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

Clinical Implications of Basic Research: Exploring the Transformative Potential of Spatial 'Omics in Uro-oncology

New spatial molecular technologies are poised to transform our understanding and treatment of urological cancers. By mapping the spatial molecular architecture of tumours, these platforms uncover the complex heterogeneity within and around individual malignancies, offering novel insights into disease development, progression, diagnosis, and treatment. They enable tracking of clonal phylogenetics in situ and immune-cell interactions in the tumour microenvironment. A whole transcriptome/genome/proteome-level spatial analysis is hypothesis generating, particularly in the areas of risk stratification and precision medicine. Current challenges include reagent costs, harmonisation of protocols, and computational demands. Nonetheless, the evolving landscape of the technology and evolving machine learning applications have the potential to overcome these barriers, pushing towards a future of personalised cancer therapy, leveraging detailed spatial cellular and molecular data. PATIENT SUMMARY: Tumours are complex and contain many different components. Although we have been able to observe some of these differences visually under the microscope, until recently, we have not been able to observe the genetic changes that underpin cancer development. Scientists are now able to explore molecular/genetic differences using approaches such as "spatial transcriptomics" and "spatial proteomics", which allow them to see genetic and cellular variation across a region of normal and cancerous tissue without destroying the tissue architecture. Currently, these technologies are limited by high associated costs, and a need for powerful and complex computational analysis workflows. Future advancements and results through these new technologies may assist patients and their doctors as they make decisions about treating their cancer.

Cost of upper tract imaging obtained during hematuria evaluation: Analysis of a national claims database

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.

Is the excretory phase necessary to identify upper tract urothelial neoplasms at CT urography? A 10-year population-based study

PURPOSE

To assess the proportion of upper tract urothelial carcinomas (UTUC) that are evident without the excretory phase at CT urography (CTU), and the proportion of potentially avoidable radiation.

METHODS

UTUCs diagnosed between January 2008-December 2017 were retrospectively identified from a population-based cancer registry. For each patient, US, non-urographic CT, and MRI exams were assessed for a primary mass and secondary imaging findings (hydronephrosis, urinary tract thickening, luminal distention, fat stranding, and lymphadenopathy/metastatic disease). CTUs were assessed for primary and secondary findings, and whether the tumor was evident as a filling defect on excretory phase. The dose-length product (DLP) of potentially avoidable excretory phases was calculated as a fraction of total DLP.

RESULTS

288 patients (mean age, 72±11 years, 165 males) and 545 imaging examinations were included. Of 192 patients imaged with 370 non-urographic CTs, a primary mass was evident in 154 (80.2%), secondary findings were evident in 172 (89.6%), and primary or secondary findings were evident in 179 (93.2%). Of 175 CTUs, primary and secondary findings were evident in 157 (89.7%) and 166 (94.9%) examinations, respectively, and primary or secondary findings were evident in 170/175 (97.1%). 131/175 (74.9%) UTUCs were evident as a filling defect, including the 5/175 (2.9%) UTUCs without primary or secondary findings. Of 144 CTUs with available DLP data, the proportion of potentially avoidable radiation was 103.7/235.8 (44.0%) Gy⋅cm.

CONCLUSION

In our population, almost all UTUCs were evident via primary or secondary imaging findings without requiring the excretory phase. These results support streamlining protocols and pathways.

Potential of an mRNA-Based Urine Assay (Xpert® Bladder Cancer Detection1) in Hematuria Patients - Results from a Cohort Study

BACKGROUND AND OBJECTIVE

Assessment of patients with hematuria (aH) remains a challenge in urological practice, balancing the benefits of diagnosing a potentially underlying bladder cancer (UCa) against the risks of possibly unnecessary diagnostic interventions. This study analyzes the potential of an mRNA-based urine assay, the Xpert® Bladder Cancer Detection- CE-IVD (Xpert BC-D), in patients with hematuria.

MATERIALS AND METHODS

Overall, 368 patients with newly observed painless hematuria and no history of UCa were included in this observational study. Patients received urological workup, including urethrocystoscopy (WLC), upper tract imaging, urine cytology and Xpert BC-D. Patients with positive WLC were recommended to undergo tumor resection (TUR-B).

RESULTS

After excluding non-assessable cases, 324 patients were considered for analysis (188 males, 136 females; median age: 61 years). Eight of twenty-eight patients with a positive TUR-B had Ta low grade (LG) tumors; the others were diagnosed with high grade (HG) lesions (Ta: 4, CIS: 2, T1:11, > T1:3). The Xpert BC-D was more sensitive than urine cytology (96% vs. 61%) (p = 0.002). Increased risk ratios (RR) were observed for gross hematuria, gender, urine cytology, and positive Xpert BC-D (all p < 0.05). Age and positive Xpert BC-D remained independent predictors of UCa in multivariate analysis. Simulating a triage with WLC restricted to patients with positive Xpert BC-D could have saved 240 (74.1%) assessments at the cost of missing one pTa LG tumor.

CONCLUSIONS

The results suggest a potential role for Xpert BC-D in preselecting patients with hematuria for either further invasive diagnosis or an alternate diagnostic procedure.

Diagnostic value of repeated comprehensive investigation with CT urography and cystoscopy for recurrent macroscopic haematuria

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.

Summary of the Clinical Practice Guidelines for Upper Tract Urothelial Carcinoma 2023 by the Japanese Urological Association

This article is an English translation of the Clinical Practice Guidelines for Upper Tract Urothelial Carcinoma (2nd edition) published in June 2023. The Japanese Urological Association's (JUA) Guidelines Committee on Upper Tract Urothelial Carcinoma (UTUC) created a 2023 update guideline to support clinicians' current evidence-based management of UTUC and to incorporate its recommendations into clinical practice. The new guideline adhered as closely as possible to the Minds Manual for Guideline Development 2020 ver. 3.0. Findings related to epidemiological, pathological, diagnosis, treatment, and follow-up were reviewed. In addition, seven clinical questions (CQs) were set to determine the grade of recommendation and level of evidence. Preconceptions and biases were removed from the preparation process, the overall evidence was evaluated appropriately, and recommendations were made after fully considering the balance between benefits and harms. Although the evidence is still insufficient to be taken up as a CQ, the latest important information is described in seven columns, and clinical issues that should be resolved in the future related to the CQ are described as recommendations for tomorrow. We hope that these guidelines will help medical professionals, patients, and their families involved in the treatment of UTUC in their decision-making, and hope that a critical review of these guidelines will lead to further refinements in the next edition.

Discrepant guidelines in the evaluation of hematuria

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.

Abandoning testing for asymptomatic microscopic haematuria in Sweden - a long-term follow-up

OBJECTIVES

To test the hypothesis that the Swedish national policy of abandoning testing for asymptomatic microscopic haematuria (AMH) introduced in 1999 did not adversely affect the prognosis of patients with urinary bladder cancer. Specific aims were to investigate possible effects on (1) Diagnostic delay as represented by stage distribution at diagnosis, (2) Survival and mortality trends, also in comparison to other countries and (3) National health care costs.

MATERIAL AND METHODS

The design was an observational study using open sources on patients included in the Swedish National Bladder Cancer Registry 1997-2016. Outcome measures were: Changes in initial tumour presentation during 5 years after the change and long-term relative survival and mortality in comparison to the other Nordic countries. Costs related to investigations were estimated based on the national price lists.

RESULTS

The proportion of patients diagnosed with muscle-invasive bladder cancer decreased following the policy change. The long-term relative 5-year survival increased during the study period. Mortality has remained constant during the period. In comparison to the other Nordic countries, Sweden remains among those with the best outcome despite a more restrictive approach. Cost savings because of the policy change were estimated to be substantial.

CONCLUSIONS

Based on open-source registry data, the new restrictive policy was not found to adversely affect the survival of patients with urinary bladder cancer in Sweden. These observations argue against a major negative impact of abandoning further work-up for patients with AMH and may be of use for other countries when revising guidelines. The reduced number of patients undergoing investigation may allow for increased focus and be a relief both for caregivers and the health budget.

Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use

INTRODUCTION

Citing high costs, limited diagnostic benefit, and ionizing radiation-associated risk from CT urogram, in 2020 the AUA revised its guidelines from recommending CT urogram for all patients with microscopic hematuria to a deintensified risk-stratified approach, including the deimplementation of low-value CT urogram (ie, not recommending CT urogram for patients with low- to intermediate-risk microscopic hematuria). Adherence to revised guidelines and reasons for continued low-value CT urogram are unknown.

METHODS

With the overarching objective of improving guideline implementation, we used a mixed-method convergent explanatory design with electronic health record data for a retrospective cohort at a single academic tertiary medical center in the southeastern United States and semistructured interviews with urology and nonurology providers to describe determinants of low-value CT urogram following guideline revision.

RESULTS

Of 391 patients with microscopic hematuria, 198 (51%) had a low-value CT urogram (136 [69%] pre-guideline revision, 62 [31%] postrevision). The odds of ordering a low-value CT urogram were lower after guideline revisions, but the change was not statistically significant (OR: 0.44, P = .08); odds were 1.89 higher (P = .06) among nonurology providers than urology providers, but the difference was not statistically significant. Provider interviews suggested low-value CT urogram related to nonurology providers' limited awareness of revised guidelines, the role of clinical judgment in microscopic hematuria evaluation, and professional and patient influences.

CONCLUSIONS

Our findings suggest low-value CT urogram deimplementation may be improved with guidelines and implementation support directed at both urology and nonurology providers and algorithms to support guideline-concordant microscopic hematuria evaluation approaches. Future studies should test these strategies.

Novel urine-based DNA methylation biomarkers for urothelial bladder carcinoma detection in patients with hematuria

Background

Urothelial bladder carcinoma (UBC) is usually detected during work-up for hematuria. Cystoscopy and/or contrast-enhanced imaging are the gold standard tools for UBC diagnosis, despite limited by being invasive, expensive and low yield in small flat tumors.

Objectives

To assess the diagnostic performance of urine-based DNA methylation of six genes (GATA4, P16, P14, APC, CDH1 and CD99) for UBC detection in patients with hematuria.

Patients and methods

Voided urine was collected from consecutive patients presented with hematuria for urine cytology and DNA methylation assay of the assigned genes using methylation-specific Polymerase Chain Reaction (PCR). Further assessment by office cystoscopy and imaging with subsequent inpatient cystoscopic biopsy for positive findings was done. The diagnostic characteristics of DNA methylation and urine cytology were assessed based on its capability to predict UBC.

Results

We included 246 patients in the study with identified macroscopic hematuria in 204 (82.9%) patients. Positive cytology was found in 78 (31.7%) patients. DNA methylation of GATA4, P16, P14, APC, CDH1 and CD99 genes was identified in 127 (51.6%), 52 (21.1%), 117 (47.6%), 106 (43.1%), 90 (36.6%) and 71 (28.9%) patients, respectively. The sensitivity of the assigned genes for UBC detection ranges from 35% (95%CI: 31-39) to 83% (95%CI: 79-87). Optimal specificity (SP) (100%) was noted for P16, APC and CDH1 genes. While for the other genes (GATA4, P14 and CD99), the SP was 95% (95%CI: 92-98), 96% (95%CI: 92-99) and 97% (95%CI: 93-99), respectively. On multivariate logistic regression analysis, all genes exclusively demonstrated independent prediction of UBC. On receiver operator characteristic (ROC) analysis, all tested genes methylation showed superior area under the curve (AUC) when compared to urine cytology.

Conclusions

We have developed a novel urine-based DNA methylation assay for detection of UBC in patients with hematuria with superior diagnostic performance and independent predictive capacity over urine cytology.

A Urine-based Genomic Assay Improves Risk Stratification for Patients with High-risk Hematuria Stratified According to the American Urological Association Guidelines

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.

RNA-based urinary assays for non-muscle invasive bladder cancer

PURPOSE OF REVIEW

To provide an overview of the recent literature on RNA-based molecular urine assays for the diagnosis and surveillance of non-muscle invasive bladder cancer (NMIBC).

RECENT FINDINGS

Articles were eligible for inclusion if performance metrics sensitivity, specificity, and negative-predictive value (NPV) were reported or could be calculated. Only prospective studies published between 2020-2022 were included. Five out of fourteen studies addressed the primary diagnostic setting; the proportion of gross hematuria patients in all study populations was >50%. Only one study reported performance metrics within a microscopic hematuria subgroup. This study evaluated Xpert Bladder and reported a sensitivity: 73%, specificity: 84%, NPV: 99%, and PPV: 12%. Ten studies assessed test performance during surveillance for NMIBC. For the detection of high-grade (HG) and high-risk (HR) NMIBC, sensitivity, specificity, NPV, and PPV varied between 78-100%, 64-89%, 97.0-99.7%, and 9.2-39%.

SUMMARY

Multiple RNA-based urine assays have been investigated for the detection of urothelial cancer in the primary or surveillance setting. However, studies included within this review have important limitations, hampering the interpretation of study results. As such, performance metrics should be interpreted with caution and further research is required to evaluate the clinical impact of RNA-based urine assays in daily practice.

Sensitivity of virtual non-contrast dual-energy CT urogram for detection of urinary calculi: a systematic review and meta-analysis

OBJECTIVE

To determine the sensitivity of dual-energy (DE) virtual non-contrast computed tomography (vNCT), generated from the excretory phase of a CT urogram, compared to true non-contrast CT (tNCT) for the detection of urinary calculi.

METHODS

A search of multiple medical literature databases was performed using predetermined search terms. Inclusion and exclusion criteria were applied, and bias risk was assessed by two independent reviewers using the quality assessment of diagnostic accuracy studies (QUADAS) tool. Collated estimates of sensitivity were generated, and sources of heterogeneity were identified and reviewed.

RESULTS

Thirteen studies (1760 patients; 1740 urinary calculi) were included for sensitivity assessment. Pooled sensitivity for urinary calculi on vNCT was 78.1% (95% CI: 70.2 to 85.0%); however, heterogeneity between studies was very high (I² = 92.0%). Sources of heterogeneity between studies were explored through subgroup analysis by categorising studies according to slice thickness (≥ 2 mm and < 2 mm), use of oral hydration, and use of intravenous furosemide. Pooled sensitivity for detection of urinary calculi on vNCT for studies that used oral hydration and < 2 mm slice thickness was 92.2% (95% CI: 89.5 to 94.5%). Pooled specificity was not performed as true negatives were not reported in most studies. Potential sources of bias were identified in included studies.

CONCLUSION

vNCT demonstrated a moderate pooled sensitivity compared to tNCT for the detection of urinary calculi in split bolus CT urogram protocols. However, subgroup analysis suggests higher sensitivity when employing oral hydration and < 2 mm slice thickness or increment.

KEY POINTS

• vNCT demonstrated moderate pooled sensitivity for the detection of urinary calculi in split bolus CT urogram protocols. • Subgroup analysis suggested higher sensitivity with oral hydration and < 2 mm slice thickness or increment.

Computed tomography urography with corticomedullary phase can exclude urinary bladder cancer with high accuracy

BACKGROUND

To evaluate the diagnostic accuracy of computed tomography-urography (CTU) to rule out urinary bladder cancer (UBC) and whether patients thereby could omit cystoscopy.

METHODS

All patients evaluated for macroscopic hematuria with CTU with cortico-medullary phase (CMP) and cystoscopy at our institute between 1st November 2016 and 31st December 2019 were included. From this study cohort a study group consisting of all UBC patients and a control group of 113 patients randomly selected from all patients in the study cohort without UBC. Two radiologists blinded to all clinical data reviewed the CTUs independently. CTUs were categorized as positive, negative or indeterminate. Diagnostic accuracy and proportion of potential omittable cystoscopies were calculated for the study cohort by generalizing the results from the study group.

RESULTS

The study cohort consisted of 2195 patients, 297 of which were in the study group (UBC group, n = 207 and control group, n = 90). Inter-rater reliability was high (κ 0.84). Evaluation of CTUs showed that 174 patients were assesessed as positive (showing UBC), 46 patients as indeterminate (not showing UBC but with limited quality of CTU), and 77 patients as negative (not showing UBC with good quality of CTU). False negative rate was 0.07 (95%, CI 0.04-0.12), false positive rate was 0.01 (95% CI 0.0-0.07) and negative predictive value was 0.99 (95% CI 0.92-1.0). The area under the curve was 0.93 (95% CI 0.90-0.96). Only 2.9% (3/102) with high-risk tumors and 11% (12/105) with low- or intermediate-risk tumors had a false negative CTU. Cystoscopy could potentially have been omitted in 57% (1260/2195) of all evaluations.

CONCLUSIONS

CTU with CMP can exclude UBC with high accuracy. In case of negative CTU, it might be reasonable to omit cystoscopy, but future confirmative studies with possibly refined technique are needed.

Standardized care pathways for patients with suspected urinary bladder cancer: the Swedish experience

OBJECTIVES

To compare time intervals to diagnosis and treatment, tumor characteristics, and management in patients with primary urinary bladder cancer, diagnosed before and after the implementation of a standardized care pathway (SCP) in Sweden.

MATERIALS AND METHODS

Data from the Swedish National Register of Urinary Bladder Cancer was studied before (2011-2015) and after (2016-2019) SCP. Data about time from referral to transurethral resection of bladder tumor (TURBT), patients and tumor characteristics, and management were analyzed. Subgroup analyses were performed for cT1 and cT2-4 tumors.

RESULTS

Out of 26,795 patients, median time to TURBT decreased from 37 to 27 days after the implementation of SCP. While the proportion of cT2-T4 tumors decreased slightly (22-21%, p < 0.001), this change was not stable over time and the proportions cN + and cM1 remained unchanged. In the subgroups with cT1 and cT2-4 tumors, the median time to TURBT decreased and the proportions of patients discussed at a multidisciplinary team conference (MDTC) increased after SCP. In neither of these subgroups was a change in the proportions of cN + and cM1 observed, while treatment according to guidelines increased after SCP in the cT1 group.

CONCLUSION

After the implementation of SCP, time from referral to TURBT decreased and the proportion of patients discussed at MDTC increased, although not at the levels recommended by guidelines. Thus, our findings point to the need for measures to increase adherence to SCP recommendations and to guidelines.

An analysis of the evidence underpinning the American Urologic Association clinical practice guidelines

OBJECTIVE

To evaluate the reporting quality of systematic reviews (SRs) underpinning the American Urologic Association (AUA) clinical practice guidelines (CPGs).

METHODS

We searched the AUA for CPGs from 2015-2021. We extracted all SRs from the reference sections and two independent investigators evaluated eligible SR/meta-analysis using the PRISMA (Preferred Reporting Instrument for Systematic Reviews and Meta-Analyses) and AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews 2) instruments. We compared SRs conducted by the Cochrane group to non-Cochrane SRs using a Mann-Whitney test. A multivariate regression was used to compare study characteristics.

RESULTS

Eighteen CPG's met inclusion criteria. We extracted 120 unique SRs, which accounted for 5.1% (n=120/2346) of all citations. Mean percent adherence to PRISMA and AMSTAR-2 was 65.4% and 55.2% respectively. SRs conducted by the Cochrane Collaboration scored higher on AMSTAR-2 compared to non-Cochrane (z = -4.41, p <0.01) and a positive correlation between PRISMA and AMSTAR-2 scores (r=0.56, p<0.001) was determined.

CONCLUSION

Our study indicated the quality of SRs used to develop AUA CPGs across both PRISMA and AMSTAR-2 was variable. Despite higher evaluations, Cochrane SRs accounted for less than 15% of SRs underpinning CPG recommendations. Given the importance placed on CPGs within clinical practice, we recommended a synergistic relationship between the AUA and the Cochrane Collaboration to increase the number of quality urologic SRs.