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

Abstract

What ' s known on the subject? and What does the study add?Haematuria clinics with same day imaging and fl exible cystoscopy are an effi cient 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 fl exible cystoscopy. Patients positive for bladder cancer on CT urography should be referred directly for rigid cystoscopy and so avoid fl exible cystoscopy. The number of fl exible 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 fl exible cystoscopy. OBJECTIVES• To evaluate and compare the diagnostic accuracy of computed tomography (CT) urography with fl exible 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 fl exible cystoscopy examinations for analysis.• On the same day, patients underwent examination by a clinical nurse specialist followed by voided urine cytology, CT urography and fl exible cystoscopy. Voided urine cytology was scored using a 5-point system. CT urography was reported immediately by a uroradiologist and fl exible 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% (156/77...

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