Is routine urine cytology useful in the haematuria clinic?

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

French ccAFU guidelines – Update 2018–2020: Bladder cancer

Objective

To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.

Methods

A Medline search was achieved between 2015 and 2018, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

Results

Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS < 1) and renal function (creatinine clearance > 60 mL/min) allow it (only in 50 % of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

Conclusion

These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.

Metabolomic Heterogeneity of Urogenital Tract Cancers Analyzed by Complementary Chromatographic Techniques Coupled with Mass Spectrometry

BACKGROUND

In regard to urogenital tract cancer studies, an estimated 340,650 new cases and 58,360 deaths from genital system cancer and about 141,140 new cases and 29330 deaths from urinary system were projected to occur in the United States in 2012. The main drawbacks of currently available diagnostic tests constitute the low specificity, costliness and quite high invasiveness.

OBJECTIVE

The main goal of this pilot study was to determine and compare urine metabolic fingerprints in urogenital tract cancer patients and healthy controls.

METHOD

A comparative analysis of the metabolic profile of urine from 30 patients with cancer of the genitourinary system (bladder (n=10), kidney (n=10) and prostate (n=10)) and 30 healthy volunteers as a control group was provided by LC-TOF/MS and GCQqQ/ MS. The data analysis was performed by the use of U-Mann Whitney test or Student's t-test, principal component analysis (PCA) and orthogonal partial least-squares discriminant analysis (OPLS-DA).

RESULTS

As a result, 33, 43, and 22 compounds were identified as statistically significant in bladder, prostate and kidney cancer, respectively, compared to healthy groups.

CONCLUSION

Diverse compounds such as purine, sugars, amino acids, nucleosides, organic acids which play a role in purine metabolism, in tricarboxylic acid cycle, in amino acid metabolism or in gut microbiota metabolism were identified. Only two metabolites namely glucocaffeic acid and lactic acid were found to be in common in studied three types of cancer.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la vessie French ccAFU guidelines — Update 2018—2020: Bladder cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.006. That newer version of the text should be used when citing the article.

Upper Tract Imaging in Patients with Initial or Terminal Hematuria Suggestive of Bleeding from the Lower Urinary Tract: How Often is the Upper Urinary Tract Responsible for the Hematuria?

Objectives

Visible hematuria (VH) is a common urological complaint. A history of initial or terminal VH in men is indicative of a lower urinary tract (LUT) source. A careful clinical history could limit unnecessary extensive upper tract imaging in this group of patients with VH. We conducted a single-center prospective study to examine the usefulness of investigating the upper tract in patients with a history of VH likely from a LUT source (initial and/or terminal VH) with specific reference to the incidence of demonstrable significant upper tract abnormalities.

Methods

We conducted a single-center prospective study of consecutive male patients presenting with VH over eight months. All patients underwent standard investigations including physical examination, flexible cystoscopy (FC), and radiological imaging (ultrasound scan (USS) and/or computed tomography urogram (CTU)). Those with a clear history of initial or terminal VH were identified for further scrutiny with regards to detectable upper tracts abnormalities.

Results

In total, 57 patients (aged 23-95 years) with initial or terminal VH were identified. Of these, 56 had FC and nine patients were subsequently diagnosed with a LUT malignancy. With regards to upper urinary tract (UUT), 35 patients (61.4%) had an USS, 46 (80.7%) underwent a CTU, and 25 (43.9%) patients had both. In this group, no UUT malignancy was identified on upper tract imaging.

Conclusions

Initial or terminal VH patients may not need extensive upper tract imaging. FC is recommended, but a non-invasive USS can be a safe initial investigation for the UUT, with a CTU subsequently considered in those with abnormalities on USS and those with ongoing bleeding. Further combined multicenter analysis will help corroborate these findings and could have several beneficial outcomes including a reduction in investigations cost, patient inconvenience, and ionizing radiation.

Targeted metabolomics in bladder cancer: From analytical methods development and validation towards application to clinical samples

Bladder cancer constitutes the ninth most common cancer worldwide and, despite continuous development of new diagnostic approaches, the thirteenth leading cause of global cancer mortality. In our previous untargeted urine metabolomic investigation, seventeen metabolites were found to be statistically differentiating bladder cancer patients and healthy volunteers. Therefore, the main goal of this study was to develop and validate an analytical method for simultaneous quantitative determination of those metabolites using reversed phase high-performance liquid chromatography coupled with triple quadrupole mass spectrometry technique (RP-HPLC-QQQ/MS). Different chromatographic conditions, as well as various sample treatment procedures were tested in order to provide the best separation and the lowest limit of quantification (LOQ) values for studied compounds. The validation was performed according to the Food and Drug Administration guidelines (FDA). The limit of determination (LOD) and the LOQ values were in the range of 0.21-10.51 ng/ml and 0.69-35.02 ng/ml, respectively. The concentration range of compounds was developed between 2.5 and 12500 ng/ml. Only one compound (trimethyllysine) showed a significant matrix effect (61%) and consequently low process efficiency (64%). Overall, developed method presented recovery and precision values within the ranges proposed by FDA guidelines. The optimized and validated method was applied to urine samples obtained from 40 patients with bladder cancer and 40 healthy volunteers matched according to ones of the most important risk factors for developing urinary bladder tumors, e.i. age, gender and BMI. Afterwards, statistical analysis was provided by the use of Student's t-test or U-Mann Whitney test. The developed method was sensitive, selective and reproducible to be applied for the quantification of metabolites in the investigation of urine samples. As a consequence, ten out of previously chosen seventeen compounds, participating in different metabolites' pathways (gut floral metabolism, RNA degradation, purine metabolism, etc.), were found to be statistically significantly different in the urine concentration (p < 0.05) between cancer and control groups.

Correlation of Transabdominal Ultrasonography and Cystoscopy in Follow-up of Patients with Non-muscle Invasive Bladder Cancer

Cystoscopy (CS) is considered to be the gold standard in the follow-up of non-muscle invasive bladder cancer. However, CS is invasive, time-consuming, and expensive. On the other hand, modern sensitive transducers have improved the imaging of urinary tract rendering transabdominal ultrasonography (US) more effective in visualizing intraluminal filling defects in the bladder than it was in the past. Twenty-five follow-up patients of low-risk bladder cancer meeting the inclusion and exclusion criteria were included in study. Ultrasonography of the bladder was performed by a single senior radiologist, and subsequently, these patients were subjected to flexible cystoscopy under local anesthesia. Pain score was calculated for each of the cystoscopies done. Findings of transabdominal ultrasound of the bladder were correlated and compared with those of cystoscopy. Subjects with US and/or CS findings suggestive of recurrence underwent transurethral resection of bladder tumor (TURBT) under general anesthesia and confirmation of the bladder carcinoma was achieved by the histopathological examination. Mean patient age was 60.56 years with range of 29 to 77 years. The sensitivity of modern ultrasonographic techniques was found to be 84.61% with specificity of 91.7% taking flexible cystoscopy as the gold standard for detection of recurrence. The accuracy of US was 88% with positive predictive value of 91.7% and negative predictive value of 84.61%. Technological evolution has improved the accuracy of ultrasonography in diagnosis of bladder carcinoma. It represents a valuable surveillance tool in selected sub group of low risk non-muscle invasive bladder cancer patients.

Clinical Utility of Cxbladder for the Diagnosis of Urothelial Carcinoma

Introduction

This study aimed to demonstrate the clinical utility of non-invasive multigene Cxbladder urine tests in reducing the overall number of diagnostic tests and invasive procedures used in the clinical evaluation of patients presenting with microhematuria, a key symptom of urothelial carcinoma (UC). There is a belief that using non-invasive molecular diagnostic tests in patients with hematuria may lead to patients undergoing unnecessary and costly invasive procedures that can cause adverse events and decrease patient quality of life. The objective of this study was to determine whether or not this was the case, using Cxbladder.

Methods

Data from 396 patient-by-urologist interactions generated 792 decision points from a standardized cohort of 33 patients evaluated by 12 urologists. Participant physicians recommended a selection of tests and procedures based on referral data, then reviewed and amended their recommendations in the context of diagnostic information from Cxbladder used in the Triage and Triage and Detect clinical modalities.

Results

All urologists changed their diagnostic behavior in at least one patient case with the addition of Cxbladder results. The total number of diagnostic procedures was reduced by 5% and 25% following disclosure of results from Cxbladder in the Triage and the Triage and Detect modalities, respectively. The total number of requested invasive procedures was reduced from 425 at referral to 379 (−11%) and 292 (−31%) following disclosure of Cxbladder information in the Triage and Triage and Detect modalities, respectively.

Conclusions

Urologists made compelling changes to their clinical decision-making when they were provided with Cxbladder results for patients presenting with hematuria. Cxbladder provides an increase in clinical utility by focusing the use of invasive diagnostic procedures to appropriate patients, reducing both the total number and number of invasive procedures used in the clinical management of patients with hematuria, thereby improving the diagnostic experience and outcomes for patients.

Funding

Pacific Edge Ltd.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-017-0518-7) contains supplementary material, which is available to authorized users.

Voided urine versus bladder washing cytology for detection of urothelial carcinoma: which is better?

OBJECTIVE

Cytology is recommended as part of the follow-up of high-grade non-muscle-invasive bladder cancer (NMIBC). However, currently there are no solid guideline recommendations regarding the use of voided urine versus bladder washing for cytology as part of the diagnosis or follow-up of NMIBC. The aim of this study was to investigate whether the cytological outcome was equal regarding the two techniques.

MATERIALS AND METHODS

The authors reviewed all outpatient flexible cystoscopies carried out in their department in 2013. Patient records in the registry of pathology were examined and those with simultaneous urine and bladder washing cytology were included. Previous urothelial disease and positive histology within 3 months after the cystoscopy were registered.

RESULTS

A total of 1458 patients had both voided urine and bladder washing cytology and were included in the study, of whom 643 (44%) had a history of urothelial disease. An equal outcome of urine and bladder washing cytology was found in 1447 patients (99.2%). For the remaining 11 patients, only four patients underwent further examinations based on cytology findings in addition to what had already been planned after cystoscopy. Of the included patients, 100 (6.9%) had a positive histological outcome within 3 months.

CONCLUSIONS

In most patients, no relevant difference between voided urine and bladder washing cytology was observed. Therefore, if cytology is indicated, it is recommended to use the test that is most readily available locally. The additional gain in using both urine and bladder wash is minimal, and can therefore be discarded.

Evaluation of microscopic hematuria: a critical review and proposed algorithm

Microscopic hematuria (MH), often discovered incidentally, has many causes, including benign processes, kidney disease, and genitourinary malignancy. The clinician, therefore, must decide how intensively to investigate the source of MH and select which tests to order and referrals to make, aiming not to overlook serious conditions while simultaneously avoiding unnecessary tests. Existing professional guidelines for the evaluation of MH are largely based on expert opinion and have weak evidence bases. Existing data demonstrate associations between isolated MH and various diseases in certain populations, and these associations serve as the basis for our proposed approach to the evaluation of MH. Various areas of ongoing uncertainty regarding the appropriate evaluation should be the basis for ongoing research.

A segregation index combining phenotypic (clinical characteristics) and genotypic (gene expression) biomarkers from a urine sample to triage out patients presenting with hematuria who have a low probability of urothelial carcinoma

Background

Hematuria can be symptomatic of urothelial carcinoma (UC) and ruling out patients with benign causes during primary evaluation is challenging. Patients with hematuria undergoing urological work-ups place significant clinical and financial burdens on healthcare systems. Current clinical evaluation involves processes that individually lack the sensitivity for accurate determination of UC. Algorithms and nomograms combining genotypic and phenotypic variables have largely focused on cancer detection and failed to improve performance. This study aimed to develop and validate a model incorporating both genotypic and phenotypic variables with high sensitivity and a high negative predictive value (NPV) combined to triage out patients with hematuria who have a low probability of having UC and may not require urological work-up.

Methods

Expression of IGFBP5, HOXA13, MDK, CDK1 and CXCR2 genes in a voided urine sample (genotypic) and age, gender, frequency of macrohematuria and smoking history (phenotypic) data were collected from 587 patients with macrohematuria. Logistic regression was used to develop predictive models for UC. A combined genotypic-phenotypic model (G + P INDEX) was compared with genotypic (G INDEX) and phenotypic (P INDEX) models. Area under receiver operating characteristic curves (AUC) defined the performance of each INDEX: high sensitivity, NPV >0.97 and a high test-negative rate was considered optimal for triaging out patients. The robustness of the G + P INDEX was tested in 40 microhematuria patients without UC.

Results

The G + P INDEX offered a bias-corrected AUC of 0.86 compared with 0.61 and 0.83, for the P and G INDEXs respectively. When the test-negative rate was 0.4, the G + P INDEX (sensitivity = 0.95; NPV = 0.98) offered improved performance compared with the G INDEX (sensitivity = 0.86; NPV = 0.96). 80% of patients with microhematuria who did not have UC were correctly triaged out using the G + P INDEX, therefore not requiring a full urological work-up.

Conclusion

The adoption of G + P INDEX enables a significant change in clinical utility. G + P INDEX can be used to segregate hematuria patients with a low probability of UC with a high degree of confidence in the primary evaluation. Triaging out low-probability patients early significantly reduces the need for expensive and invasive work-ups, thereby lowering diagnosis-related adverse events and costs.

Investigation of two week wait referred haematuria patients in the UK: A national survey

Aim:

To analyse current UK practice for investigation of patients with visible haematuria (VH) or non-visible haematuria (NVH) who meet referral criteria according to National Institute of Clinical Excellence referral guidelines for suspected cancer.

Patients and methods:

Questionnaires were sent to 131 trusts. Data collected included demographics, conformity with NICE improving outcomes in urological cancer guidelines, standard first line investigations into VH and NVH and criteria for second line investigations.

Results:

Seventy-two trusts (55%) responded from 15 deaneries including 48 cancer centres. Almost two-thirds (63.9%) provide a one-stop service. First line investigations into VH varied considerably: 82% of trusts undertake urine tests (cytology 43.0%); three-quarters perform blood tests (prostate-specific antigen 54.2%); all conduct varying radiological imaging of the upper tracts; 95.8% of patients had flexible cystoscopy. Forty per cent of trusts’ first line investigations differ for NVH. Triple phase computed tomography-urogram is not routinely undertaken. Of the trusts, 55.5% perform second line investigations for VH and 55.5% for recurrent VH including computed tomography-urogram or retrograde studies; 20.5% perform non-contrast helical computed tomography scan of the kidneys, ureters and bladder or urine cytology for NVH if the history is indicative.

Conclusion:

Across trusts, there are wide variations in the regimes for investigation of haematuria. Development of an evidence based guideline to standardise practice across the National Health Service for haematuria referrals is required to abolish the postcode lottery system.

The health economics of bladder cancer: an updated review of the published literature

The purpose of this paper is to provide a current view of the economic burden of bladder cancer, with a focus on the cost effectiveness of available interventions. This review updates a previous systematic review and includes 72 new papers published between 2000 and 2013. Bladder cancer continues to be one of the most common and expensive malignancies. The annual cost of bladder cancer in the USA during 2010 was $US4 billion and is expected to rise to $US5 billion by 2020. Ten years ago, urinary markers held the potential to lower treatment costs of bladder cancer. However, subsequent real-world experiments have demonstrated that further work is necessary to identify situations in which these technologies can be applied in a cost-effective manner. Adjunct cytology remains a part of diagnostic standard of care, but recent research suggests that it is not cost effective due to its low diagnostic yield. Analysis of intravesical chemotherapy after transurethral resection of bladder tumor (TURBT), neo-adjuvant therapy for cystectomy, and robot-assisted laparoscopic cystectomy suggests that these technologies are cost effective and should be implemented more widely for appropriate patients. The existing literature on the cost effectiveness of bladder cancer treatments has improved substantially since 2000. The body of work now includes many new models, registry analyses, and real-world studies. However, there is still a need for new implementation guidelines, new risk modeling tools, and a better understanding of the empirical burden of bladder cancer.

Utility of urine cytology in evaluating hematuria with sonographically suspected bladder lesion in patients older than 50 years

Purpose:

Investigate the utility of urine cytology (UC) in patients older than 50 years with hematuria and sonographically suspected bladder lesion.

Patients and Methods:

Between April 2010 and June 2012, 152 patients above 50 years suffering from hematuria were included in this study. In all patients, ultrasound revealed a lesion suspected to be bladder cancer. Voided urine specimens were taken from all patients and transported to Pathology laboratory and processed within 1-3 h. All patients have undergone a cystoscopy examination and biopsy was taken from any suspicious lesion. The cytological diagnosis was reported as one of three categories, positive or negative or suspicious for malignancy.

Results:

One hundred thirty three (87.5%) patients in this study proved to have bladder carcinoma in histopathological examination. The sensitivity of UC was 53.4% and only five patients were suspicious. Percentage of positive cytology was highest among patients having gross hematuria (51.3%), posterior wall lesions (75%), papillonodular configuration (81.8%), invasive cancer (59.1%) and bilharzial affection (52.5%).

Conclusion:

Hematuria in patients older than 50 years with sonographically suspected bladder lesion mandates cystoscopy and biopsy. UC does not add more significant information in this group of patients.

Streamlining the assessment of haematuria: 3-year outcomes of a dedicated haematuria clinic

BACKGROUND

Urgent assessment of haematuria is critical to exclude malignancy. The objective of this study is to report the outcomes of the first 3 years of a dedicated haematuria clinic at the Royal Melbourne Hospital, a Victorian tertiary hospital.

METHODS

All patients assessed in the haematuria clinic from April 2010 to April 2013 were included in the analysis. Outcomes were recorded prospectively and analysed retrospectively.

RESULTS

A total of 643 patients were seen in the haematuria clinic with non-visible (170, 26%) and visible haematuria (463, 72%) during this time period, all within 28 days of referral being triaged. Sixty-five (10%) patients were diagnosed with urothelial carcinoma, 63 with lower tract disease and two with upper tract urothelial carcinoma and another five (1%) patients with other tumours. Thirty out of 63 (48%) of the bladder urothelial carcinomas were invasive or high-grade. Two hundred and sixty-seven (42%) patients were discharged from the clinic after a single point of contact. One hundred and fifty-three (24%) patients were referred for further definitive management of suspected pathology. Two hundred and twenty-three (34%) patients were referred to outpatients clinic for further investigations. Urothelial carcinoma was diagnosed more often in males, older patients and patients with visible haematuria.

CONCLUSION

The Royal Melbourne Hospital haematuria clinic has served as an effective tool for rapid, streamlined assessment of patients presenting with haematuria. Follow-up of investigations by nurses and moving towards a 'one-stop' approach are helping to further decrease the number of patients requiring a second clinic visit.

Cytological findings in routine voided urine samples with hematuria from a tertiary care center in south India

Background:

Regardless of the availability of newer and more sophisticated modalities of investigation, urinary tract cytology still remains the most commonly used non-invasive test for the diagnosis of bladder cancer.

Aims:

As hematuria is the commonest presenting symptom in patients with malignancy of urinary tract, we undertook this study to know the usefulness of urine cytology in evaluation of the hematuric patients for malignancy.

Materials and Methods:

A total of 21,557 fresh voided urine samples received at our tertiary care referral centre over a period of three years were included in the study. Of these, 1428 cases had hematuria, criteria of either gross or microscopic.

Results:

Among these hematuric cases included in the study, 32.5% (464 cases) were found to have positive finding of atypical cells. In these cases with atypia, 9.5% (136 cases) were proved to have malignancy both with the histopathological biopsy and cystoscopic findings. Other cases of atypia were found to be of reactive origin, either due to instrumentation or foreign body. A large number of hematuric cases, that is, 964 cases (67.5%) were negative for atypical cells.

Conclusions:

The limited ability of urine cytology to detect low grade bladder tumors, its subjectivity and lack of uniformity in reporting, all render urine cytology a less than perfect tool. With added collaboration between clinician and cytopathologist, urine cytology can be used an adjunct tool in evaluation of patients with hematuria.

Follow-up procedures for non-muscle-invasive bladder cancer: an update

Bladder carcinoma is the most common malignancy of the urinary tract. Approximately 75-85% of patients present with a disease that is confined to the mucosa (stage Ta, carcinoma in situ) or submucosa (stage T1). The stratification of patients to low-, intermediate- and high-risk groups represents the cornerstone for the indication of adjuvant and follow-up treatment. Owing to the high recurrence rate of bladder tumors, a surveillance protocol is recommended to all patients. Currently, the combination of cystoscopy, imaging and urinary cytology represent the follow-up. A systematic review of the recent English literature on follow-up procedures of non-muscle-invasive bladder cancer is performed. The authors review the existing follow-up procedures, with a focus on novel molecular-targeted approaches. At the present time, the additional use and utility of urine-based molecular markers in the follow-up of patients remains unclear and we have to rely on cystoscopic evaluation adapted to risk group classification.

The influence of urine cytology on our practice

OBJECTIVE

Bladder cancer is a common malignancy. It is ranked ninth among male population in Saudi Arabia. Urine cytology is used by some physicians routinely in the workup for diagnosis and follow-up of patients with urothelial cancer. Our objective is to determine whether urine cytology is still essential in the work up of suspected urothelial cancer patients and to measure its cost-effectiveness.

MATERIALS AND METHODS

We reviewed all urine cytology reports that were performed over a period of five years from 2006 to 2010 in the International Medical Center in Jeddah, Saudi Arabia. The medical records of patients with cytology reports of both positive for malignant cells and atypical cells suspicious of malignancy were retrospectively, studied for age, sex, nationality, cystoscopic findings, imaging results, and total cost.

RESULTS

A total of 563 urine cytology tests were done on 516 patients. Two patients were positive for malignant cell and 10 showed atypical cells suspicious of malignancy. All 12 patients underwent imaging and/or cystoscopy as part of their complete work up for hematuria. The two patients with positive cytology had a cystoscopic confirmation of bladder tumor. In the 10 patients with atypical cells, bladder tumor was identified in seven using cystoscopy and/or imaging. The mean age was 54.6±16 year (range 15-95). The total cost was 140,750 SR (37,533 USD) for a yield of 0.3% positive results and 2% atypical cytology.

CONCLUSION

Routine urine cytology did not affect the diagnostic strategy for urothelial cancer. It should be only used in selected patients.

Hematuria one-stop clinic: first experience in Italy with 150 cases

OBJECTIVES

Starting from the UK experience, we decided to test both the feasibility and the advantages of this diagnostic pathway now established in an Italian hospital. We analyzed the outcomes in detecting transitional cell carcinoma (TCC) of the bladder, other malignant and non-malignant conditions.

MATERIALS AND METHODS

Between April and December 2010, one hundred and fifty patients presenting with hematuria were referred to the Hematuria One Stop Clinic (HOSC) at our Institution. Each patient underwent a visit, a Urinary Tract Ultrasound, a Cystoscopy and CT IVP in selected cases (evidence of alterations or lesions of the renal parenchyma, presence of stones of the urinary tract, evidence of doubtful or positive urinary cytology). Where a TCC of the bladder was diagnosed, the patient underwent TUR-BT. In other cases (stones, BPH etc.) the appropriate therapeutic pathway was followed.

RESULTS

25.3% of patients with hematuria were found to have a bladder cancer; 21.3% had a urinary stone (2% in the bladder); 1.3% had prostate cancer; 1.3% had a renal cell carcinoma. The mean age was 69.8 yrs. 6% of the patients (23.6% on patients with TCC of the bladder) had a G3 disease. The mean time from admission to the HOSC until the operation day, in case of TCC of the bladder, was 10.61 days.

CONCLUSIONS

The Italian experience of the One Stop Clinic confirms a high rate of bladder cancer detection. Furthermore, a high rate of non-malignant conditions was detected, stressing the importance of the HOSC not only as a cancer clinic but as a complete general urological clinic. We report a shorter waiting time to operation, especially for bladder TCC G3 patients.

Evaluation of diagnostic strategies for bladder cancer using computed tomography (CT) urography, flexible cystoscopy and voided urine cytology: results for 778 patients from a hospital haematuria clinic

Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Haematuria clinics with same day imaging and flexible cystoscopy are an efficient way for investigating patients with haematuria. The principal role of haematuria clinics with reference to bladder cancer is to determine which patients are 'normal' and may be discharged, and which patients are abnormal and should undergo rigid cystoscopy. It is well recognised that CT urography offers a thorough evaluation of the upper urinary tract for stones, renal masses and urothelial neoplasms but the role of CT urography for diagnosing bladder cancer is less certain. The aim of the present study was to evaluate the diagnostic accuracy of CT urography in patients with visible haematuria aged >40 years and to determine if CT urography has a role for diagnosing bladder cancer. This study shows that the optimum diagnostic strategy for investigating patients with visible haematuria aged >40 years with infection excluded is a combined strategy using CT urography and flexible cystoscopy. Patients positive for bladder cancer on CT urography should be referred directly for rigid cystoscopy and so avoid flexible cystoscopy. The number of flexible cystoscopies required therefore may be reduced by 17%. The present study also shows that the diagnostic accuracy of voided urine cytology is too low to justify its continuing use in a haematuria clinic using CT urography and flexible cystoscopy.

OBJECTIVES

To evaluate and compare the diagnostic accuracy of computed tomography (CT) urography with flexible cystoscopy and voided urine cytology for diagnosing bladder cancer. To evaluate diagnostic strategies using CT urography as: (i) an additional test or (ii) a replacement test or (iii) a triage test for diagnosing bladder cancer in patients referred to a hospital haematuria rapid diagnosis clinic.

PATIENTS AND METHODS

The clinical cohort consisted of a consecutive series of 778 patients referred to a hospital haematuria rapid diagnosis clinic from 1 March 2004 to 17 December 2007. Criteria for referral were at least one episode of macroscopic haematuria, age >40 years and urinary tract infection excluded. Of the 778 patients, there were 747 with technically adequate CT urography and flexible cystoscopy examinations for analysis. On the same day, patients underwent examination by a clinical nurse specialist followed by voided urine cytology, CT urography and flexible cystoscopy. Voided urine cytology was scored using a 5-point system. CT urography was reported immediately by a uroradiologist and flexible cystoscopy performed by a urologist. Both examinations were scored using a 3-point system: 1, normal; 2, equivocal; and 3, positive for bladder cancer. The reference standard consisted of review of the hospital imaging and histopathology databases in December 2009 for all patients and reports from the medical notes for those referred for rigid cystoscopy. Follow-up was for 21-66 months.

RESULTS

The prevalence of bladder cancer in the clinical cohort was 20% (156/778). For the diagnostic strategy using CT urography as an additional test for diagnosing bladder cancer, when scores of 1 were classified as negative and scores of 2 and 3 as positive, sensitivity was 1.0 (95% confidence interval [CI] 0.98-1.00), specificity was 0.94 (95% CI 0.91-0.95), the positive predictive value (PPV) was 0.80 (95% CI 0.73-0.85) and the negative predictive value (NPV) was 1.0 (95% CI 0.99-1.00). For the diagnostic strategy using CT urography as a replacement test for flexible cystoscopy for diagnosing bladder cancer, when scores of 1 were classified as negative and scores of 2 and 3 as positive, sensitivity was 0.95 (95% CI 0.90-0.97), specificity was 0.83 (95% CI 0.80-0.86), the PPV was 0.58 (95% CI 0.52-0.64), and the NPV was 0.98 (95% CI 0.97-0.99). Similarly using flexible cystoscopy for diagnosing bladder cancer, if scores of 1 were classified as negative and scores of 2 and 3 as positive, sensitivity was 0.98 (95% CI 0.94- 0.99), specificity was 0.94 (95% CI 0.92-0.96), the PPV was 0.80 (95% CI 0.73-0.85) and the NPV was 0.99 (95% CI 0.99-1.0). For the diagnostic strategy using CT urography and flexible cystoscopy as a triage test for rigid cystoscopy and follow-up (option 1), patients with a positive CT urography score are referred directly for rigid cystoscopy, and patients with an equivocal or normal score were referred for flexible cystoscopy. Sensitivity was 1.0 (95% CI 0.98-1.0), specificity was 0.94 (95% CI 0.91-0.95), the PPV was 0.80 (95% CI 0.73-0.85), and the NPV was 1.0 (95% CI 0.99-1.0). For the diagnostic strategy using CT urography and flexible cystoscopy as a triage test for rigid cystoscopy and follow-up (option 2), patients with a positive CT urography score are referred directly for rigid cystoscopy, patients with an equivocal score are referred for flexible cystoscopy and patients with a normal score undergo clinical follow-up. Sensitivity was 0.95 (95% CI 0.90-0.97), specificity was 0.98 (95% CI 0.97-0.99), the PPV was 0.93 (95% CI 0.87-0.96), and the NPV was 0.99 (95% CI 0.97-0.99). For voided urine cytology, if scores of 0-3 were classified as negative and 4-5 as positive for bladder cancer, sensitivity was 0.38 (95% CI 0.31-0.45), specificity was 0.98 (95% CI 0.97-0.99), the PPV was 0.82 (95% CI 0.72-0.88) and the NPV was 0.84 (95% CI 0.81-0.87).

CONCLUSIONS

There is a clear advantage for the diagnostic strategy using CT urography and flexible cystoscopy as a triage test for rigid cystoscopy and follow-up (option 1), in which patients with a positive CT urography score for bladder cancer are directly referred for rigid cystoscopy, but all other patients undergo flexible cystoscopy. Diagnostic accuracy is the same as for the additional test strategy with the advantage of a 17% reduction of the number of flexible cystoscopies performed. The sensitivity of voided urine cytology is too low to justify its continuing use in a hospital haematuria rapid diagnosis clinic using CT urography and flexible cystoscopy.

Computed tomography-urography for upper urinary tract imaging: is it required for all patients who present with hematuria?

PURPOSE

To define in which patients who present with microscopic or macroscopic hematuria CT urography (CTU) is indicated as an imaging mode for the upper urinary tract (UUT).

PATIENTS AND METHODS

We conducted a prospective study on consecutive patients who attended a modern protocol-driven hematuria clinic from January 2006 to February 2010. Standard tests (history taking, physical examination, urinalysis via dipstick method, ultrasonography of kidneys and bladder performed by urologists, cystoscopy, and cytology) were directed to all patients, whereas the mode of additional UUT imaging (ultrasonography by a radiologist or four-phase CTU/magnetic resonance (MR) urography (MRU) when CTU was contraindicated) was selected according to a risk factor-based management algorithm. The added value of cross-sectional urography (CTU/MRU) supplementary to ultrasonography (by urologists) to detect renal masses, UUT tumors, and stones was assessed. Univariate and multivariate analysis on predictive factors for cross-sectional urography result were performed.

RESULTS

From the total of 841 patients, lesions that might account for hematuria could not be identified in 462 (54.9%), whereas in 250 (29.7%) and 124 (14.7%) patients, hematuria was from benign and malignant disease, respectively. Cross-sectional urography revealed relevant UUT lesions in 73 of 525 (13.9%) patients. Only result of ultrasonography (odds ratio [OR] 7.7, 95% confidence interval [CI] 4.0-14.9), P<0.001) and type of hematuria (OR 2.6, 95% CI 1.3-5.1, P=0.01) were significant predictors for cross-sectional urography result. In 44 of 456 (9.6%) patients with no abnormalities on ultrasonography, CTU/MRU revealed that these were false negatives, with most lesions missed being stones. In 253 of 309 (81.9%) patients with macroscopic hematuria, no lesions were detected in the UUT on CTU/MRU, in contrast to 199 of 216 patients (92.1%) with microscopic hematuria.

CONCLUSION

For patients who present with microscopic hematuria, ultrasonography is sufficient to exclude significant UUT disease. For patients with macroscopic hematuria, the likelihood of finding UUT disease is higher, and a CTU as a first-line test seems justified.

The accuracy of ultrasonography in the diagnosis of superficial bladder tumors in patients presenting with hematuria

Ultrasonography has been proposed as the initial test for detection of bladder carcinomas in patients presenting with hematuria, but the accuracy of transabdominal ultrasonography in the diagnosis of superficial bladder carcinoma has not been assessed. We prospectively evaluated 173 patients presenting to the outpatient department with painless hematuria by transabdominal ultrasound and cystoscopy. The tolerability of cystoscopy was also assessed. Of 148 patients who met the inclusion criteria, 39 with bladder carcinoma were identified by cystoscopy as having bladder carcinoma, while 34 were identified by ultrasonography. For ultrasonography, the sensitivity (87.1%), specificity (98.1%), positive predictive value (94.4%) and negative predictive value (95.4%) were good but not as good as cystoscopy. While the tolerability of cystoscopy is relatively low, it is still superior to ultrasonography in the evaluation of the bladder as a possible source of hematuria.

The role of chemotherapy in upper tract urothelial carcinoma

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

The Use of the NMP22 BladderChek Test for Bladder Cancer to Optimise Investigations in a One-Stop Haematuria Clinic

Objective:

We assessed the value of the NMP22 BladderChek point-of-care (POC) test (Kyowa Hakko UK Ltd., Slough, UK) in a one-stop haematuria clinic to optimise the choice of further investigations.

Patients and methods:

Over 34 months from 2005 until 2007, 590 patients presenting to a haematuria clinic were initially assessed with the NMP22 POC test. Patients with a positive NMP22 were counselled and offered further investigation with upper tract imaging and a general anaesthetic cystoscopy without first undergoing flexible cystoscopy (FC). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the NMP22 POC test in this setting were calculated. The financial impact of this policy was assessed.

Results:

In total 58 of 590 men were NMP22 positive. Urothelial malignancy was identified in 22 patients and 5 had a non-urothelial malignancy of the genitourinary system. The sensitivity of the NMP22 test in detecting urothelial malignancy in newly presenting patients was 56.4%, specificity 93.5%, PPV 38.0% and NPV 97.0%. Eleven had no abnormality and none have subsequently developed a malignancy. The number of patients requiring FC fell by 10% resulting in significant financial savings.

Conclusion:

The NMP22 POC test can be used as the first test in a haematuria clinic to optimise the choice of subsequent investigations resulting in financial savings.