Is it necessary to perform urine cytology in screening patients with haematuria?

Prevalence of prostate cancer in men with haematuria: a systematic review and meta-analysis

OBJECTIVES

To investigate the prevalence of prostate cancer in men attending evaluation for haematuria, as this could help healthcare providers to determine whether men with haematuria should have prostate examinations performed.

METHODS

The study was performed according to a pre-specified protocol uploaded to the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022299383). A systematic search of MEDLINE, Ovid and Google Scholar was performed in December 2021. Two independent researchers evaluated all titles, available abstracts, and full texts. We included studies on adult men (aged ≥18 years) describing haematuria and prostate cancer.

RESULTS

We screened 4252 titles and abstracts when available and assessed 350 studies in full text. In total, 65 studies were included and 42 was summarised in a meta-analysis. In total, 18 752 men with haematuria were included, and the pooled prevalence (95% confidence interval [CI]) of prostate cancer was 3.0% (2.0-4.1%). In men with macroscopic haematuria, the pooled prevalence (95% CI) of prostate cancer was 5.9% (2.9-9.9%; n = 265/5373). In men with microscopic haematuria, the pooled prevalence (95% CI) of prostate cancer was 1.4% (0.8-2.2%; n = 71/6642).

CONCLUSION

Our findings indicate that the prevalence of prostate cancer is considerable in men attending evaluation for haematuria. Therefore, digital rectal examination and prostate-specific antigen measurement should become a standard procedure for all men with haematuria, especially for men with macroscopic haematuria.

The role of chemotherapy in upper tract urothelial carcinoma

Locally advanced upper tract urothelial carcinoma has a poor prognosis. While surgery represents the only potentially curable therapeutic intervention, recurrences are common and typically systemic in nature. It is thus reasonable to consider perioperative chemotherapy in an effort to decrease the risk of recurrence. There are very little direct data providing clinical guidance in this scenario. For urothelial cancer of the bladder, there are randomized phase III data demonstrating a survival advantage with neoadjuvant cisplatin-based combination chemotherapy. Although arguments favoring adjuvant chemotherapy could be made for upper tract urothelial cancer, the loss of renal function that occurs with nephrectomy can complicate administration of appropriate perioperative treatment. Therefore, by analogy to urothelial carcinoma of the lower tract, it is argued that cisplatin-based neoadjuvant chemotherapy should be the standard of care for patients with locally advanced upper tract urothelial cancer.

[Imaging capabilities in upper urothelial malignancies differentiation]

Aim of our study is to analyze sensitivity and specificity of imaging procedures in characterization upper urothelial malignancies, according to algorithm suggested by American Urology Association.

MATERIAL AND METHODS

We analyzed 242 patients with kidney tumor masses who had been operated during 2006/2007 at Urological clinic in Belgrade. Due to pathohistological exam 210 patients had kidney parenchyma and 32 patients upper urothelial kidney tumor.

RESULTS

According to tumor stage, computed tomography was sufficient and definitive diagnostic tool concerning both renal epithelial and upper urothelial malignancy. Only in four cases 1.60% (4/242; CT in 3/4, MRI 1/4) preoperative site of origin was different from histopathology findings. This mislead to inappropriate surgery plan.

CONCLUSION

Familiarity with limitations and capabilities of imaging modalities is crucial for appropriate diagnosis. It should respect algorithm but has to be individual adapted.

Best practice in primary care pathology: review 2

This second best practice review examines five series of common primary care questions in laboratory medicine: (1) laboratory testing for allergy, (2) diagnosis and monitoring of menopause, (3) the use of urine cytology, (4) the usefulness of the erythrocyte sedimentation rate, and (5) the investigation of possible urinary tract infection. The review is presented in a question-answer format. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents, and evidence based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are standards but form a guide to be set in the clinical context. Most are consensus rather than evidence based. They will be updated periodically to take account of new information.

A prospective analysis of the diagnostic yield resulting from the attendance of 4020 patients at a protocol-driven haematuria clinic

OBJECTIVE

To clarify the prevalence of disease as determined by age, sex and the degree of haematuria at presentation, and to ascertain the merits of using ultrasonography (US), i.v. urography (IVU) or both when imaging the upper urinary tract, in a prospective cohort of patients attending a protocol-based haematuria clinic.

PATIENTS AND METHODS

In a two-tier protocol, as a part of first-line investigation, all 4020 patients attending the clinic between October 1998 and August 2003 had US and flexible cystoscopy. Subsequently, IVU was used where indicated following abnormal first-line tests and in patients with persistent haematuria where no abnormality had been detected.

RESULTS

In all, 2627 men and 1393 women presented with microscopic (53.2%) or macroscopic haematuria (46.8%). The overall prevalence of malignant disease was 12.1%, but for macroscopic haematuria it was 18.9% and for microscopic haematuria 4.8%. Age and sex also influenced the observed rates of disease. Of the upper tract tumours, 70 were identified after abnormal US, with three cases of transitional cell carcinoma identified on IVU after a normal US.

CONCLUSIONS

The study provides a rationale for the appropriate investigation of all patients, moderated by the age, sex and degree of haematuria, and the ubiquitous use of US with selective IVU based on age, sex and degree of (and persistence of) haematuria.

The usefulness of urinary cytology testing in the evaluation of irritative voiding symptoms

OBJECTIVE

The purpose of this study was to assess the clinical usefulness of urinary cytology testing for the evaluation of urothelial cancer in women with irritative voiding symptoms who were examined at a urogynecology service.

STUDY DESIGN

Urinary cytology studies results that were obtained from January 1, 2000, to December 31, 2002, were cross-matched with the Rhode Island Department of Health Cancer Registry to identify those women who were diagnosed with urinary tract malignancies. The prevalence of urothelial cancer was determined, and the sensitivity, specificity, and positive and negative predictive values of urinary cytologic testing were calculated for 2 common classification strategies: (1) consideration of atypical cytologic test results to be normal and (2) consideration of atypical cytologic test results to be abnormal.

RESULTS

Among 1516 cross-matched cytologic test results from 1324 patients, 5 urothelial cancers were identified. Two of the 5 malignancies were associated with positive cytology results. The prevalence of urothelial cancer was 0.38% (95% CI, 0.1%, 0.9%). When atypical cytology studies were classified as normal, the sensitivity of urinary cytology was 40% (95% CI, 7.2%, 83.0%); the specificity was 99.9% (95% CI, 99.5%, 100%); the positive predictive value was 66.7% (95% CI, 12.5%, 98.2%), and negative predictive value was 99.8% (95% CI, 99.2%, 100%). In contrast, when atypical cytology results were classified as abnormal, the sensitivity and negative predictive value remained the same, but the specificity declined to 93.6% (95% CI, 92.1%, 94.8%), and the positive predictive value decreased to 2.3% (95% CI, 0.4%, 8.8%).

CONCLUSION

The low prevalence of urothelial cancers and low sensitivity of urinary cytology studies severely limit the usefulness of this test in the evaluation of women with irritative voiding symptoms.

Suspicious urinary cytology with negative evaluation for malignancy in the diagnostic investigation of haematuria: how to follow up?

AIMS

To define the natural history of patients with suspicious urinary cytology and negative initial evaluation for malignancy in the investigation of haematuria.

PATIENTS AND METHODS

Data from the hospital information support system on urinary cytology examinations carried out at one centre were audited over a period of 24 months. There were 102 patients who had suspicious urinary cytology for malignant cells with negative initial evaluation. Follow up investigations, treatment, and final outcome were noted.

RESULTS

There were 102 patients with suspicious urinary cytology and negative initial evaluation for malignancy in 24 months, with a mean follow up of 15.7 months. Seventy patients had no obvious pathology on initial investigations. Forty one patients were found to have urological malignancies (29 bladder, eight ureteric, and four prostate) on follow up. All patients diagnosed as having urothelial malignancies on follow up had either persistent suspicious cytology (29) or recurrent haematuria (eight). The mean duration for appearance of lesions was 5.6 months (range, 3-12 months). Three patients had suspicious digital rectal examination and biopsies confirmed adenocarcinoma of the prostate. One patient had urinary retention and transurethral resection of prostate showed prostatic adenocarcinoma. The presence of suspicious cells on repeat urine analysis was the only significant factor in predicting the presence of urothelial tumours (p = 0.002).

CONCLUSION

Patients with persistent suspicious/positive cytology or recurrent haematuria need further evaluation and follow up. Asymptomatic patients or patients with obvious benign pathology do not require repeat evaluation. Careful urological evaluation, including prostate, should be carried out in these patients.

How reliable is conventional urinary cytology in post-transplant patients?

INTRODUCTION AND OBJECTIVES

Factors like cold, flushing solutions, ischemia and reperfusion may alter the microscopic appearance of transitional cells leading to falsely positive results of urinary cytology in patients after kidney transplantation. After seeing 1 patient presenting with two consecutive highly suspicious cytology specimens 3 days after transplantation and no sign of urothelial tumor at retrograde urography, we analyzed the cytological picture of transitional cells in post-transplant patients.

MATERIAL AND METHODS

We investigated 31 urine specimens of 11 patients undergoing kidney transplantation preoperatively (if possible) and on days 1, 3 and 9 postoperatively. Microscopic cytology was performed by using Papanicolaou's criteria: 0 - no cytology possible (no cells), I+II - negative cytology, III - doubtful, IV - suspicious for tumor, V - tumor cells. All microscopic examinations were performed by one experienced senior pathologist.

RESULTS

Mean patient age was 55.8 (+/- 17.5) years, mean residual diuresis 856 (+/- 636) ml, mean cold ischemia time 13.6 (+/- 6.4) h, mean creatinine level on day 1: 582 microM/l, day 3: 533 microM/l and day 9: 259 microM/l. None of the urinary cytology results were suspicious for malignant transformation (Papanicolaou I+II). No patient presented signs of urothelial malignancy after a mean follow-up of 3 months.

CONCLUSION

Although microscopic urinary cytology may be falsely positive in 1-12% of non-transplanted patients due to urothelia atypia, inflammation or radiation/chemotherapy, the present study suggests that conventional microscopic cytology examinations in post-transplant patients are not heavily altered and do not lead to an increased false-positive rate.

Imaging for microscopic haematuria

For evaluation of the upper urinary tract, intravenous urography has for many years been the method of choice. In recent years, different imaging protocols have been suggested. In this article different strategies for the evaluation of microscopic haematuria, with a focus on the advantages and disadvantages of different imaging modalities, will be discussed.

Can biological markers replace cystoscopy? An update

Cystoscopy is currently considered the gold standard for the detection of bladder tumors. The role of urine cytology in the initial detection and follow-up of patients is under discussion. New elaborative and rapid assays are available that may circumvent the low sensitivity and poor reproducibility of urine cytology. The methods that have been tested extensively are the nuclear matrix protein (NMP22) assay, the BTA stat assay, and the BTA TRAK enzyme-linked immunosorbent assay. Both outperform cytology in the detection of low-grade lesions. The specificity of both assays, however, lags behind that of cytology. The data from retrospective analyses are insufficient to justify clinical integration, and the need to replace cystoscopy with these novel assays remains to be proven.