Does urinary cytology have a role in haematuria investigations?

Evaluation of URO17® to improve non-invasive detection of bladder cancer

BACKGROUND

The gold standard for detecting bladder cancer is cystoscopy with biopsy or transurethral resection confirming histologic diagnosis. URO17® employs a chromogenically labeled monoclonal antibody to keratin 17 (k17), an intermediate filament cytoskeleton molecule associated with bladder, pancreatic, and cervical cancers. Preliminary studies evaluating k17 demonstrated a high sensitivity and specificity for the detection of bladder cancer, supporting the need for further study.

OBJECTIVE

To evaluate the sensitivity and specificity of URO17.

METHODS

This is a cross-sectional study of participants undergoing urologic procedures between July 6, 2018 and July 17, 2019 at a single institution. Patients undergoing cystectomy, endoscopic bladder and/or upper tract procedure for probable urothelial carcinoma comprised cases; patients undergoing urologic procedures for other reasons comprised the control group (i.e. prostatectomy, nephrectomy, etc.). Voided urine samples were at the time of procedure; a minority of participants underwent multiple resections in the study period, thus, as many as three urine samples were taken from any given participant. Samples were distributed for blinded testing with URO17. Sensitivity and specificity were calculated.

RESULTS

In 152 participants and 167 samples, URO17 demonstrated an overall sensitivity of 90% and 92% and a specificity of 88% and 87%, respectively. In 76 participants and 91 samples from patients with suspected urothelial carcinoma, the sensitivity was 90% and 92%, and the specificity was 50% and 54%, respectively. No controls demonstrated a positive URO17 result, and URO17 superseded urine cytology detection of low-grade and high-grade Ta. False positive results were associated with inflamed tissue or urothelial atypia on histology; the large majority had a history of intravesical therapy.

CONCLUSION

Limitations include cross-sectional design and convenience sampling. URO17 may improve sensitivity of urine cytology in the detection of urothelial cancer, though further study is required to refine the application of this biomarker in clinical practice.

Development and validation of an artificial intelligence-based model for detecting urothelial carcinoma using urine cytology images: a multicentre, diagnostic study with prospective validation

Background

Urine cytology is an important non-invasive examination for urothelial carcinoma (UC) diagnosis and follow-up. We aimed to explore whether artificial intelligence (AI) can enhance the sensitivity of urine cytology and help avoid unnecessary endoscopy.

Methods

In this multicentre diagnostic study, consecutive patients who underwent liquid-based urine cytology examinations at four hospitals in China were included for model development and validation. Patients who declined surgery and lacked associated histopathology results, those diagnosed with rare subtype tumours of the urinary tract, or had low-quality images were excluded from the study. All liquid-based cytology slides were scanned into whole-slide images (WSIs) at 40 × magnification and the WSI-labels were derived from the corresponding histopathology results. The Precision Urine Cytology AI Solution (PUCAS) was composed of three distinct stages (patch extraction, features extraction, and classification diagnosis) and was trained to identify important WSI features associated with UC diagnosis. The diagnostic sensitivity was mainly used to validate the performance of PUCAS in retrospective and prospective validation cohorts. This study is registered with the ChiCTR, ChiCTR2300073192.

Findings

Between January 1, 2018 and October 31, 2022, 2641 patients were retrospectively recruited in the training cohort, and 2335 in retrospective validation cohorts; 400 eligible patients were enrolled in the prospective validation cohort between July 7, 2023 and September 15, 2023. The sensitivity of PUCAS ranged from 0.922 (95% CI: 0.811-0.978) to 1.000 (0.782-1.000) in retrospective validation cohorts, and was 0.896 (0.837-0.939) in prospective validation cohort. The PUCAS model also exhibited a good performance in detecting malignancy within atypical urothelial cells cases, with a sensitivity of over 0.84. In the recurrence detection scenario, PUCAS could reduce 57.5% of endoscopy use with a negative predictive value of 96.4%.

Interpretation

PUCAS may help to improve the sensitivity of urine cytology, reduce misdiagnoses of UC, avoid unnecessary endoscopy, and reduce the clinical burden in resource-limited areas. The further validation in other countries is needed.

Funding

National Natural Science Foundation of China; Key Program of the National Natural Science Foundation of China; the National Science Foundation for Distinguished Young Scholars; the Science and Technology Planning Project of Guangdong Province; the National Key Research and Development Programme of China; Guangdong Provincial Clinical Research Centre for Urological Diseases.

Enzyme-labeled liquid-based cytology (ELLBC): a new noninvasive diagnostic method for bladder cancers

BACKGROUND

Based on liquid-based cytology, we performed an enzyme histochemical staining using acid phosphatase as a marker and termed it ELLBC. The aim of this study was to investigate the value of ELLBC in the diagnosis of bladder cancer.

METHODS

Fifty patients who were initially diagnosed with suspected bladder cancers (hematuria or bladder irritation symptoms, urinary ultrasound suggestive of bladder mass) at the Second Affiliated Hospital of Anhui Medical University (Anhui, China) from January 2022 to December 2022 were selected as the study subjects, all of whom underwent ELLBC, CC, and histopathology Histopathology was used as the gold standard to calculate the diagnostic efficacy of ELLBC, CC and ELLBC combined with CC in bladder cancer.

RESULTS

Histopathological examination revealed 35 positive cases in 50 patients, including 15 cases of high-grade uroepithelial carcinoma (HGUC) and 20 cases of low-grade uroepithelial carcinoma (LGUC.) The sensitivity of ELLBC was 82.86%, the specificity was 93.33%, the positive predictive value (PPV) was 96.67%, the negative predictive value (NPV) was 70.00%, and the accuracy was 86.00%; CC had a sensitivity of 37.14%, specificity of 80.00%, PPV of 81.25%, NPV of 35.29%, and accuracy of 50%; ELLBC combined with CC had a sensitivity of 88.57%, specificity of 73.33%, PPV of 88.57%, NPV of 73.33%, and accuracy of 84.00%. The sensitivity and specificity of ELLBC were higher than that of CC, and the difference was statistically significant (p < 0.05), ELLBC combined with CC achieved higher sensitivity, but the diagnostic accuracy decreased. For clinical staging, the diagnostic accuracy was 86.36% for ELLBC and 40.91% for CC in patients in Stage I, and 90.91% for ELLBC and 36.36% for CC in patients in Stage II.

CONCLUSION

ELLBC has high clinical application value for the diagnosis of bladder cancer and can provide new options and methods for the early screening of bladder cancer.

Highly Sensitive and Specific Detection of Bladder Cancer via Targeted Ultra-deep Sequencing of Urinary DNA

BACKGROUND

There is an unmet need for an accurate, validated, noninvasive test for diagnosing and monitoring bladder cancer (BC). Detection of BC-associated mutations in urinary DNA via targeted deep sequencing could meet this need.

OBJECTIVE

To test the ability of mutational analysis of urinary DNA to noninvasively detect BC within the context of haematuria investigations and non-muscle-invasive BC (NMIBC) surveillance.

DESIGN, SETTING, AND PARTICIPANTS

Capture-based ultra-deep sequencing was performed for 443 somatic mutations in 23 genes in 591 urine cell-pellet DNAs from haematuria clinic patients and 293 from NMIBC surveillance patients. Variant calling was optimised to minimise false positives using urine samples from 162 haematuria clinic patients without BC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The sensitivity and specificity for BC diagnosis were determined.

RESULTS AND LIMITATIONS

Mutational analysis of urinary DNA detected 144 of the 165 haematuria patients diagnosed with incident BC from two independent cohorts, yielding overall sensitivity of 87.3% (95% confidence interval [CI] 81.2-92.0%) at specificity of 84.8% (95% CI 79.9-89.0%). The sensitivity was 97.4% for grade 3, 86.5% for grade 2, and 70.8% for grade 1 BC. Among NMIBC surveillance patients, 25 out of 29 recurrent BCs were detected, yielding sensitivity of 86.2% (95% CI 70.8-97.7%) at specificity of 62.5% (95% CI 56.1-68.0%); a positive urine mutation test in the absence of clinically detectable disease was associated with a 2.6-fold increase in the risk of future recurrence. The low number of recurrences in the NMIBC surveillance cohort and the lower sensitivity for detecting grade 1 pTa BC are limitations.

CONCLUSIONS

Detection of mutations in a small panel of BC-associated genes could facilitate noninvasive BC testing and expedite haematuria investigations. Following further validation, the test could also play a role in NMIBC surveillance.

PATIENT SUMMARY

Identification of alterations in genes that are frequently mutated in bladder cancer appears to be a promising strategy for detecting disease from urine samples and reducing reliance on examination of the bladder via a telescopic camera inserted through the urethra.

Urine exosomes as biomarkers in bladder cancer diagnosis and prognosis: From functional roles to clinical significance

Bladder cancer is one of the top ten most common cancers and top ten causes of cancer death globally. 5-year survival rates have decreased in Australia from 66% to 55% in the past three decades. The current gold standard for diagnosis is cystoscopy. However, cystoscopies are an invasive and health-resource intensive procedure which has sub-optimal sensitivity for flat lesions such as CIS (carcinoma in situ) and low specificity for differentiating inflammation from cancer - hence requiring biopsies under anesthesia. Frequent and life-long surveillance cystoscopy is required for most patients since there are high rates of progression and local recurrence in high-risk non-muscle invasive cancer (NMIBC) as well as poor outcomes associated with delayed detection of muscle-invasive bladder cancer (MIBC). There is an unmet need for a non-invasive test to provide better discrimination and risk-stratification of bladder cancer which could aid clinicians by improving patient selection for cystoscopy; enhanced risk stratification methods may guide the frequency of surveillance cystoscopies and inform treatment choices. Exosomes, which are nano-sized extracellular vesicles containing genetic material and proteins, have been shown to have functional roles in the development and progression of bladder cancer. Exosomes have also been demonstrated to be a robust source of potential biomarkers for bladder cancer diagnosis and prognosis and may also have roles as therapeutic agents. In this review, we summarize the latest evidence of biological roles of exosomes in bladder cancer and highlight their clinical significance in bladder cancer diagnosis, surveillance and treatment.

[How has the Paris System contributed to urine cytology? Evaluating the contribution of the Paris System to urine cytology. A comparative study of the Paris System and the Papanicolaou method in a tertiary centre]

INTRODUCTION AND OBJECTIVES

The Paris System (PS) has replaced the classical Papanicolaou System (PapS) in reporting urine cytology, due to its improved sensitivity and negative predictive value (NPV) without loss of specificity. Furthermore, it has enabled the risk of malignancy to be established in each cytological category. The aim of this study is to compare the Paris System with previous results and determine the changes in sensitivity, specificity, positive predictive value, NPV and risk of malignancy in our centre, MATERIALS AND METHODS: Evaluation of the diagnostic power of urine cytology by means of a retrospective cohort study, comparing two series of 400 cytological studies, one using the Papanicolaou System and the other the Paris System.

RESULTS

In the detection of high-grade urothelial carcinoma, Paris System has better specificity (93.82% PapS vs 98.64% PS; P=.001) and PPV (39.5% PapS vs 70.6% PS; P=.044) than Papanicolaou System, without changes in sensitivity (53.5% PapS vs 37.5% PS; P=.299) or NPV (96.4% PapS vs 94.8% PS; P=.183). The risk of malignancy for the atypical category increases from low to high levels (1.6% PapS vs 40.0% PS; P=.001); the other categories showed no significant statistical changes.

CONCLUSION

The Paris System improves specificity and positive predictive value and establishes a better indication of risk of malignancy for each category, enabling specific clinical management in each case.

Performance characteristics of urinary cytology in patients presenting with gross and microscopic hematuria

PURPOSE

Hematuria investigations presently entail cystoscopy with upper urinary tract imaging albeit without use of urinary biomarkers including cytology. The purpose is to investigate the performance characteristics of urinary cytology in a population of patients presenting with gross (GH) and microscopic (MH) hematuria.

METHODS

Records for 409 consecutive patients undergoing a complete hematuria evaluation (cystoscopy with upper-tract imaging) who also had urinary cytology were reviewed. Performance characteristics (sensitivity, specificity, PPV, NPV) of cytology for urothelial malignancy were determined. For those with urothelial cancer, the predictive value of a positive cytology for high grade and high stage urothelial cancer was determined.

RESULTS

29 of 409 patients (7.1%) were diagnosed with urothelial carcinoma including 24 (9.2%) and 5 (3.4%) from the GH and MH populations, respectively. Eighteen (62%) of these tumors were high grade of which 5 (28%) were muscle-invasive. The performance characteristics of cytology for urothelial malignancy included a sensitivity of 41%, specificity of 99%, PPV of 75%, NPV of 96%, and diagnostic accuracy of 95%. No observed differences were noted when comparing gender (P=0.55), type of hematuria (P=0.37), or smoking history (P=0.22). For those diagnosed with urothelial malignancy, a positive cytology was not associated with higher grade (P=1.0) or stage tumors (P=0.62).

CONCLUSIONS

Urine cytology had low sensitivity and PPV for urothelial carcinoma irrespective of smoker status, hematuria type, or gender. These data support the 2020 AUA Microhematuria Guideline emphasizing that urine cytology should not routinely be used in a hematuria screening population.

Nurse‐led one stop hematuria clinic: Outcomes from 2,714 patients

Objectives

Objective of this study is to report the results of nurse led hematuria clinic service outcome of 2,714 patients.

Subjects and methods

We conducted a retrospective, single center review of 2714 patients with visible and nonvisible hematuria managed by a well‐trained nurse specialist in a rapid access clinic (RAC) between 2014 and 2020. All patients received a full review, flexible cystoscopy performed by a nurse, and ultrasound of urinary tracts. After investigations, patients were reassured and discharged or referred for rigid cystoscopy, TURBT, and CT urography.

Results

In total, 2714 patients attended the RAC between October 2014 and March 2020. Of these, 1684 (62%) were males and 1030 (38%) females. The median age of patients was 68.3 (IQR 58‐79). Of the 1030 females, 500 (48.5%) presented with nonvisible hematuria (NVH), and 530 (51.5%) presented with visible hematuria (VH). The median age was 66 (IQR 56‐76). The number of females diagnosed with any form of malignancy was 72 (7% of all females). Of the 1684 males, 288 (17.1%) presented with NVH, and 1396 (82.9%) presented with VH. The median age was 72 (IQR 59‐81). The number of males diagnosed with some form of malignancy was 258 (15.3% of all males). Overall, 1926 patients presented with VH and 788 patients presented with NVH. After investigations, 290 patients (15.1%) with VH and 40 (5.1%) patients with NVH had some form of malignancy. The highest number of malignancies found in VH was bladder cancer (n = 222, 11.5%), followed by prostate (n = 28, 1%), renal (n = 23, 0.8%), UT urothelial (n = 17, 0.6%), gynaecological (n = 7, 0.3%), and gastrointestinal (n = 5, 0.2%) cancer. The highest number of pathologies found in NVH was infection (n = 44, 5.6%). Cancer detection rate for symptomatic NVH was more than double that of asymptomatic NVH, 6.5% versus 3.1%, respectively.

Conclusion

Overall, 15.1% with VH and 5.1% with NVH present with malignancy. Nurse‐led rapid access hematuria clinic and flexible cystoscopy investigation by trained nurse is safe and feasible.

Urinary-based tumor markers enhance microhematuria risk stratification according to baseline bladder cancer prevalence

INTRODUCTION

The 2020 AUA microhematuria (MH) guideline stratifies patients into low, intermediate and high-risk for urologic malignancy based on established risk-factors for urothelial carcinoma. Notably, urine-based tumor markers (UBTMs) were not included in the risk classification. We evaluated the impact of incorporating UBTMs (cytology and multiple commercially available UBTMs) into this risk stratification.

METHODS

We performed a systematic review of performance characteristics of UBTMs for the detection of bladder cancer during hematuria evaluation, pooled the reported sensitivity and specificity, and calculated positive and negative likelihood ratios (LR). These were then applied to the estimated pre-test probability for the diagnosis for each AUA risk strata: low-risk 0.5%, intermediate-risk 1.0%, and high-risk (2%-3%) in order to calculate a post-test probability of bladder cancer in the event of a positive or negative test.

RESULTS

The pooled sensitivity for urinary cytology and commercially available UBTMs was 68% and 58%-95%, respectively while the specificity was estimated at 91% and 34%-90%, respectively. The positive LRs of UBTMs ranged from 2.1-7.67 and negative LRs ranged from 0.07-0.48. A negative UBTM was associated with a post-test probability of cancer for low, intermediate, and high-risk patients of 0-0.2%, 0.2%-0.5%, and 0.4%-1.1%, respectively. In the setting of a positive UBTM, the post-test probability of cancer for low, intermediate, and high-risk patients was 1.1%-3.7%, 2.1%-7.8%, 4.2%-19.2%, respectively.

CONCLUSION

Pending prospective validation, UBTMs may be able to enhance risk stratification and inform shared decision-making over clinical factors alone and allow for re-classification of patients into higher or lower risk categories.

[Abnormal urine color assessment: The urine wheel]

Looking at the urine for diagnostic purposes, once performed by ancient Egyptians, can still provide some valuable clues in modern medicine. Several diseases have been named after their associated urine color and this underlines the clinical value of visual urine inspection: blue diaper disease, purple urine bag syndrome, black urine disease or porphyria. Abnormal urine color could be challenging for the clinician: it may reveal neoplastic disease (urologic cancer; melanoma), cell lysis (rhabdomyolysis; hemolysis), infection (lymphatic filariasis; malaria), enzyme deficiency (porphyria; alkaptonuria), medication or food intake. In this article, we present the diagnostic approach, the mechanisms involved and the main causes of abnormal urine color.

Atypical cells parameter in Sysmex UN automated urine analyzer: feedback from the field

BACKGROUND

"Atypical cells" parameter in automated urinalysis has recently been introduced. An instrument capable of measuring quantitative and qualitative features of nuclear and cytoplasmic properties of a cell has the potential to detect cellular atypia. Instruments using flow cytometry have been detecting atypical cells in blood for a long time; yet instruments using the same methodology very lately developed this parameter in urinalysis.

MATERIALS AND METHODS

Samples with an atypical cells value higher than 1 atypical cell/µL were included in the study. Besides automated urinalysis, every sample was reflexed to modular unit for digital imaging. The remainder of each sample was stained with Sternheimer dye and examined manually under a light microscope.

RESULTS

50 samples with higher than1 atypical cell/µL result were included in the study. Patients were composed of 43 females (86 %) and 7 males (14 %). The mean age was 47.12 ± 19.45 years. The median atypical cells value was 1.8/µL (95 % range 1.5-2.4/µL). Manual microscopic evaluation of the 50 samples showed atypical cells in 1 sample. The patient had papillary lesions on cystoscopy and pathology report informed a high grade urothelial carcinoma. Other 49 samples were negative for atypical cells in manual microscopy. They were crowded samples with leucocytes and squamous epithelial cells.

CONCLUSIONS

The positive case provided evidence for Sysmex UN's capability to detect atypical cells in urine. The negative cases presented clues that probable vulvovaginal contamination and crowded specimens could be deceptive for Sysmex UN in this particular parameter.

A Diagnostic Nomogram of Pathologic Grade for Preoperative Risk Stratification in Upper Tract Urothelial Carcinoma

Background:

To develop a novel nomogram to improve the preoperative diagnosis of pathological grade of upper tract urothelial carcinoma (UTUC).

Methods:

Retrospective study was conducted with 245 patients with UTUC treated by radical nephroureterectomy from 2002 to 2016. Of the cohort, 57.6% received ureteroscopic (URS) biopsy and 35.9% received urine cytology examination. Preoperative clinical characteristics and examination results were collected. Final pathological grade was diagnosed by postoperative pathology. Univariable and multivariable binary logistic regressions were applied to establish a preoperative predictive model for tumor grade, and significant factors were included in the nomogram. The area under curve (AUC) was used to show the predictive efficacy, and the calibration plot was drawn for validation.

Results:

Of the 245 patients, 72.7% were diagnosed with pathological high-grade disease. Age (odds ratio [OR] = 1.03, P = .039), sessile (OR = 3.86, P = .021), positive urinary cytology (OR = 6.87, P = .035), and biopsy high-grade result (OR = 10.85, P < .001) were independent predictors for pathological high-grade disease. The predictive nomogram containing these factors achieved an AUC of 0.78, which was significantly better than URS biopsy alone (AUC = 0.62, P = .003) in the whole cohort. In the URS biopsy subgroup, the nomogram achieved an AUC of 0.79, better than biopsy alone (AUC = 0.76), but was not statistically significant (P = .431). When the cutoff value of the nomogram was set at 0.64, the sensitivity of detecting a high-grade lesion versus low-grade lesion was 80.3%, better than that of URS biopsy alone (sensitivity = 65.7%).

Conclusions:

Advanced age, sessile, positive urinary cytology, and biopsy high-grade were independent predictors of pathological high-grade disease in patients with UTUC. A nomogram containing these factors can improve diagnostic accuracy, potentially reducing the risk of “undergrading” by URS biopsy.

Using adaptive genetic algorithms combined with high sensitivity single cell-based technology to detect bladder cancer in urine and provide a potential noninvasive marker for response to anti-PD1 immunotherapy

OBJECTIVE

To use adaptive genetic algorithms (AGA) in combination with single-cell flow cytometry technology to develop a noninvasive test to detect bladder cancer.

MATERIALS AND METHODS

Fifty high grade, cystoscopy confirmed, superficial bladder cancer patients, and 15 healthy donor early morning urine samples were collected in an optimized urine collection media. These samples were then used to develop an assay to distinguish healthy from cancer patients' urine using AGA in combination with single-cell flow cytometry technology. Cell recovery and test performance were verified based on cystoscopy and histology for both bladder cancer determination and PD-L1 status.

RESULTS

Bladder cancer patients had a significantly higher percentage of white blood cells with substantial PD-L1 expression (P< 0.0001), significantly increased post-G1 epithelial cells (P < 0.005) and a significantly higher DNA index above 1.05 (P < 0.05). AGA allowed parameter optimization to differentiate normal from malignant cells with high accuracy. The resulting prediction model showed 98% sensitivity and 87% specificity with a high area under the ROC value (90%).

CONCLUSIONS

Using single-cell technology and machine learning; we developed a new assay to distinguish bladder cancer from healthy patients. Future studies are planned to validate this assay.

Keratin 17 is a sensitive and specific biomarker of urothelial neoplasia

There is a clinical need to identify novel biomarkers to improve diagnostic accuracy for the detection of urothelial tumors. The current study aimed to evaluate keratin 17 (K17), an oncoprotein that drives cell cycle progression in cancers of multiple anatomic sites, as a diagnostic biomarker of urothelial neoplasia in bladder biopsies and in urine cytology specimens. We evaluated K17 expression by immunohistochemistry in formalin-fixed, paraffin embedded tissue specimens of non-papillary invasive urothelial carcinoma (UC) (classical histological cases), high grade papillary UC (PUC-LG), low grade papillary UC (PUC-HG), papillary urothelial neoplasia of low malignant potential (PUNLMP), and normal bladder mucosa. A threshold was established to dichotomize K17 status in tissue specimens as positive vs. negative, based on the proportion of cells that showed strong staining. In addition, K17 immunocytochemistry was performed on urine cytology slides, scoring positive test results based on the detection of K17 in any urothelial cells. Mann-Whitney and receiver operating characteristic analyses were used to compare K17 expression between histologic diagnostic categories. The median proportion of K17 positive tumor cells was 70% (range 20-90%) in PUNLMP, 30% (range 5-100%) in PUC-LG, 20% (range 1-100%), in PUC-HG, 35% (range 5-100%) in UC but staining was rarely detected (range 0-10%) in normal urothelial mucosa. Defining cases in which K17 was detected in ≥10% of cells were considered positive, the sensitivity of K17 in biopsies was 89% (95% CI: 80-96%) and the specificity was 88% (95% CI: 70-95%) to distinguish malignant lesions (PUC-LG, PUC-HG, and UC) from normal urothelial mucosa. Furthermore, K17 immunocytochemistry had a sensitivity of 100% and a specificity of 96% for urothelial carcinoma in 112 selected urine specimens. Thus, K17 is a sensitive and specific biomarker of urothelial neoplasia in tissue specimens and should be further explored as a novel biomarker for the cytologic diagnosis of urine specimens.

Development and validation of a haematuria cancer risk score to identify patients at risk of harbouring cancer

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.