of the 4453 patients (median age, 58 years; interquartile range, 44.6-73.3 years), 1487 (33.4%) had gross hematuria, 2305 (51.8%) had AMH, and 661 (14.8%) had SMH. Results In the 1487 patients with gross hematuria, the prevalence of RCC, UT-UC, and LT-UC was 1.3%, 0.8%, and 9.0%, respectively. In the 2305 patients with AMH, the prevalence of RCC, UT-UC, and LT-UC was 0.2%, 0.3%, and 1.6%, respectively. In the 661 patients with SMH, the prevalence of RCC, UT-UC, and LT-UC was 0.6%, 0.2%, and 0.3%, respectively. Age was the most relevant risk factor for any hematuria type. Conclusion This unique cohort study reported that the prevalence of RCC or UC in patients with AMH and SMH was low, especially in the young cohort, and a large number of intense work-ups, such as cystoscopy and computed tomography urography, currently conducted could be omitted if stratified by hematuria type and age.
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Key Words
- AMH, asymptomatic microhematuria
- AUA, American Urological Association
- CT, computed tomography
- GH, gross hematuria
- LT-UC, lower urinary tract urothelial carcinoma
- OR, odds ratio
- RBC, red blood cell
- RCC, renal cell carcinoma
- REP, Rochester Epidemiology Project
- SMH, symptomatic microhematuria
- UC, urothelial carcinoma
- UT-UC, upper urinary tract urothelial carcinoma
- UTI, urinary tract infection
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Follow-up in non-muscle invasive bladder cancer: facts and future. World J Urol 2020; 39:4047-4053. [PMID: 33367941 PMCID: PMC8571151 DOI: 10.1007/s00345-020-03569-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/12/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with non-muscle invasive bladder cancer (NMIBC) have high recurrence and progression rates in spite of tumor resection and adjuvant instillation therapy. To detect recurrences and progression, these patients remain under frequent follow-up. Follow-up, however, is not well defined. Frequency and duration of follow recommendations are based on low levels of evidence, which is illustrated by clear differences in these recommendations per guideline, even when specified per risk group. Additionally, follow-up is recommended with cystoscopy and cytology in selected patients, which both have clear limitations. Fact is that follow-up in NMIBC is too frequent, with low levels of evidence and suboptimal tools, and it is patient unfriendly and costly. Improved cystoscopy techniques are unproven or impractical in the outpatient follow-up setting. Urinary markers have been around for decades, but never widely used in clinical practice. New (epi)genetic markers, however, could play a significant role in future follow-up of NMIBC. They have been shown to have very high negative predictive values for recurrences in follow-up of NMIBC, especially high-grade recurrences. Several studies suggested that these markers could be used to adapt follow-up cystoscopy frequency. What still needs study and confirmation is the cost-effectiveness of the use of these markers, which is highly dependent on health care costs per country and marker price. In all, however, implementation of these new urinary markers after confirmation of current results might significantly reduce patient burden and health care costs in the near future without reducing quality.
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Pak JS, Wang EY, Lee K, Pina LA, McKiernan JM, Anderson CB. Diagnostic yield of repeat evaluation for asymptomatic microscopic hematuria after negative initial workup. Urol Oncol 2020; 39:300.e1-300.e6. [PMID: 33339726 DOI: 10.1016/j.urolonc.2020.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/23/2020] [Accepted: 11/21/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The American Urological Association guideline for asymptomatic microhematuria recommends in patients with a negative initial workup, repeat workup should be considered for those with persistent/recurrent microhematuria. However, there is little data on the yield of repeat evaluation. Our hypothesis was that repeat workup yields a low detection rate of urologic malignancy. MATERIALS AND METHODS We retrospectively reviewed all patients at our institution who underwent microhematuria workup with cystoscopy and upper tract imaging from May 2010 to June 2016. Microhematuria was defined as ≥3 RBCs/HPF on a properly collected specimen in the absence of a benign cause. Demographics, age, smoking history, history of radiation, and findings on repeat cystoscopy and imaging were collected. Our primary endpoint was a new diagnosis of urologic malignancy. RESULTS Our initial cohort included 1,332 patients, of whom 21 were diagnosed with urothelial carcinoma and 7 with suspicious renal masses on initial workup. A total of 637 patients with negative initial workup had persistent/recurrent microhematuria. Repeat cystoscopy was performed in 161 (25%) patients at a median of 39 months, and repeat upper tract imaging was performed in 317 (50%) patients at a median of 39 months. Overall, repeat cystoscopy revealed new bladder cancer in 2 (1.2%) patients and repeat imaging revealed new suspicious renal mass in 4 (1.3%) patients. CONCLUSIONS We observed a low number of newly diagnosed malignancies among patients with persistent/recurrent asymptomatic microhematuria who had a prior negative workup. Additional research is required to determine the utility of a repeat AMH workup.
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Affiliation(s)
- Jamie S Pak
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth Y Wang
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Kevin Lee
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Luis A Pina
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - James M McKiernan
- Department of Urology, Columbia University Irving Medical Center, New York, NY
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Developments in the follow-up of nonmuscle invasive bladder cancer: what did we learn in the last 24 months: a critical review. Curr Opin Urol 2020; 30:387-391. [PMID: 32141938 DOI: 10.1097/mou.0000000000000741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Patients with nonmuscle invasive bladder cancer (NMIBC) have a high risk of recurrent tumors, even in spite of contemporary guideline recommended therapy. Follow-up recommendations are also clear (cystoscopy with cytology and upper urinary tract imaging in high-risk patients), but frequency and duration of follow-up are well defined. However, recent developments in follow-up tools might be of interest for clinical practice. RECENT FINDINGS Enhanced endoscopy improves detection and treatment of recurrences, and it can help in tailoring follow-up. However, it remains an invasive procedure. Most recently cystoscopy augmented with artificial intelligence has shown some promising results. Active surveillance, frequently done in prostate cancer patients, is also gaining attention in NMIBC follow-up. Finally markers are being studied and launched. Although not recommended by guidelines, and not used in clinical practice, recent studies have shown marker combinations with very high negative predictive values for (high risk) recurrences in follow-up of NMIBC patients. SUMMARY New tools for follow-up such as enhanced cystoscopy and urinary markers might help to individualize follow-up, which will result in decreasing patient discomfort, workload and costs while quality of care is maintained.
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Accuracy of ultrasound vs computed tomography scan for upper urinary tract malignancies and development of a risk-based diagnostic algorithm for haematuria in a UK tertiary centre. Int Urol Nephrol 2020; 53:49-57. [PMID: 32844354 DOI: 10.1007/s11255-020-02615-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE There is no consensus across guidelines on a diagnostic algorithm for upper urinary tract (UUT) evaluation following presentation with haematuria. Our aim is to compare the diagnostic accuracy of ultrasound (USS) compared to CT-scan for UUT malignancies and also determine the considerations important for a risk-based diagnostic protocol for haematuria. METHODS We reviewed our 'haematuria clinic' database to identify patients who had both USS and CT-scan for UUT evaluation between September 2015 and August 2017, and calculated the diagnostic accuracy of these imaging modalities for histologically confirmed UUT cancers. Furthermore, we identified risk factors in our diagnostic algorithm for haematuria and conducted regression analysis to determine their ability to predict UUT malignancies. RESULTS Overall, 575 patient records were studied. Age range was 21-92 years, M:F was 1.4:1, majority (81.2%) had visible haematuria, and 12 (2.1%) UUT cancers were diagnosed [renal cell carcinoma-1.4%; upper tract urothelial cancer-0.7%]. USS and CT-scan had diagnostic accuracy for UUT cancers of 95.8 and 99.1%, respectively (p < 0.001). Haematuria type was a significant consideration only on univariate analysis, while multivariate binary logistic regression showed that male gender, smoking, occupational exposure, and positive urologic history were the main risk factors associated with UUT malignancies. CONCLUSION USS and CT-scan have comparably high diagnostic accuracy for detecting UUT malignancies. USS may, therefore, be considered as the first-line UUT imaging modality when utilized in a risk-based diagnostic algorithm. Larger, multicentred studies are needed to validate our findings and influence guideline development.
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Editorial Comment on "Utilization and Yield of CT Urography: Are the American Urological Association Guidelines for Imaging of Patients With Asymptomatic Microscopic Hematuria Being Followed?". AJR Am J Roentgenol 2020; 216:110. [PMID: 32755192 DOI: 10.2214/ajr.20.24089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Utilization and Yield of CT Urography: Are the American Urological Association Guidelines for Imaging of Patients With Asymptomatic Microscopic Hematuria Being Followed? AJR Am J Roentgenol 2020; 216:106-110. [PMID: 32755213 DOI: 10.2214/ajr.20.22998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purposes of this study were to determine whether patients with asymptomatic microscopic hematuria undergoing CT urography (CTU) meet the American Urological Association criteria for radiologic evaluation and to determine the yield of CTU for upper tract malignancy. MATERIALS AND METHODS A retrospective review was conducted of consecutive CTU examinations performed for asymptomatic microscopic hematuria in adult patients. Patients with clinical evidence suggestive of a benign cause of hematuria (stone, urinary tract infection, trauma) or prior urologic malignancy were excluded. The study group included 419 patients (173 men, 246 women). CT reports were reviewed to identify causes of hematuria in all cases. Evaluate for appropriateness was conducted with 200 randomly allocated patients. Urinalysis results were reviewed, and appropriate use of CTU was defined as more than 3 RBCs per high-power field in the absence of urinary tract infection. Cystoscopy results after CTU were noted. RESULTS In total, 58 of 200 patients (29.0%; 95% CI, 23.2-35.6%) did not meet American Urological Association criteria for radiologic evaluation. Fifteen (7.5%) received dipstick analysis only. Thirty-eight (19.0%) had urinalysis results showing 0-2 RBCs per high-power field. Five patients (2.5%) were found to have urinary tract infections. No upper tract urothelial neoplasms were identified (0/419; 95% CI, 0.0-0.9%). One solid renal mass was identified without pathologic confirmation. One possible bladder mass was seen at CTU but not visualized at subsequent cystoscopy. CONCLUSION In 29.0% of examinations, CTU is performed for patients who do not meet the criteria for radiologic evaluation. The yield of CTU for upper urinary tract malignancy is low.
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Common J, Ramonas M, Alabousi A. The Diagnostic Yield of CT Urography in the Workup of Hematuria With Negative Cystoscopy [Formula: see text]. Can Assoc Radiol J 2020; 72:728-735. [PMID: 32615787 DOI: 10.1177/0846537120933952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To determine the diagnostic yield of computed tomography urography (CTU) in patients evaluated for hematuria with negative cystoscopy and to assess the added value of CTU when compared with ultrasound (US) in this patient population. METHODS A retrospective study was conducted of patients who underwent CTU within 12 months of negative cystoscopy for workup of hematuria at our institution from January 2016 to December 2017. Computed tomography urography findings were recorded and compared to clinical diagnoses to determine diagnostic yield. Computed tomography urography and US findings were compared in patients who underwent both examinations. Patient characteristics (age, sex, smoking history, and hematuria subtype) were reported. RESULTS A total of 657 patients met the inclusion criteria, including 108 patients aged 50 years and younger. No cause for hematuria was identified in 41% of patients overall and 58% of patients aged 50 years and younger. The most common diagnoses were benign prostatic hyperplasia and urolithiasis, accounting for 25% and 21% of patients, respectively; 0.6% of patients were diagnosed with an upper urinary tract malignancy, all older than 50 years. Although US was superior or equal to CTU for diagnosis in 83% of patients who underwent both examinations, US had a 0% sensitivity for detection of upper urinary tract malignancy. CONCLUSION The low diagnostic yield of CTU and low prevalence of upper urinary tract malignancy in patients evaluated for hematuria with negative cystoscopy, particularly those aged 50 years and younger, call into question the appropriateness of multiphasic CTU as a first-line imaging modality in this population.
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Affiliation(s)
- Jessica Common
- Faculty of Medicine, Department of Radiology, 3710McMaster University, Ontario, Canada
| | - Milita Ramonas
- Department of Radiology, Hamilton Health Sciences, 3710McMaster University, Juravinski Hospital and Cancer Centre, Ontario, Canada
| | - Abdullah Alabousi
- Department of Radiology, 3710McMaster University, St. Joseph's Healthcare Hamilton, Ontario, Canada
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Use of a Risk Stratification Tool to Guide Evaluation of Patients With Asymptomatic Microscopic Hematuria. Urology 2020; 141:27.e1-27.e6. [DOI: 10.1016/j.urology.2020.03.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/09/2020] [Accepted: 03/29/2020] [Indexed: 11/22/2022]
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Carneiro A, Wroclawski ML, Nahar B, Soares A, Cardoso AP, Kim NJ, Carvalho FT. Impact of the COVID-19 Pandemic on the Urologist's clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period. Int Braz J Urol 2020; 46:501-510. [PMID: 32271512 PMCID: PMC7239291 DOI: 10.1590/s1677-5538.ibju.2020.04.03] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 01/09/2023] Open
Abstract
This letter to the Editor aims to provide suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countries. It is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (PPE), Hospital/ICU beds, as well as ventilators. In places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome. Therefore, most worldwide authorities are recommending to avoid, as much as possible, patient's elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system. While efforts should be directed to the care of COVID-19 patients, other conditions (especially urgencies and oncological cases) must continue to be assisted. Thus, through a panel of experts, we have prepared a practical guide for Thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main Urologic Associations, as well as data from the literature to support the suggested management. We will try to follow the standard guideline recommendations from the American Urological Association (AUA) and European Association of Urology (EAU), with the aim of pursuing the best outcomes possible. However, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the COVID-19 crisis. Most importantly, all recommendations on this manuscript are based on the expectancy of a maximum 3-month duration of the crisis. If this period shall extended, these recommendations will be revised and updated.
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Affiliation(s)
- Arie Carneiro
- Departamento de UrologiaHospital Albert EinsteinSão PauloSPBrasil Departamento de Urologia , Hospital Albert Einstein , São Paulo , SP , Brasil ;
- Grupo Internacional de Urologia AvançadaSão PauloSPBrasil Diretor Científico e Executivo - Grupo Internacional de Urologia Avançada , São Paulo , SP , Brasil ;
| | - Marcelo Langer Wroclawski
- Departamento de UrologiaHospital Albert EinsteinSão PauloSPBrasil Departamento de Urologia , Hospital Albert Einstein , São Paulo , SP , Brasil ;
- Departamento de UrologiaBeneficiência Portuguesa de São PauloSão PauloSPBrasil Departamento de Urologia - Beneficiência Portuguesa de São Paulo , São Paulo , SP , Brasil ;
| | - Bruno Nahar
- Department of UrologyUniversity of Miami MillerSchool of MedicineFLUSA Department of Urology , University of Miami Miller School of Medicine , FL , USA ;
| | - Andrey Soares
- Departamento de Oncologia MédicaHospital Albert EinsteinSão PauloSPBrasil Departamento de Oncologia Médica , Hospital Albert Einstein , São Paulo , SP , Brasil ;
- Departamento de Oncologia MédicaCentro Paulista de OncologiaSão PauloSPBrasil Departamento de Oncologia Médica , Centro Paulista de Oncologia – Oncoclínicas, São Paulo , SP , Brasil ;
- Grupo Latino-Americano de Oncologia CooperativaSão PauloSPBrasil Diretor científico - Grupo Latino-Americano de Oncologia Cooperativa , São Paulo , SP , Brasil ;
| | - Ana Paula Cardoso
- Departamento de Oncologia MédicaHospital Albert EinsteinSão PauloSPBrasil Departamento de Oncologia Médica , Hospital Albert Einstein , São Paulo , SP , Brasil ;
| | - Nam Jin Kim
- Programa de Cirurgia e Cirurgia RobóticaHospital Albert EinsteinSão PauloSPBrasil Chefe do Programa de Cirurgia e Cirurgia Robótica , Hospital Albert Einstein , São Paulo , SP , Brasil ;
| | - Fabricio Torres Carvalho
- Departamento de Doenças InfecciosasHospital Albert EinsteinSão PauloSPBrasil Departamento de Doenças Infecciosas , Hospital Albert Einstein , São Paulo , SP , Brasil ;
- Departamento de Medicina IntensivaUnidade de Terapia IntensivaAC Camargo Cancer CenterSão PauloSPBrasil Departamento de Medicina Intensiva e Unidade de Terapia Intensiva - AC Camargo Cancer Center , São Paulo , SP , Brasil
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Non-visible haematuria for the Detection of Bladder, Upper Tract, and Kidney Cancer: An Updated Systematic Review and Meta-analysis. Eur Urol 2020; 77:583-598. [DOI: 10.1016/j.eururo.2019.10.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/18/2019] [Indexed: 12/12/2022]
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Tang Y, Chen J, Dai M, Li L. Imaging features of inflammatory myofibroblastic tumour in the urinary bladder. Br J Hosp Med (Lond) 2020; 81:1-2. [PMID: 32339008 DOI: 10.12968/hmed.2020.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Yan Tang
- Department of Pathology, Chengdu Third People's Hospital, Chengdu, China
| | - Juan Chen
- Department of Pathology, Chengdu Third People's Hospital, Chengdu, China
| | - Maoliang Dai
- Department of Radiology, Chengdu Third People's Hospital, Chengdu, China
| | - Ling Li
- Department of Pathology, Chengdu Third People's Hospital, Chengdu, China
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John JB, Coscione A, Acher P, Speakman M. Non-visible haematuria: would discontinuing urgent investigation have a visible impact? Br J Hosp Med (Lond) 2020; 81:1-7. [PMID: 32339006 DOI: 10.12968/hmed.2020.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
National guidance in the UK continues to recommend urgent referral of selected patients with non-visible haematuria for urological assessment. The positive predictive value of non-visible haematuria for urological cancer is low, so it is uncertain whether this is an effective and equitable use of healthcare resources. This article considers rationales for and against continuing this practice, and outlines alternative investigative strategies for patients presenting with non-visible haematuria based on current knowledge and modern technology.
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Affiliation(s)
- Joseph B John
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Alberto Coscione
- Department of Urology, Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
| | - Peter Acher
- Department of Urology, Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK
| | - Mark Speakman
- Department of Urology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
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Tan WS, Teo CH, Chan D, Ang KM, Heinrich M, Feber A, Sarpong R, Williams N, Brew-Graves C, Ng CJ, Kelly J. Exploring patients' experience and perception of being diagnosed with bladder cancer: a mixed-methods approach. BJU Int 2020; 125:669-678. [PMID: 31975539 PMCID: PMC7318301 DOI: 10.1111/bju.15008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective To determine patient experience and perception following a diagnosis of non‐muscle‐invasive bladder cancer (NMIBC). Patient and methods Patients were part of a prospective multicentre observational study recruiting patients with NMIBC for a urine biomarker study (DETECT II; ClinicalTrials.gov: NCT02781428). A mixed‐methods approach comprising: (i) the Brief Illness Perception Questionnaire (Brief‐IPQ) and (ii) semi‐structured interviews to explore patients’ experience of having haematuria, and initial and subsequent experience with a NMIBC diagnosis. Both assessments were completed at 6 months after NMIBC diagnosis. Results A total of 213 patients completed the Brief‐IPQ. Patients felt that they had minimal symptoms (median [interquartile range, IQR] score 2 [0–5]) and were not particularly affected emotionally (median [IQR] score 3 [1–6]) with a minimal effect to their daily life (median [IQR] score 2 [0–5]). However, they remained concerned about their cancer diagnosis (median [IQR] score 5 [3–8]) and felt that they had no personal control over the cancer (median [IQR] score 2 [2–5]) and believed that their illness would affect them for some time (median [IQR] score 6 [3–10]). A significant association with a lower personal control of the disease (P < 0.05) and a poorer understanding of the management of NMIBC (P < 0.05) was seen in patients aged >70 years. Many patients were uncertain about the cause of bladder cancer. Qualitative analysis found that at initial presentation of haematuria, most patients were not aware of the risk of bladder cancer. Patients were most anxious and psychologically affected between the interval of cystoscopy diagnosis and transurethral resection of bladder tumour (TURBT). Following TURBT, most patients were positive about their cancer prognosis. Conclusion Patients with NMIBC have a poor perception of disease control and believe that their disease will continue over a prolonged period of time. This is particularly more pertinent in the elderly. Patients are most psychologically affected during the interval between cancer diagnosis following cystoscopy and TURBT. Health awareness about bladder cancer remained poor with a significant number of patients unaware of the causes of bladder cancer. Psychological support and prompt TURBT following bladder cancer diagnosis would help improve the mental health of patients with NMIBC.
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Affiliation(s)
- Wei Shen Tan
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, Northwick Park Hospital, London, UK
| | - Chin Hai Teo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Delcos Chan
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kar Mun Ang
- Department of Medicine, Royal Free Hospital, London, UK
| | - Malgorzata Heinrich
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - Andrew Feber
- Division of Surgery and Interventional Science, University College London, London, UK.,UCL Cancer Institute, London, UK
| | - Rachael Sarpong
- Surgical & Interventional Trials Unit, University College London, London, UK
| | - Norman Williams
- Surgical & Interventional Trials Unit, University College London, London, UK
| | - Chris Brew-Graves
- Surgical & Interventional Trials Unit, University College London, London, UK
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - John Kelly
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital, London, UK
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Bladder cancer and its mimics: a sonographic pictorial review with CT/MR and histologic correlation. Abdom Radiol (NY) 2019; 44:3827-3842. [PMID: 31676920 DOI: 10.1007/s00261-019-02276-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Bladder cancer is the most common cancer of the urinary system and often presents with hematuria. Despite its relatively high incidence, bladder cancer is often under-recognized sonographically. Moreover, even when bladder abnormalities are identified, numerous other entities may mimic the appearance of bladder cancer. Given the incidence and prevalence of bladder cancer, it is important to recognize its variable appearance sonographically and distinguish it from its common mimics. We review the sonographic appearance of bladder cancer and its mimics, providing correlative CT/MR imaging as well as pathology. We stress the importance and advantage of ultrasound as a dynamic imaging modality, with the ability to optimize distinguishing bladder cancer from similar-appearing entities.
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John JB, Wijeyaratne S, Speakman M. Impact of the 2015 NICE guidance for urgent assessment of patients with non-visible haematuria. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415819872910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To assess the impact of the 2015 National Institute of Health and Care Excellence (NICE) guidance for referral of non-visible haematuria (NVH) and to compare diagnostic findings in patients referred using 2005 and 2015 guidance. Patients and method: Review of the referral details and diagnostic findings for urgent NVH referrals was assessed over a 27-month period. Referrals continued to be received under 2005 and 2015 NICE guidance during this period, and the diagnostic findings from each pathway were compared. Results: The number of urgent haematuria referrals reduced by 34% over the 27-month period. NVH referrals fell from 144 in the first quarter to 30 in the last quarter. The transitional cell carcinoma (TCC) diagnosis rate was low in patients referred using 2005 and 2015 criteria (1.7 and 1.9% respectively). No muscle-invasive bladder cancer (MIBC) was diagnosed. There was a high rate of benign urological findings. Non-adherence to referral criteria was high in the 2015 pathway (56%). Conclusion: The reduction in NVH referrals following introduction of 2015 NICE guidance could allow resource re-allocation. Low adherence to referral criteria should be investigated. The absence of MIBC and low rate of TCC diagnosis is reassuring and consideration should be given to investigating NVH patients semi-urgently. Level of evidence: 2C
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Affiliation(s)
- Joseph B John
- Department of Urology, Taunton and Somerset NHS Foundation Trust, UK
| | | | - Mark Speakman
- Department of Urology, Taunton and Somerset NHS Foundation Trust, UK
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44
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Bolenz C, Schröppel B, Eisenhardt A, Schmitz-Dräger BJ, Grimm MO. The Investigation of Hematuria. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:801-807. [PMID: 30642428 DOI: 10.3238/arztebl.2018.0801] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 05/13/2018] [Accepted: 11/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hematuria can be either grossly visible (macrohematuria) or only detectable under a microscope (microhematuria). Microhematuria is often asymptomatic and has a prevalence of 4-5% in routine clinical practice. It may be due to an underlying disease of the kidneys or the urogenital tract. In this article, we provide an overview of the causes of hematuria and of the recommendations of current guidelines for its diagnostic evaluation. A risk-adapted diagnostic strategy for the evaluation of asymptomatic microhematuria (aMH) is presented. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed, as well as on guidelines from Germany and abroad. RESULTS Hematuria has many causes, and a broad urological and nephrological differential diagnosis must be considered. In the absence of high-quality scientific evidence, the recommendations of current guidelines for the diagnostic evaluation of hematuria are not uniform; this is particularly so for aMH. Microhematuria is said to be present when urine microscopy reveals three or more erythrocytes per highpower field. The basic diagnostic evaluation consists of a thorough history and physical examination, measurement of inflammatory parameters and renal function tests, and ultrasonography of the kidneys and bladder. Patients with non-glomerular aMH who have risk factors such as smoking, advanced age, and male sex are more likely to have relevant underlying conditions and should therefore undergo augmented, risk-adapted diagnostic evaluation with urethrocystoscopy, urine cytology, and, when indicated, CT urography. Patients with isolated glomerular hematuria are at elevated risk for renal disease and should undergo follow-up checks at six-month intervals. CONCLUSION Although hematuria is common, there is no uniform, internationally accepted, evidence-based algorithm for its diagnostic evaluation. All potential causes of hematuria must be considered, and all individual risk factors taken into account, so that an underlying disease requiring treatment can be identified or ruled out.
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Affiliation(s)
- Christian Bolenz
- Department of Urology and Pediatric Urology, University Hospital Ulm; Clinic of Internal Medicine I, Nephrology Division, University Hospital Ulm; Praxisklinik Urologie Rhein Ruhr, Mülheim an der Ruhr; Clinic for Urology, Pediatric Oncology and Oncology, Essen University Hospital; Division of Urologic Oncology, Department of Urology, St. Theresienkrankenhaus, Nürnberg and Department of Urology and Pediatric Urology at Erlangen University; Clinic for Urology, Jena University Hospital
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45
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Smith MR, Read KC, Stegman ML, Kroll NJ, Van Every MJ. Evaluation of Asymptomatic Microscopic Hematuria by Renal Ultrasound to Detect Upper Tract Malignancy: A 20-Year Experience in a Community Hospital. Urology 2019; 133:34-39. [PMID: 31310767 DOI: 10.1016/j.urology.2019.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/18/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the sensitivity of ultrasound imaging in detecting upper urinary tract malignancy in patients with asymptomatic microscopic hematuria (AMH) in an outpatient community setting. MATERIALS AND METHODS A list of all patients who received renal ultrasound for hematuria in our health care system between January 1, 1997 and July 1, 2015 was obtained, and electronic health records were retrospectively reviewed. Patients were excluded for age (<18 years), <3 years follow-up, prior upper tract malignancy, recent urinary tract catheterization, inpatient status, pregnancy, insufficient data, or gross hematuria. The initial ultrasound was considered positive if suspicious findings led to a subsequent diagnosis of an upper tract malignancy. False negatives were determined by electronic medical record follow-up for at least 3 years. RESULTS Of the 2138 patients with AMH who met inclusion criteria, ultrasound imaging detected suspicious findings in 9 of 9 patients with renal cell carcinoma and 3 of 3 patients with upper tract urothelial cancer, indicating a sensitivity of 100% and 100%, respectively. Four additional malignancies were diagnosed more than 3 years after the initial evaluation for an incidence rate of 1.6 cases of upper tract malignancy per 10,000 person-years. CONCLUSION The prevalence of upper urinary tract malignancy was low in patients with AMH. Ultrasonography is an appropriate modality for upper tract imaging in the initial evaluation of patients with AMH. Practice guidelines should be updated to reflect the high sensitivity of ultrasound and low risk of upper tract malignancy in patients with AMH.
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Affiliation(s)
- Matthew R Smith
- Departments of Medical Education, Gundersen Health System, La Crosse, WI.
| | - Keaton C Read
- Departments of Medical Research, Gundersen Health System, La Crosse, WI
| | - Matthew L Stegman
- Departments of Medical Education, Gundersen Health System, La Crosse, WI
| | - Neil J Kroll
- Departments of Medical Education, Gundersen Health System, La Crosse, WI
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Lucca I, Hofbauer SL, Haitel A, Susani M, Shariat SF, Klatte T, De Martino M. Urinary expression of genes involved in DNA methylation and histone modification for diagnosis of bladder cancer in patients with asymptomatic microscopic haematuria. Oncol Lett 2019; 18:57-62. [PMID: 31289472 DOI: 10.3892/ol.2019.10330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 04/25/2019] [Indexed: 12/18/2022] Open
Abstract
The aim of the present study was to identify and test a urine marker panel of genes involved in DNA methylation and histone modification for the detection of urothelial carcinoma of the bladder (UCB). RNA samples obtained from the voided urine of 227 patients with asymptomatic microscopic haematuria (AMH) were analysed. Gene array analysis was performed on 18 randomly selected cDNA samples, which revealed that histone deacetylase 9 (HDAC9), HDAC3, tRNA (cytosine-5-)-methyltransferase1 and DNA methyltransferase 1 were differentially expressed between patients with UCB and control subjects. Subsequently, reverse transcription-quantitative polymerase chain reaction analysis was employed to test the performance of the identified four-gene panel on the remaining 209 cDNA samples. In this targeted discovery cohort, all four genes were significantly associated with UCB on univariable analyses [each odds ratio (OR) >2, P<0.05], but only HDAC3 was significant following multivariable analysis (OR=2.8, P=0.011). The addition of HDAC3 to a base risk factor model improved its accuracy by 1.4%. These data suggest that urinary HDAC3 is associated with the presence of UCB in patients with AMH; however, HDAC3 improved the accuracy of the established risk factors only to a marginal extent.
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Affiliation(s)
- Ilaria Lucca
- Department of Urology, Medical University of Vienna, A-1090 Vienna, Austria.,Department of Urology, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
| | | | - Andrea Haitel
- Department of Pathology, Medical University of Vienna, A-1090 Vienna, Austria
| | - Martin Susani
- Department of Pathology, Medical University of Vienna, A-1090 Vienna, Austria
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, A-1090 Vienna, Austria.,Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, A-1090 Vienna, Austria.,Karl Landsteiner Society, Urology and Andrology, A-1090 Vienna, Austria.,Department of Urology, Weill Cornell Medical College, New York, NY 10011, USA.,Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Tobias Klatte
- Department of Urology, Medical University of Vienna, A-1090 Vienna, Austria
| | - Michela De Martino
- Department of Urology, Medical University of Vienna, A-1090 Vienna, Austria
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Tan WS, Ahmad A, Feber A, Mostafid H, Cresswell J, Fankhauser CD, Waisbrod S, Hermanns T, Sasieni P, Kelly JD. Development and validation of a haematuria cancer risk score to identify patients at risk of harbouring cancer. J Intern Med 2019; 285:436-445. [PMID: 30521125 PMCID: PMC6446724 DOI: 10.1111/joim.12868] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND A lack of consensus exists amongst national guidelines regarding who should be investigated for haematuria. Type of haematuria and age-specific thresholds are frequently used to guide referral for the investigation of haematuria. OBJECTIVES To develop and externally validate the haematuria cancer risk score (HCRS) to improve patient selection for the investigation of haematuria. METHODS Development cohort comprise of 3539 prospectively recruited patients recruited at 40 UK hospitals (DETECT 1; ClinicalTrials.gov: NCT02676180) and validation cohort comprise of 656 Swiss patients. All patients were aged >18 years and referred to hospital for the evaluation of visible and nonvisible haematuria. Sensitivity and specificity of the HCRS in the validation cohort were derived from a cut-off identified from the discovery cohort. RESULTS Patient age, gender, type of haematuria and smoking history were used to develop the HCRS. HCRS validation achieves good discrimination (AUC 0.835; 95% CI: 0.789-0.880) and calibration (calibration slope = 1.215) with no significant overfitting (P = 0.151). The HCRS detected 11.4% (n = 8) more cancers which would be missed by UK National Institute for Health and Clinical Excellence guidelines. The American Urological Association guidelines would identify all cancers with a specificity of 12.6% compared to 30.5% achieved by the HCRS. All patients with upper tract cancers would have been identified. CONCLUSION The HCRS offers good discriminatory accuracy which is superior to existing guidelines. The simplicity of the model would facilitate adoption and improve patient and physician decision-making.
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Affiliation(s)
- W. S. Tan
- Division of Surgery & Interventional ScienceUniversity College LondonLondonUK
- Department of UrologyUniversity College London HospitalLondonUK
| | - A. Ahmad
- Cancer IntelligenceCancer Research UKLondonUK
| | - A. Feber
- Division of Surgery & Interventional ScienceUniversity College LondonLondonUK
- UCL Cancer InstituteLondonUK
| | - H. Mostafid
- Department of UrologyRoyal Surrey County HospitalGuildfordUK
| | - J. Cresswell
- Department of UrologyJames Cook University HospitalMiddlesbroughUK
| | - C. D. Fankhauser
- Department of UrologyUniversity Hospital ZurichUniversity of ZurichZurichSwitzerland
| | - S. Waisbrod
- Department of UrologyUniversity Hospital ZurichUniversity of ZurichZurichSwitzerland
| | - T. Hermanns
- Department of UrologyUniversity Hospital ZurichUniversity of ZurichZurichSwitzerland
| | - P. Sasieni
- Faculty of Life Sciences & MedicineSchool of Cancer & Pharmaceutical SciencesInnovation HubGuys Cancer CentreGuys HospitalKing's College LondonLondonUK
| | - J. D. Kelly
- Division of Surgery & Interventional ScienceUniversity College LondonLondonUK
- Department of UrologyUniversity College London HospitalLondonUK
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Bolenz C, Schröppel B, Eisenhardt A, J. Schmitz-Dräger B, Grimm MO. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:192-193. [PMID: 31014454 PMCID: PMC6503176 DOI: 10.3238/arztebl.2019.0192b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Christian Bolenz
- *Klinik für Urologie und Kinderurologie, Universitätsklinikum Ulm
| | - Bernd Schröppel
- **Klinik für Innere Medizin 1, Sektion Nephrologie, Universitätsklinikum Ulm
| | - Andreas Eisenhardt
- ***Praxisklinik Urologie Rhein Ruhr, Mühlheim an der Ruhr Klinik für Urologie, Kinderurologie und Uroonkologie, Universitätsklinikum Essen
| | - Bernd J. Schmitz-Dräger
- ****Sektion Urologische Onkologie, Urologische Klinik St. Theresienkrankenhaus, Nürnberg und Urologische Klinik und Kinderklinik der Universität Erlangen
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Schulz GB, Gresser EK, Casuscelli J, Strittmatter F, Tritschler S, Karl A, Stief CG, Nörenberg D. [Value of imaging in upper urinary tract tumors]. Urologe A 2019; 58:5-13. [PMID: 30617530 DOI: 10.1007/s00120-018-0828-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Staging of bladder cancer, hematuria as well as the evaluation of unclear findings of the kidneys and ureters are the most frequent indications for imaging of the upper urinary tract (UUT). Endourological assessment of the UUT is much more invasive compared to imaging of the bladder, raising the question of the optimal imaging technique. Several technical improvements regarding computed tomography (CT) as well as magnetic resonance imaging (MRI) were implemented in recent years. OBJECTIVES To compare the efficacy and limitations of the most important imaging techniques regarding the UUT. MATERIALS AND METHODS Systematic review of the literature and current German, European, and American guidelines regarding bladder cancer, urothelial carcinoma of the UUT and hematuria. RESULTS The CT-based urography has superseded excretory urography and is the first choice for imaging of the UUT. In case of contraindications, MRI is a feasible alternative. In all cases, a urography phase is indispensable. CONCLUSIONS Imaging of the UUT has to be used in a reasonable combination together with endourological methods and cytology. Optical coherence tomography, confocal laser endomicroscopy and scientific innovations such as radiomics might improve UUT imaging and differential diagnosis of UUT lesions in the future.
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Affiliation(s)
- G B Schulz
- Urologische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - E K Gresser
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - J Casuscelli
- Urologische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - F Strittmatter
- Urologische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - S Tritschler
- Urologische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - A Karl
- Urologische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - C G Stief
- Urologische Klinik und Poliklinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - D Nörenberg
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, München, Deutschland
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Tan WS, Sarpong R, Khetrapal P, Rodney S, Mostafid H, Cresswell J, Watson D, Rane A, Hicks J, Hellawell G, Davies M, Srirangam SJ, Dawson L, Payne D, Williams N, Brew‐Graves C, Feber A, Kelly JD. Does urinary cytology have a role in haematuria investigations? BJU Int 2019; 123:74-81. [PMID: 30003675 PMCID: PMC6334509 DOI: 10.1111/bju.14459] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the diagnostic accuracy of urinary cytology to diagnose bladder cancer and upper tract urothelial cancer (UTUC) as well as the outcome of patients with a positive urine cytology and normal haematuria investigations in patients in a multicentre prospective observational study of patients investigated for haematuria. PATIENT AND METHODS The DETECT I study (clinicaltrials.gov NCT02676180) recruited patients presenting with haematuria following referral to secondary case at 40 hospitals. All patients had a cystoscopy and upper tract imaging (renal bladder ultrasound [RBUS] and/ or CT urogram [CTU]). Patients, where urine cytology were performed, were sub-analysed. The reference standard for the diagnosis of bladder cancer and UTUC was histological confirmation of cancer. A positive urine cytology was defined as a urine cytology suspicious for neoplastic cells or atypical cells. RESULTS Of the 3 556 patients recruited, urine cytology was performed in 567 (15.9%) patients from nine hospitals. Median time between positive urine cytology and endoscopic tumour resection was 27 (IQR: 21.3-33.8) days. Bladder cancer was diagnosed in 39 (6.9%) patients and UTUC in 8 (1.4%) patients. The accuracy of urinary cytology for the diagnosis of bladder cancer and UTUC was: sensitivity 43.5%, specificity 95.7%, positive predictive value (PPV) 47.6% and negative predictive value (NPV) 94.9%. A total of 21 bladder cancers and 5 UTUC were missed. Bladder cancers missed according to grade and stage were as follows: 4 (19%) were ≥ pT2, 2 (9.5%) were G3 pT1, 10 (47.6%) were G3/2 pTa and 5 (23.8%) were G1 pTa. High-risk cancer was confirmed in 8 (38%) patients. There was a marginal improvement in sensitivity (57.7%) for high-risk cancers. When urine cytology was combined with imaging, the diagnostic performance improved with CTU (sensitivity 90.2%, specificity 94.9%) superior to RBUS (sensitivity 66.7%, specificity 96.7%). False positive cytology results were confirmed in 22 patients, of which 12 (54.5%) had further invasive tests and 5 (22.7%) had a repeat cytology. No cancer was identified in these patients during follow-up. CONCLUSIONS Urine cytology will miss a significant number of muscle-invasive bladder cancer and high-risk disease. Our results suggest that urine cytology should not be routinely performed as part of haematuria investigations. The role of urine cytology in select cases should be considered in the context of the impact of a false positive result leading to further potentially invasive tests conducted under general anaesthesia.
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Affiliation(s)
- Wei Shen Tan
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
- Department of UrologyUniversity College London HospitalLondonUK
| | - Rachael Sarpong
- Surgical and Interventional Trials UnitUniversity College LondonLondonUK
| | - Pramit Khetrapal
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
- Department of UrologyUniversity College London HospitalLondonUK
| | - Simon Rodney
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
- UCL Cancer InstituteLondonUK
| | - Hugh Mostafid
- Department of UrologyRoyal Surrey County HospitalGuildfordUK
| | - Joanne Cresswell
- Department of UrologyJames Cook University HospitalMiddlesbroughUK
| | - Dawn Watson
- Department of UrologyJames Cook University HospitalMiddlesbroughUK
| | - Abhay Rane
- Department of UrologyEast Surrey HospitalRedhillUK
| | - James Hicks
- Department of UrologyWorthing HospitalWorthingUK
| | | | - Melissa Davies
- Department of UrologySalisbury District HospitalSalisburyUK
| | | | | | - David Payne
- Department of UrologyKettering General HospitalKetteringUK
| | - Norman Williams
- Surgical and Interventional Trials UnitUniversity College LondonLondonUK
| | - Chris Brew‐Graves
- Surgical and Interventional Trials UnitUniversity College LondonLondonUK
| | - Andrew Feber
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
- UCL Cancer InstituteLondonUK
| | - John D. Kelly
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
- Department of UrologyUniversity College London HospitalLondonUK
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