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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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Drożdż A, Duggan B, Ruddock MW, Reid CN, Kurth MJ, Watt J, Irvine A, Lamont J, Fitzgerald P, O’Rourke D, Curry D, Evans M, Boyd R, Sousa J. Stratifying risk of disease in haematuria patients using machine learning techniques to improve diagnostics. Front Oncol 2024; 14:1401071. [PMID: 38779086 PMCID: PMC11109371 DOI: 10.3389/fonc.2024.1401071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Background Detailed and invasive clinical investigations are required to identify the causes of haematuria. Highly unbalanced patient population (predominantly male) and a wide range of potential causes make the ability to correctly classify patients and identify patient-specific biomarkers a major challenge. Studies have shown that it is possible to improve the diagnosis using multi-marker analysis, even in unbalanced datasets, by applying advanced analytical methods. Here, we applied several machine learning algorithms to classify patients from the haematuria patient cohort (HaBio) by analysing multiple biomarkers and to identify the most relevant ones. Materials and methods We applied several classification and feature selection methods (k-means clustering, decision trees, random forest with LIME explainer and CACTUS algorithm) to stratify patients into two groups: healthy (with no clear cause of haematuria) or sick (with an identified cause of haematuria e.g., bladder cancer, or infection). The classification performance of the models was compared. Biomarkers identified as important by the algorithms were also analysed in relation to their involvement in the pathological processes. Results Results showed that a high unbalance in the datasets significantly affected the classification by random forest and decision trees, leading to the overestimation of the sick class and low model performance. CACTUS algorithm was more robust to the unbalance in the dataset. CACTUS obtained a balanced accuracy of 0.747 for both genders, 0.718 for females and 0.803 for males. The analysis showed that in the classification process for the whole dataset: microalbumin, male gender, and tPSA emerged as the most informative biomarkers. For males: age, microalbumin, tPSA, cystatin C, BTA, HAD and S100A4 were the most significant biomarkers while for females microalbumin, IL-8, pERK, and CXCL16. Conclusions CACTUS algorithm demonstrated improved performance compared with other methods such as decision trees and random forest. Additionally, we identified the most relevant biomarkers for the specific patient group, which could be considered in the future as novel biomarkers for diagnosis. Our results have the potential to inform future research and provide new personalised diagnostic approaches tailored directly to the needs of the individuals.
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Affiliation(s)
- Anna Drożdż
- Personal Health Data Science Group, Sano – Centre for Computational Personalised Medicine - International Research Foundation, Krakow, Poland
| | - Brian Duggan
- South Eastern Health and Social Care Trust, Ulster Hospital Dundonald, Belfast, United Kingdom
| | - Mark W. Ruddock
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - Cherith N. Reid
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - Mary Jo Kurth
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - Joanne Watt
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - Allister Irvine
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - John Lamont
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - Peter Fitzgerald
- Clinical Studies Group, Randox Laboratories Ltd., Co., Antrim, United Kingdom
| | - Declan O’Rourke
- Belfast Health and Social Care Trust, Belfast City Hospital, Belfast, United Kingdom
| | - David Curry
- Belfast Health and Social Care Trust, Belfast City Hospital, Belfast, United Kingdom
| | - Mark Evans
- Belfast Health and Social Care Trust, Belfast City Hospital, Belfast, United Kingdom
| | - Ruth Boyd
- Northern Ireland Clinical Trials Network, Belfast City Hospital, Belfast, United Kingdom
| | - Jose Sousa
- Personal Health Data Science Group, Sano – Centre for Computational Personalised Medicine - International Research Foundation, Krakow, Poland
- Centre for Public Health, Institute of Clinical Sciences, Queen’s University, Belfast, United Kingdom
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Abuhasanein S, Chaves V, Mohsen AM, Al‐Haddad J, Sunila M, Ströck V, Jerlström T, Liedberg F, Swärd J, Gårdmark T, Jahnson S, Kjölhede H. Diagnostic value of repeated comprehensive investigation with CT urography and cystoscopy for recurrent macroscopic haematuria. BJUI COMPASS 2024; 5:253-260. [PMID: 38371208 PMCID: PMC10869664 DOI: 10.1002/bco2.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/10/2023] [Accepted: 09/26/2023] [Indexed: 02/20/2024] Open
Abstract
Objectives To perform a descriptive analysis of a series of patients with recurrent macroscopic haematuria after a primary standard evaluation including computed tomography urography (CTU) and cystoscopy negative for urinary bladder cancer (UBC) and upper tract urothelial cancer (UTUC) and to identify potential factors associated with occurrence of recurrent macroscopic haematuria. Methods All patients older than 50 years who underwent urological investigation for macroscopic haematuria with both cystoscopy and CTU 2015-2017 were retrospectively reviewed. A descriptive analysis of the primary and later investigations for recurrent macroscopic haematuria was performed. To investigate the association between explanatory variables and the occurrence of recurrent macroscopic haematuria, a Poisson regression analysis was performed. Results A total of 1395 eligible individuals with primary standard investigation negative for UBC and UTUC were included. During a median follow-up of 6.2 (IQR 5.3-7) years, 248 (18%) patients had recurrent macroscopic haematuria, of whom six patients were diagnosed with UBC, two with prostate cancer, one with renal cell carcinoma and one had a suspected UTUC at the repeated investigation. Within 3 years, 148 patients (11%) experienced recurrent macroscopic haematuria, of whom two patients were diagnosed with low-grade UBC (TaG1-2), one with T2G3 UBC and one with low-risk prostate cancer. The presence of an indwelling catheter, use of antithrombotic medication, pathological findings at CTU or cystoscopy or history of pelvic radiotherapy were all statistically significant independent predictors for increased risk for recurrent macroscopic haematuria. Conclusion In the case of recurrent macroscopic haematuria within 3 years of primary standard evaluation for urinary tract cancer, there was a low risk of later urological malignancies in patients initially negative for UBC and UTUC. Therefore, waiting 3 years before conducting another complete investigation in cases of recurrent macroscopic haematuria might be appropriate.
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Affiliation(s)
- Suleiman Abuhasanein
- Department of Urology, Institute of Clinical Science, Sahlgrenska AcademyUniversity of GothenburgGöteborgSweden
- Department of Surgery, Urology SectionNU Hospital GroupUddevallaSweden
| | - Vanessa Chaves
- Department of Surgery, Urology SectionNU Hospital GroupUddevallaSweden
| | | | - Jasmine Al‐Haddad
- Department of Surgery, Urology SectionNU Hospital GroupUddevallaSweden
| | - Merete Sunila
- Department of Surgery, Urology SectionNU Hospital GroupUddevallaSweden
| | - Viveka Ströck
- Department of Urology, Institute of Clinical Science, Sahlgrenska AcademyUniversity of GothenburgGöteborgSweden
- Department of UrologySahlgrenska University HospitalGöteborgRegion Västra GötalandSweden
| | - Tomas Jerlström
- Department of Urology, School of Medical Sciences, Faculty of Medicine, and HealthÖrebro UniversityÖrebroSweden
| | - Fredrik Liedberg
- Department of Urology Skåne University Hospital, Malmö, Sweden and Institution of Translational MedicineLund UniversityMalmöSweden
| | - Jesper Swärd
- Department of Urology, Institute of Clinical Science, Sahlgrenska AcademyUniversity of GothenburgGöteborgSweden
| | - Truls Gårdmark
- Department of Clinical Sciences, Danderyd HospitalKarolinska InstituteStockholmSweden
| | - Staffan Jahnson
- Department of Clinical and Experimental Medicine, Division of UrologyLinköping UniversityLinköpingSweden
| | - Henrik Kjölhede
- Department of Urology, Institute of Clinical Science, Sahlgrenska AcademyUniversity of GothenburgGöteborgSweden
- Department of UrologySahlgrenska University HospitalGöteborgRegion Västra GötalandSweden
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Galtung KF, Lauritzen PM, Sandbæk G, Bay D, Ponzi E, Baco E, Cowan NC, Naas AM, Rud E. Computed tomography for visible haematuria - a single nephrographic phase is sufficient for detecting renal cell carcinoma. Scand J Urol 2024; 59:10-18. [PMID: 38226799 DOI: 10.2340/sju.v59.18467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/30/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVES No previous studies have compared two computed tomography (CT) protocols in patients presenting with visible haematuria, and most patients undergo a multiphase CT in order to detect upper tract malignancies. We aimed to prospectively compare the diagnostic performance of single- and four-phase CT for detecting renal cell carcinoma (RCC) in patients with visible haematuria. MATERIALS & METHODS 'A Prospective Trial for Examining Hematuria using Computed Tomography' (PROTEHCT) was a single-centre prospective paired diagnostic study in patients referred for CT due to painless visible haematuria between September 2019 and June 2021. All patients underwent four-phase CT (control) from which a single nephrographic phase dual energy CT (experimental) was extracted. Both were independently assessed for RCC by randomised radiologists. Histologically verified RCC defined a positive reference standard. Follow-up ascertainment of RCC diagnosis was completed in May 2022. Descriptive statistics were used to calculate the accuracies. Inter-reader agreement was assessed by kappa statistics. RESULTS A total of 308 patients (median age, 68 years [interquartile range 53-77, range 18-96], 250 males) were included for analysis. RCC was diagnosed in seven (2.3%) patients during a median follow-up time of 19 months (interquartile range: 15-25). For the control and experimental CT, sensitivity was 100% versus 100%, specificity was 97% versus 98% and accuracy 97% versus 97%. The positive predictive value was 44% versus 50%, and the negative predictive value was 100% versus 100%. The agreement between the control and experimental CT was 98% (k = 0.79). CONCLUSION A single nephrographic phase dual energy CT is sufficient for detecting RCC in patients with visible haematuria.
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Affiliation(s)
- Kristina Flor Galtung
- Department of Radiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.
| | - Peter Mæhre Lauritzen
- Department of Radiology, Oslo University Hospital, Oslo, Norway; Department of Life Sciences and Health, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
| | - Gunnar Sandbæk
- Department of Radiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway
| | - Dag Bay
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Erica Ponzi
- Department of Research Support for Clinical Trials, Clinical Trial Unit, Oslo University Hospital, Oslo, Norway; Oslo Center for Biostatistics and Epidemiology (OCBE), Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Eduard Baco
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway; Department of Urology, Oslo University Hospital, Oslo, Norway
| | | | | | - Erik Rud
- Department of Radiology, Oslo University Hospital, Oslo, Norway
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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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6
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Kashkoush J, Gupta M, Meissner MA, Nielsen ME, Kirchner HL, Garg T. Performance Characteristics of a Rule-Based Electronic Health Record Algorithm to Identify Patients with Gross and Microscopic Hematuria. Methods Inf Med 2023; 62:183-192. [PMID: 37666279 DOI: 10.1055/a-2165-5552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND Two million patients per year are referred to urologists for hematuria, or blood in the urine. The American Urological Association recently adopted a risk-stratified hematuria evaluation guideline to limit multi-phase computed tomography to individuals at highest risk of occult malignancy. OBJECTIVES To understand population-level hematuria evaluations, we developed an algorithm to accurately identify hematuria cases from electronic health records (EHRs). METHODS We used International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, urine color, and urine microscopy values to identify hematuria cases and to differentiate between gross and microscopic hematuria. Using an iterative process, we refined the ICD-9 algorithm on a gold standard, chart-reviewed cohort of 3,094 hematuria cases, and the ICD-10 algorithm on a 300 patient cohort. We applied the algorithm to Geisinger patients ≥35 years (n = 539,516) and determined performance by conducting chart review (n = 500). RESULTS After applying the hematuria algorithm, we identified 51,500 hematuria cases and 488,016 clean controls. Of the hematuria cases, 11,435 were categorized as gross, 26,658 as microscopic, 12,562 as indeterminate, and 845 were uncategorized. The positive predictive value (PPV) of identifying hematuria cases using the algorithm was 100% and the negative predictive value (NPV) was 99%. The gross hematuria algorithm had a PPV of 100% and NPV of 99%. The microscopic hematuria algorithm had lower PPV of 78% and NPV of 100%. CONCLUSION We developed an algorithm utilizing diagnosis codes and urine laboratory values to accurately identify hematuria and categorize as gross or microscopic in EHRs. Applying the algorithm will help researchers to understand patterns of care for this common condition.
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Affiliation(s)
- Jasmine Kashkoush
- Department of Urology, Geisinger, Danville, Pennsylvania, United States
| | - Mudit Gupta
- Phenomic Analytics and Clinical Data Core, Geisinger, Danville, Pennsylvania, United States
| | | | - Matthew E Nielsen
- Department of Urology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, United States
| | - H Lester Kirchner
- Department of Population Health Sciences, Geisinger, Danville, Pennsylvania, United States
| | - Tullika Garg
- Department of Population Health Sciences, Geisinger, Danville, Pennsylvania, United States
- Department of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
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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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Mandrik O, Hahn AI, Catto JWF, Zauber AG, Cumberbatch M, Chilcott J. Critical Appraisal of Decision Models Used for the Economic Evaluation of Bladder Cancer Screening and Diagnosis: A Systematic Review. PHARMACOECONOMICS 2023; 41:633-650. [PMID: 36890355 PMCID: PMC10548889 DOI: 10.1007/s40273-023-01256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Bladder cancer is common among current and former smokers. High bladder cancer mortality may be decreased through early diagnosis and screening. The aim of this study was to appraise decision models used for the economic evaluation of bladder cancer screening and diagnosis, and to summarise the main outcomes of these models. METHODS MEDLINE via PubMed, Embase, EconLit and Web of Science databases was systematically searched from January 2006 to May 2022 for modelling studies that assessed the cost effectiveness of bladder cancer screening and diagnostic interventions. Articles were appraised according to Patient, Intervention, Comparator and Outcome (PICO) characteristics, modelling methods, model structures and data sources. The quality of the studies was also appraised using the Philips checklist by two independent reviewers. RESULTS Searches identified 3082 potentially relevant studies, which resulted in 18 articles that met our inclusion criteria. Four of these articles were on bladder cancer screening, and the remaining 14 were diagnostic or surveillance interventions. Two of the four screening models were individual-level simulations. All screening models (n = 4, with three on a high-risk population and one on a general population) concluded that screening is either cost saving or cost effective with cost-effectiveness ratios lower than $53,000/life-years saved. Disease prevalence was a strong determinant of cost effectiveness. Diagnostic models (n = 14) assessed multiple interventions; white light cystoscopy was the most common intervention and was considered cost effective in all studies (n = 4). Screening models relied largely on published evidence generalised from other countries and did not report the validation of their predictions to external data. Almost all diagnostic models (n = 13 out of 14) had a time horizon of 5 years or less and most of the models (n = 11) did not incorporate health-related utilities. In both screening and diagnostic models, epidemiological inputs were based on expert elicitation, assumptions or international evidence of uncertain generalisability. In modelling disease, seven models did not use a standard classification system to define cancer states, others used risk-based, numerical or a Tumour, Node, Metastasis classification. Despite including certain components of disease onset or progression, no models included a complete and coherent model of the natural history of bladder cancer (i.e. simulating the progression of asymptomatic primary bladder cancer from cancer onset, i.e. in the absence of treatment). CONCLUSIONS The variation in natural history model structures and the lack of data for model parameterisation suggest that research in bladder cancer early detection and screening is at an early stage of development. Appropriate characterisation and analysis of uncertainty in bladder cancer models should be considered a priority.
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Affiliation(s)
- Olena Mandrik
- Health Economics and Decision Science, School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Anne I Hahn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James W F Catto
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, S10 2RX, UK
- Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marcus Cumberbatch
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, S10 2RX, UK
- Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK
| | - James Chilcott
- Health Economics and Decision Science, School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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Kuckuck EC, Hennenlotter J, Todenhöfer T, Brünn LA, Rass GC, Stenzl A, Hakenberg OW, Roghmann F, Goebell PJ, Grimm MO, Pycha A, Bolenz C, Burger M, Benderska-Söder N, Schmitz-Dräger BJ. Discriminative capacity of guideline recommendations in the assessment of patients with asymptomatic microhematuria. Urol Oncol 2023; 41:254.e1-254.e8. [PMID: 36274029 DOI: 10.1016/j.urolonc.2022.08.011] [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: 03/21/2022] [Revised: 08/20/2022] [Accepted: 08/26/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND & OBJECTIVE Asymptomatic microhematuria (aMh) remains a diagnostic challenge in urological practice: while aMh is a risk factor of urothelial carcinoma (UC), prevalence of aMh is high. Guidelines were developed to permit risk stratification and reduce diagnostic workload. This study investigates the efficacy of several recommendations. MATERIAL & METHODS Sixty hundred eight patients with newly diagnosed aMh without previous UC from an academic referral center (A; n = 320) and a private outpatient clinic (B; n = 288) were included. All patients underwent clinical workup including medical history, urine cytology, upper tract imaging and cystoscopy. Eleven former and current guidelines were applied to each patient individually; every patient was classified as either low risk (no further workup recommended) or high risk. Furthermore, a recently developed nomogram for hematuria assessment was included. RESULTS The cohort comprised 142 females and 466 males (mean age 62 [range 18-92] years). Sixty-one patients (10.0%) were diagnosed with UC. Excluding the Swedish and recent NICE guideline generally advising against urologic workup, application of 9 other recommendations would have diagnosed all UCs and saved 1.6% to 16.1% of patients from workup. For the 2020 US guideline, solely applied to cohort B, 10.6% of patients were classified as low risk. The use of the nomogram would have saved 17.1% to 25% of patients from workup. CONCLUSIONS Practical relevance of current guidelines is limited as they do not sufficiently identify patients not requiring clinical work up. Thus, guideline adherence may trigger overdiagnosis and even overtreatment. New ways of risk stratification are needed to improve aMh assessment.
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Affiliation(s)
| | | | - Tilman Todenhöfer
- Department of Urology, Eberhard-Karl University, Tuebingen, Germany; Studienpraxis Urologie, Nürtingen, Germany
| | | | | | - Arnulf Stenzl
- Department of Urology, Eberhard-Karl University, Tuebingen, Germany
| | | | | | | | | | - Armin Pycha
- General Hospital of Bolzano, Department of Urology, Bolzano, Italy; Sigmund Freud University Vienna, Medical School Vienna, Austria
| | | | - Maximilian Burger
- Department of Urology, St. Josefs Hospital, University of Regensburg, Germany
| | | | - Bernd J Schmitz-Dräger
- Urologie 24, Nuremberg, Germany; Department of Urology, University Clinic, Erlangen, Germany.
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10
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EDITORIAL COMMENT. Urology 2022; 169:33-34. [DOI: 10.1016/j.urology.2022.06.049] [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]
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11
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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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Persistent asymptomatic isolated microscopic hematuria in adolescents is not associated with an increased risk for early onset urinary tract cancer. Urology 2022; 169:29-34. [PMID: 35985524 DOI: 10.1016/j.urology.2022.06.048] [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: 02/12/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To elucidate the association between adolescent microscopic hematuria and early onset urothelial carcinoma and renal cell carcinoma. METHODS Nationwide, population-based, retrospective cohort study using medical data of 970,366 adolescents aged 16 through 19 years (58.6% male) examined for fitness for military service between 1980 and 1997. Diagnoses of persistent isolated microscopic hematuria were given after thorough work up process excluding any other renal abnormalities. Incident cases of urothelial carcinoma and renal cell carcinoma diagnosed during the years of 1982 to 2012 were retrieved from the Israeli National Cancer Registry. Cox proportional hazards models were used to estimate the hazard ratio (HR) separately for urothelial carcinoma and renal cell carcinoma. RESULTS During a cumulative follow-up of 22,115,629 person-years (median follow-up, 22.8), persistent isolated microscopic hematuria was diagnosed among 5509 (0.6%) adolescents. Urothelial carcinoma and renal cell carcinoma developed in 332 (3 among those with persistent isolated microscopic hematuria) and 292 (2) individuals, respectively. The adjusted HR for incident urothelial carcinoma among adolescents with isolated microscopic hematuria was 1.17 (95% CI, 0.38-3.66) and the adjusted HR for renal cell carcinoma was 1.02 (95% CI, 0.25-4.12). CONCLUSIONS Persistent asymptomatic isolated microscopic hematuria at adolescence was not associated with increased risk for urothelial carcinoma nor renal cell carcinoma.
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Malinaric R, Mantica G, Lo Monaco L, Mariano F, Leonardi R, Simonato A, Van der Merwe A, Terrone C. The Role of Novel Bladder Cancer Diagnostic and Surveillance Biomarkers-What Should a Urologist Really Know? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159648. [PMID: 35955004 PMCID: PMC9368399 DOI: 10.3390/ijerph19159648] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 05/20/2023]
Abstract
The aim of this review is to analyze and describe the current landscape of bladder cancer diagnostic and surveillance biomarkers. We researched the literature from 2016 to November 2021 to find the most promising new molecules and divided them into seven different subgroups based on their function and location in the cell. Although cystoscopy and cytology are still the gold standard for diagnosis and surveillance when it comes to bladder cancer (BCa), their cost is quite a burden for national health systems worldwide. Currently, the research is focused on finding a biomarker that has high negative predictive value (NPV) and can exclude with a certainty the presence of the tumor, considering missing it could be disastrous for the patient. Every subgroup has its own advantages and disadvantages; for example, protein biomarkers cost less than genomic ones, but on the other hand, they seem to be less precise. We tried to simplify this complicated topic as much as possible in order to make it comprehensible to doctors and urologists that are not as familiar with it, as well as encourage them to actively participate in ongoing research.
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Affiliation(s)
- Rafaela Malinaric
- Department of Urology, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, 16132 Genoa, Italy
- Correspondence:
| | - Guglielmo Mantica
- Department of Urology, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
| | - Lorenzo Lo Monaco
- Department of Urology, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, 16132 Genoa, Italy
| | - Federico Mariano
- Department of Urology, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, 16132 Genoa, Italy
| | - Rosario Leonardi
- Department of Urology, Casa di Cura Musumeci GECAS, 95030 Gravina di Catania, Italy
| | - Alchiede Simonato
- Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, 90133 Palermo, Italy
| | - André Van der Merwe
- Department of Urology, Tygerberg Academic Hospital, Stellenbosch University, Cape Town 7600, South Africa
| | - Carlo Terrone
- Department of Urology, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, 16132 Genoa, Italy
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Rai BP, Luis Dominguez Escrig J, Vale L, Kuusk T, Capoun O, Soukup V, Bruins HM, Yuan Y, Violette PD, Santesso N, van Rhijn BWG, Hugh Mostafid A, Imran Omar M. Systematic Review of the Incidence of and Risk Factors for Urothelial Cancers and Renal Cell Carcinoma Among Patients with Haematuria. Eur Urol 2022; 82:182-192. [PMID: 35393159 DOI: 10.1016/j.eururo.2022.03.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/12/2022] [Accepted: 03/17/2022] [Indexed: 12/21/2022]
Abstract
CONTEXT The current impact of haematuria investigations on health care organisations is significant. There is currently no consensus on how to investigate patients with haematuria. OBJECTIVE To evaluate the incidence of bladder cancer, upper tract urothelial carcinoma (UTUC), and renal cell carcinoma (RCC) among patients undergoing investigation for haematuria and identify any risk factors for bladder cancer, UTUC, and RCC (BUR). EVIDENCE ACQUISITION Medline, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov were searched for all relevant publications from January 1, 2000 to June 2021 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Prospective, retrospective, and cross-sectional studies with a minimum population of 50 patients with haematuria were considered for the review. EVIDENCE SYNTHESIS A total of 44 studies were included. The total number of participants was 229701. The pooled incidence rate for urothelial bladder cancer was 17% (95% confidence interval [CI] 14-20%) for visible haematuria (VH) and 3.3% (95% CI 2.45-4.3%) for nonvisible haematuria (NVH). The pooled incidence rate for RCC was 2% (95% CI 1-2%) for VH and 0.58% (95% CI 0.42-0.77%) for NVH. The pooled incidence rate for UTUC was 0.75% (95% CI 0.4-1.2%) for VH and 0.17% (95% CI 0.081-0.299%) for NVH. On sensitivity analysis, the proportions of males (risk ratio [RR] 1.14, 95% CI 1.10-1.17 for VH; 1.54, 95% CI 1.34-1.78 for NVH; p < 0.00001; moderate certainty evidence) and individuals with a smoking history (RR 1.41, 95% CI 1.24-1.61 for VH; 1.53, 95% CI 1.36-1.72 for NVH; p < 0.00001; moderate certainty evidence) appeared to be higher in BUR than in non-BUR groups. CONCLUSIONS Male gender and smoking history are risk factors for BUR cancer in haematuria, with bladder cancer being the commonest cancer. The incidence of RCC and UTUC in NVH is low. The review serves as a reference standard for future policy-making on investigation of haematuria by global organisations. PATIENT SUMMARY Our review shows that male gender and smoking history are risk factors for cancers of the bladder, kidney, and ureter. The review also provides information on the proportion of patients who have cancer when they have blood in their urine (haematuria) and will allow policy-makers to decide on the most appropriate method for investigating haematuria in patients.
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Affiliation(s)
- Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | | | - Luís Vale
- Department of Urology, Centro Hospital Universitário S. João, Porto, University of Porto, Porto, Portugal
| | - Teele Kuusk
- Department of Urology, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, UK
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Harman M Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, The Netherlands
| | - Yuhong Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Philippe D Violette
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Cochrane Canada Centre, 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
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
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15
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Harrison H, Usher-Smith JA, Li L, Roberts L, Lin Z, Thompson RE, Rossi SH, Stewart GD, Walter FM, Griffin S, Zhou Y. Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review. Br J Gen Pract 2022; 72:e11-e18. [PMID: 34844922 PMCID: PMC8714528 DOI: 10.3399/bjgp.2021.0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/25/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Timely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients. AIM To identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer. DESIGN AND SETTING Systematic review. METHOD A search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool. RESULTS The search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models (n = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias. CONCLUSION Models were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.
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Affiliation(s)
- Hannah Harrison
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Juliet A Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Lanxin Li
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Lydia Roberts
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Zhiyuan Lin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Rachel E Thompson
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Grant D Stewart
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, and director, Wolfson Institute of Population Health, Queen Mary University of London, London
| | - Simon Griffin
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Yin Zhou
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge
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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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18
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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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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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Sosna J. The Value of Virtual Unenhanced Dual-Energy CT for Renal Mass and Hematuria Evaluation. Radiology 2021; 298:620-621. [PMID: 33475468 DOI: 10.1148/radiol.2021203947] [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)
- Jacob Sosna
- From the Department of Radiology, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel 91120
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21
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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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Wallis CJD, Sayyid RK, Manyevitch R, Perlis N, Lokeshwar VB, Fleshner NE, Terris MK, Nielsen ME, Klaassen Z. Diagnostic utility of axial imaging in the evaluation of hematuria: A systematic review and critical appraisal of the literature. Can Urol Assoc J 2020; 15:48-55. [PMID: 32745004 DOI: 10.5489/cuaj.6522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Increasing severity of hematuria is instinctively associated with higher likelihood of urological malignancy. However, the robustness of the evidentiary base for this assertion is unclear, particularly as it relates to the likelihood of upper urinary tract pathology. Thus, the value of axial imaging in the diagnostic workup of hematuria is unclear due to differences in the underlying patient populations, raising concern for sampling bias. We performed a systematic review to characterize the literature and association between severity of hematuria and likelihood of upper urinary tract cancer based on axial imaging. METHODS MEDLINE, EMBASE, and Cochrane were systematically searched for all studies reporting on adult patients presenting with hematuria. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for reporting of this systematic review and meta-analysis and the Newcastle-Ottawa Scale for risk of bias assessment. Degree of hematuria was classified as "microscopic," "gross," or "unspecified." Three urological malignancies (bladder, upper tract urothelial, and renal cancer) were considered both individually and in aggregate. Random-effects model with pairwise comparisons was employed to arrive at the axial imaging diagnostic yields. RESULTS Twenty-nine studies were included, of which six (20.7%) reported on patients with gross hematuria only, four (13.8%) reported on patients with microscopic hematuria only, seven (24.1%) included both, and 12 (41.4%) did not define or specify the severity of hematuria. Of 29 studies, two (6.9%) were at high-risk of bias, 21 (72.4%) at intermediate-risk, and six (20.7%) at low-risk of bias using the Newcastle-Ottawa criteria. Based on axial imaging, rates of diagnoses of renal, upper tract urothelial, and bladder cancers differed with differing severity of hematuria. Notably, rates of renal and upper tract urothelial carcinoma were higher in studies of patients with unspecified hematuria severity (3.6% and 10.4%, respectively) than among patients with gross hematuria (1.5% and 1.3%, respectively). When all urological malignancies were pooled, patients with unspecified hematuria were diagnosed more frequently (19.5%) compared to those with gross (15.3%) and microscopic hematuria (4.5%, difference=1.51%, 99% confidence interval 3.6-26.5%). CONCLUSIONS Lack of granularity in the available literature, particularly with regards to patients with unspecified hematuria severity, limits the generalizability of these results and highlights the need for future studies that provide sufficient baseline information, allowing for firmer conclusions to be drawn.
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Affiliation(s)
- Christopher J D Wallis
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States.,Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Rashid K Sayyid
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States
| | - Roni Manyevitch
- School of Medicine, St. George's University, University Centre Grenada, West Indies, Grenada
| | - Nathan Perlis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Neil E Fleshner
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Martha K Terris
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States.,Georgia Cancer Center, Augusta, GA, United States
| | - Matthew E Nielsen
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States
| | - Zachary Klaassen
- Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA, United States.,Georgia Cancer Center, Augusta, GA, United States
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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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24
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Microscopic Hematuria: Diagnosis Is Only Half the Battle. Eur Urol 2020; 77:599-600. [DOI: 10.1016/j.eururo.2019.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 12/12/2019] [Indexed: 11/23/2022]
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25
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Fankhauser CD, Waisbrod S, Fierz C, Becker AS, Kranzbühler B, Eberli D, Sulser T, Mostafid H, Hermanns T. Diagnostic accuracy of ultrasonography, computed tomography, cystoscopy and cytology to detect urinary tract malignancies in patients with asymptomatic hematuria. World J Urol 2020; 39:97-103. [PMID: 32240349 DOI: 10.1007/s00345-020-03171-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To report the incidence of urinary tract malignancies (UTM) and to compare the diagnostic accuracy of cytology with cystoscopy, renal ultrasound (US) and computed tomography (CT) in patients with hematuria. METHODS A retrospective analysis was conducted of patients who underwent cystoscopy, cytology, US and CT for hematuria between 2011 and 2017. Age, gender, BMI, smoking status, and results of further diagnostic interventions including transurethral resection of the bladder (TURB), ureterorenoscopy (URS), renal biopsy and imaging were extracted from medical charts. Logistic regression to identify risk factors for UTM was performed. Discriminatory accuracy of US, CT and cytology was assessed by 2 × 2 tables. RESULTS Of 847 patients, 432 (51%) presented with non-visible hematuria (NVH) and 415 (49%) with visible hematuria (VH). Of all patients with NVH, seven (1.6%) had bladder cancer (BCA), three (< 1%) had renal cell cancer (RCC) and no single patient had upper tract urothelial cancer (UTUC). Of the patients with VH, 62 (14.9%) were diagnosed with BCA, 7 (1.6%) with RCC and 4 (< 1%) with UTUC. In multivariable analysis VH, higher age, smoking and lower BMI were associated with an increased risk for UTM. The specificity/negative predictive value of US for the detection of RCC or UTUC in patients with NVH and VH were 96%/100% and 95%/99%, respectively. CONCLUSION Due to the low incidence of UTM, the necessity of further diagnostics should be questioned in patients with NVH. In contrast, patients with VH are at considerable risk for BCA, and cystoscopy and upper tract imaging is justified.
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Affiliation(s)
- Christian Daniel Fankhauser
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Sharon Waisbrod
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Cindy Fierz
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Anton S Becker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Benedikt Kranzbühler
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Tullio Sulser
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, UK
| | - Thomas Hermanns
- Department of Urology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Khadhouri S, Gallagher KM, MacKenzie K, Shah TT, Gao C, Moore S, Zimmermann E, Edison E, Jefferies M, Nambiar A, MacLennan G, McGrath JS, Kasivisvanathan V. IDENTIFY: The investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer: A multicentre cohort study. Int J Surg Protoc 2020; 21:8-12. [PMID: 32322764 PMCID: PMC7163317 DOI: 10.1016/j.isjp.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 11/12/2022] Open
Abstract
IDENTIFY study: The largest prospective cohort study of haematuria in secondary care. Contemporary urinary cancer detection rates and diagnostic strategies. The effectiveness of diagnostic tests, e.g. ultrasound, in detecting urinary cancer. Novel patient risk factors associated with bladder and upper tract urinary cancers.
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Affiliation(s)
- Sinan Khadhouri
- Aberdeen Royal Infirmary, Dept of Urology, Aberdeen, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Kevin M Gallagher
- Western General Hospital, Dept. of Urology, Edinburgh, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Kenneth MacKenzie
- Sunderland Royal Hospital, Dept. of Urology, Sunderland, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Taimur T Shah
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Dept. of Surgery and Cancer, London, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Chuanyu Gao
- Addenbrookes Hospital, Cambridge, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Sacha Moore
- Wrexham Maelor Hospital, Dept. of Urology, Wrexham, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Eleanor Zimmermann
- Torbay and South Devon NHS Foundation Trust, Dept. of Urology, Torbay, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Eric Edison
- North Middlesex Hospital, Dept. of Urology, London, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Matthew Jefferies
- Morriston Hospital, Dept. of Urology, Swansea, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Arjun Nambiar
- Sunderland Royal Hospital, Dept. of Urology, Sunderland, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
| | - Graeme MacLennan
- University of Aberdeen, Health Services Research Unit, Aberdeen, United Kingdom
| | - John S McGrath
- University of Exeter Medical School, Dept. of Urology, Exeter, United Kingdom
| | - Veeru Kasivisvanathan
- Division of Surgery and Interventional Science, University College London.,University College London Hospitals NHS Foundation Trust, Dept. of Urology, London, United Kingdom.,British Urology Researchers in Surgical Training (BURST) Collaborative
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27
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de Jong JJ, van Kessel KEM, Roobol MJ, Boormans JL. Challenges of urine-based molecular assays for the detection of urothelial cancer. Transl Androl Urol 2020; 8:S493-S496. [PMID: 32042629 DOI: 10.21037/tau.2019.08.27] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joep J de Jong
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Kim E M van Kessel
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost L Boormans
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Koya M, Osborne S, Chemaslé C, Porten S, Schuckman A, Kennedy-Smith A. An evaluation of the real world use and clinical utility of the Cxbladder Monitor assay in the follow-up of patients previously treated for bladder cancer. BMC Urol 2020; 20:12. [PMID: 32046687 PMCID: PMC7014779 DOI: 10.1186/s12894-020-0583-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/31/2020] [Indexed: 11/24/2022] Open
Abstract
Background Surveilling recurrent urothelial carcinoma (UC) requires frequent cystoscopy, which is invasive, expensive and time-consuming. An accurate urinary biomarker has the potential to reduce the number of cystoscopies required during post-treatment surveillance. Objective To audit the clinical utility of a new surveillance protocol incorporating the Cxbladder Monitor (CxbM) test in real-world practice. Methods Three hospitals implemented a new surveillance protocol. Patients were risk stratified, and then provided urine samples for CxbM testing. Low-risk CxbM-positive patients and all high-risk patients had cystoscopy at 2–3 months. Low-risk CxbM-negative patients had cystoscopy at ~ 12 months. Results 443 CxbM tests were conducted on samples from 309 patients: 257 (83.2%) low-risk and 52 (16.8%) high-risk. No pathology-confirmed recurrences were seen in low-risk CxbM-negative patients (n = 108) during the first post-CxbM cystoscopy undertaken a mean ± SD 10.3 ± 3.9 months after testing. Three recurrences were detected during cystoscopy at 2.7 ± 3.4 months in 53 low-risk CxbM-positive patients. In 49 high-risk patients, 39 (79.6%) were CxbM-negative with no pathology-confirmed recurrences. Ten high-risk patients (20.4%) were CxbM-positive with four confirmed recurrences; 2 high-grade and 2 low-grade. The median time to first cystoscopy was 12.13 (95% CI: 11.97–12.4) months in patients with a CxbM-negative result versus 1.63 (95% CI: 1.13–2.3) months in patients with a CxbM-positive result (p < 0.00001). No positive cases were missed, no patients progressed to invasive or metastatic disease, and no patient died of cancer over 35 months of follow-up. Conclusions CxbM accurately identified a high proportion of patients (77.8%) who were safely managed with only one cystoscopy per year. Including CxbM in the protocol for patient surveillance provided clinical utility by reducing the average number of annual cystoscopies by approximately 39%, thereby sparing patients the potential discomfort and anxiety, without compromising detection rates. No advantage was observed for risk stratification prior to CxbM.
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Affiliation(s)
| | - Sue Osborne
- Waitemata District Health Board, Auckland, New Zealand.
| | | | - Sima Porten
- University of California San Francisco, San Francisco, CA, USA
| | - Anne Schuckman
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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29
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Siemens DR. Taking a more critical look at the use of costly and invasive testing. Can Urol Assoc J 2019; 13:368-369. [PMID: 31799916 DOI: 10.5489/cuaj.6334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- D Robert Siemens
- Department of Urology, Queen's University, Kingston, ON, Canada, and CUAJ Editor-in-Chief
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