Can Renal and Bladder Ultrasound Replace Computerized Tomography Urogram in Patients Investigated for Microscopic Hematuria?

Abstract

PurposeComputerized tomography urogram is recommended when investigating patients with hematuria. We determined the incidence of urinary tract cancer and compared the diagnostic accuracy of computerized tomography urogram to that of renal and bladder ultrasound for identifying urinary tract cancer.Materials and MethodsThe DETECT (Detecting Bladder Cancer Using the UroMark Test) I study is a prospective observational study recruiting patients 18 years old or older following presentation with macroscopic or microscopic hematuria at a total of 40 hospitals. All patients underwent cystoscopy and upper tract imaging comprising computerized tomography urogram and/or renal and bladder ultrasound.ResultsA total of 3,556 patients with a median age of 68 years were recruited in this study, of whom 2,166 underwent renal and bladder ultrasound, and 1,692 underwent computerized tomography urogram in addition to cystoscopy. The incidence of bladder, renal and upper tract urothelial cancer was 11.0%, 1.4% and 0.8%, respectively, in macroscopic hematuria cases. Patients with microscopic hematuria had a 2.7%, 0.4% and 0% incidence of bladder, renal and upper tract urothelial cancer, respectively. The sensitivity and negative predictive value of renal and bladder ultrasound to detect renal cancer were 85.7% and 99.9% but they were 14.3% and 99.7%, respectively, to detect upper tract urothelial cancer. Renal and bladder ultrasound was poor at identifying renal calculi. Renal and bladder ultrasound sensitivity was lower than that of computerized tomography urogram to detect bladder cancer (each less than 85%). Cystoscopy had 98.3% specificity and 83.9% positive predictive value.ConclusionsComputerized tomography urogram can be safely replaced by renal and bladder ultrasound in patients who have microscopic hematuria. The incidence of upper tract urothelial cancer is 0.8% in patients with macroscopic hematuria and computerized tomography urogram is recommended. Patients with suspected renal calculi require noncontrast renal tract computerized tomography. Imaging cannot replace cystoscopy to diagnose bladder cancer.

Does urinary cytology have a role in haematuria investigations?

“…Under ideal conditions, CTU has been shown to achieve a sensitivity of 95% and an NPV of 98%, suggesting that CTU can be used as a form of triage to refer patients directly for rigid cystoscopy where transurethral resection of bladder tumour can be performed, bypassing the need for flexible cystoscopy [30]. While we did not find such a high sensitivity and NPV for both CTU and RBUS for the detection of cancer in our patient cohort, we found that the combination of urinary cytology with imaging resulted in an improved sensitivity for the detection of cancer, but this improvement was not sufficient to replace cystoscopy [12].…”

“…The combination of urinary cytology with CTU (sensitivity: 92.3, specificity: 94.9%) was superior to urinary cytology with RBUS (sensitivity: 66.7%, specificity: 96.7%). By comparison, CTU alone achieved a diagnostic performance of sensitivity 80.5%, specificity 97.0%, PPV 79.3% and NPV 97.2%, while RBUS had a sensitivity of 50.7%, a specificity of 99.3%, a PPV 84.3% and an NPV of 96.5% .…”

Impact of the COVID-19 Pandemic on the Urologist’s clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period

“…The gold standard test for investigation of the upper urinary tract is uro-tomography, but in times when we need to consider the use of resources, ultrasound could potentially be used since many imaging services are overloaded due to the frequent indication of thoracic CTs for the diagnosis and follow-up of patients with Sars-Cov-2. These data are extrapolations from recent evidence that ultrasound could replace tomography in the investigation of microscopic hematuria (14). However, once the outbreak is resolved or if the resource is available, uro-tomography should be performed.…”

“…In all other cases, even if there is urinary retention, we recommend postponing the procedure. If necessary, indwelling urinary catheter placement or percutaneous cystostomy with local anesthesia are indicated for preservation of renal function (13,14).…”

Exploring patients’ experience and perception of being diagnosed with bladder cancer: a mixed‐methods approach

“…Nevertheless, patients were psychologically affected particularly between the period of initial cancer diagnosis after flexible cystoscopy and TURBT. This interval represents a period of great uncertainty, where patients are often told of a diagnosis of cancer given the high positive predictive value of cystoscopy but are not informed of disease prognosis given the lack of histopathology [15]. While the implementation of the '2-week wait' pathway in the UK has reduced the time from primary care referral to urology consultation for the investigation of haematuria and diagnosis of bladder cancer, the time to treatment has not reduced [16].…”