Practical use of investigations in patients with hematuria

OBJECTIVE: The majority of patients with microscopic hematuria undergo a complete evaluation resulting in negative findings. The outcome of patients with hematuria was analyzed in an effort to optimize the use of investigations. PATIENTS AND METHODS: The records for 404 patients who presented with hematuria were reviewed. Data were collected on demographics, type of hematuria, investigations, and final diagnosis. RESULTS: The hematuria was microscopic in 140 patients (35%) and gross in 264 patients (65%). In gross hematuria patients, 10% had urinary tract tumors and 12% had calculi. All patients with genitourinary tumors and 87% of patients with calculi had gross hematuria and/or > or =5 RBCs/HPF (red blood cells per high-power microscopic field) on urinalysis. The sensitivity and specificity were 94% and 6% for the dipstick urine test, 37% and 71% for urine cytology, 92% and 93% for computed tomography (CT), 50% and 95% for ultrasound scans, and 38% and 90% for intravenous pyelography, respectively. Logistic regression analysis showed that age and number of RBCs/HPF in the urinalyses were the only significant factors predicting genitourinary cancer. In patients < or =40 years old, there was one patient with malignancy and seven patients with stones. In older patients, there were 31 patients with malignancy and 32 patients with stones. CONCLUSIONS: Patients with <5 RBCs/HPF on three urinalyses are unlikely to have significant pathology and could possibly be followed up conservatively. Patients < or =40 years of age should have a noncontrast CT or ultrasound study if they present with microscopic hematuria, and a cystoscopy should be added if gross hematuria exists. In older patients, a pre- and postcontrast CT and a cystoscopy should be performed.     

Methods and current significance of the evaluation of microscopic haematuria

Haematuria is the main symptom of malignant diseases of the urinary tract. Hence urine analysis for the detection of microscopic haematuria is an accepted diagnostic procedure in daily urologic practice. Until now there are neither international nor national agreements relating to the definition of microscopic haematuria, the choice of verification procedures and a diagnostic algorithm. As there are diverse reasons for microscopic haematuria the extent of continuative diagnostics should be adapted to the existence of risk factors for a clinically apparent disease. Low-risk patients with asymptomatic microscopic haematuria do not necessarily have to undergo primary cystoscopy if there are no pathological findings on urine cytology or ultrasound examination. Microhaematuria in high-risk patients should lead to a more intensive evaluation of the urinary tract, which should include cystoscopy and imaging of the upper urinary tract. In the diagnostics of microhaematuria you have to be aware of that intermittent bleeding is often characteristic of urothelial malignancies. Therefore, a single negative urine analysis should not lead to abandonment of further diagnostic procedures.     

输尿管肾镜术处理上尿路血尿

目的　提高上尿路血尿的诊治水平。　方法　血尿病例 12 1例 ,经B超、KUB加IVU、CT及膀胱镜检查怀疑为上尿路来源 ,行输尿管肾镜进一步明确诊断并采取相应治疗措施。　结果　输尿管肾镜术对上尿路血尿的诊断率为 92 % (111/ 12 1) ,诊断输尿管中下段小结石 4 5例 ;肾盂输尿管肿瘤 32例 ,其中 <10mm者 3例 ;肾出血性疾病 19例 ;输尿管息肉 15例。 19例肾出血性疾病和 10例未发现明确病灶者治疗后随访 6个月～ 8年 ,长期成功率 79% (2 3/ 2 9)。　结论　应用输尿管肾镜术诊断和处理上尿路血尿效果良好 ,值得推广。     

Value of selective upper tract cytology for recognition of upper tract tumors after treatment of superficial bladder cancer

Background: The value of selective upper urinary tract (UT) cytology in patients who are asymptomatic and tumor free at control cystoscopy after being treated for superficial bladder carcinoma has not been studied. The present study was performed to evaluate the value of selective UT cytology in patients who are tumor free at control cystoscopy after being treated for superficial bladder cancer. Methods: Forty‐seven consecutive patients who had undergone definitive surgical treatment for superficial bladder cancer at least 24 months prior and were tumor free at control cystoscopy were evaluated with bladder wash for cytology as well as selective UT urine cytology by catheterization of both ureteral orifices. Of the 47 patients, disease was stage Ta in 30 (63.8%), T1 in 15 (31.9%) and Ta/Tcis in 2 (4.3%). Primary tumor was unifocal in 24 (51.1%) and multifocal in 23 (48.9%) patients. The time elapsed from the initial diagnosis to the last evaluation ranged from 2 to 21 years (mean 5.39). Results: UT cytology was positive in 2 cases. Although, excretory urography (IVP) revealed mild pelvicalicectasis in 1 of these 2 patients, ureterorenoscopy (URS) revealed no abnormality. In the other patient with normal IVP and retrograde pyelography (RGP), URS revealed a ureteral tumor 5 mm in diameter. Although the UT cytology was normal in the remaining 45 patients, IVP revealed right hydronephrosis in 1 patient and URS revealed multiple ureteral tumors. Conclusion: Given the normal appearance of the UT, it is highly unlikely that these patients have tumor in the UT. Thus, during the follow‐up of patients with superficial bladder cancer, it is not useful to perform UT select cytology in the absence of any identifiable filling defects in the upper urinary tract.     

Diagnostik von Urothelkarzinomen des oberen Harntrakts

Upper urinary tract transitional cell carcinomas represent 5–6% of all urothelial carcinomas. Macroscopic hematuria is the most common symptom. The diagnostic algorithm contains medical history, clinical investigation, cystoscopy, urinary cytology, ultrasound and intravenous urography. When suspected, a complementary retrograde pyeloureterography with collecting selective urinary cytology is conducted. When radiological findings are doubted or when conservative treatment is planned, an ureterorenoscopy for biopsy of the suspected area is indicated. Computed tomography and magnetic resonance tomography is used to define the local extension of invasive tumors and to detect metastases. The use of urinary markers in the diagnosis of upper urinary tract urothelial carcinoma has to be evaluated in prospective trials.     

Is it necessary to perform urine cytology in screening patients with haematuria?

All patients with gross haematuria and those older than 50 years with microscopic haematuria need investigations to rule out the presence of a urological malignancy. OBJECTIVE: To study the role of urine cytology in the evaluation of patients with haematuria. METHODS: Two hundred and eighty-five patients were evaluated. All patients underwent evaluation including urine cytology, flexible cystoscopy, ultrasonography and/or IVU. RESULTS: The mean age of the patients was 62.4 years. Sixty-five percent had gross and 35% microscopic haematuria. Fifty-five tumours were discovered (19.2%); of these 48 were transitional cell carcinomas, 3 renal cell carcinomas and 3 carcinomas of the prostate. Thirty-seven urinary cytologies were abnormal. The overall sensitivity of urinary cytology was 42.4% and specificity 94.3%. Of 18 patients with positive cytology, all were found to have transitional cell carcinomas on cystoscopy or imaging. Of 19 patients with suspicious cytologies, only 6 were found to have tumours. The remaining 13 patients had no evidence of tumour on combined upper tract imaging (IVU and ultrasound) or on rigid cystoscopy and bladder biopsy. Whilst all the other investigation modalities contributed to diagnoses (and/or exclusion of tumours), no additional tumours were discovered solely by urinary cytology. A moderate cost saving could be made without compromising diagnostic accuracy. CONCLUSION: Our study suggests that performing routine urine cytology is not relevant in the investigation of patients with haematuria, its role is at best supportive.     

Microscopic hematuria after blunt trauma. Is pyelography necessary?

Hematuria after blunt abdominal trauma is common with multiple organ system injuries, and many trauma centers routinely perform intravenous pyelography (IVP) on all trauma patients having any degree of hematuria. However, it has been suggested that many IVPs could be avoided if more selective criteria were used. To help determine the need for an IVP, we reviewed the records of 102 consecutive patients undergoing IVP after blunt abdominal trauma over a 17-month period. Twenty-six (25%) patients had gross hematuria. Of these, seven (27%) had abnormal IVPs, and two (7.7%) of those required urologic surgery. Seventy-six (75%) patients had microscopic hematuria. Of these, one (1.3%) had an abnormal IVP but required no urologic surgery. Thus, if IVP had been performed only when gross hematuria was present, then all surgically significant urinary tract lesions would have been recognized, and 75 per cent of these 102 patients would have been spared IVPs. We agree with others that microscopic hematuria alone is not an indication for emergency IVP in these trauma patients. However, gross hematuria or other strong clinical evidence of renal injury still mandates IVP early during the assessment of patients who have suffered blunt abdominal trauma.     

Value of urologic investigation in a targeted group of women with recurrent urinary tract infections.

According to the conclusions of clinical studies, excretory urography and cystoscopy are of no value in managing the majority of women who have a history of recurrent urinary tract infection (UTI). Of 475 women with recurrent UTIs, 186 were prospectively targeted for evaluation by cystoscopy and ultrasonography or excretory urography from selection criteria based on the degree of complicating factors, to determine the value of urologic investigation. Thirty-nine patients had significant detectable abnormalities, and 20 of them required surgical intervention. Definite indications for urologic evaluation include hematuria (gross hematuria and persistent microscopic hematuria between infections), pyelonephritis and a presentation that is not typical for simple uncomplicated UTIs (obstructive symptoms, infection with urea-splitting bacteria, clinical impression of persistent infection or urinary calculi). Diabetes itself does not warrant urologic evaluation. The findings from this study suggest that cystoscopy and upper urinary tract evaluation do play a role in the management of a selected group of women with UTIs.     

Diagnosis and management of eosinophilic cystitis: a pooled analysis of 135 cases

OBJECTIVE: Eosinophilic cystitis is a rare disease. We reviewed the literature for clinical presentation, diagnosis and therapeutic options to establish recommendations for diagnostic and therapeutic management. METHODS: A pooled analysis was performed of 135 patients with eosinophilic cystitis presented in the literature. The evaluation included patient age, sex and race, presenting symptoms, diagnostic examinations, treatment and results, and complications. RESULTS: The mean age at diagnosis was 41.6 years (range 5 days to 87 years). An equal distribution existed between males (44%) and females (35%), but in children (21%) boys were more often affected (14%) than girls (7%). The most common presenting symptoms were frequency (67%), dysuria (62%), gross/microscopic hematuria (68%), suprapubic pain (49%) and urinary retention (10%). All patients had a cystoscopy and biopsy; a biopsy is mandatory to establish the diagnosis. Positive urine cultures were found in 26% of the patients. Periferal eosinophilia was present in 43%. An intravenous urography was performed in 66%, ultrasonography in 15%, cystography in 23% and a CT scan in 10%. The majority of patients was treated with combinations of corticosteroids, antihistaminics and antibiotics (45%), avoiding of the suspected antigen (17%), transurethral resection of the lesions (9%), partial cystectomy (4%) or total cystectomy (4%). The success rates for the different treatments were variable: transurethral resection combined with corticosteroids, antihistaminics or antibiotics seemed most successful, while total cystectomy is reserved for patients with unresponsive disease and hematuria. The most common complications were dilation of the upper urinary tract (27%) and eosinophilic gastroenteritis (4.5%); all other complications occurred in less than 3% of the patients. CONCLUSION: Eosinophilic cystitis is equally distributed among the sexes, but in children boys are affected more often than girls. The presenting symptoms are frequency, dysuria, hematuria, suprapubic pain and urinary retention. The treatment of choice is (radical) transurethral resection of the lesions in the bladder and a combination of corticosteroids and antihistaminics. Antibiotics are given when a urinary tract infection is present, or when dilation of the upper urinary tract exists. Most patients are cured but recurrence is a frequent finding.     

Intraprostatic Botulinum Toxin Type A injection in patients with benign prostatic enlargement: duration of the effect of a single treatment

Background

We determine the utility of serial urinary cytologies in patients presenting with microscopic hematuria who were evaluated with upper and lower urinary tract studies to rule out a malignancy.

Methods

Two hundred and thirty-seven patients with the diagnosis of microscopic hematuria were evaluated at an inner-city tertiary care hospital. Of these 239 patients, 182 patients had 405 cytologies obtained as part of their evaluation for hematuria. In addition, all patients had their lower urinary tract and upper tract thoroughly evaluated.

Results

Two hundred and seventy four cytology samples were read as normal, 104 (26%) as atypia, 7 (2%) as suspicious/malignant, and 20 (5%) as unsatisfactory. Seventeen patients (9.3%) had biopsy confirmed bladder cancer. Of these 17 patients, 2 had normal cytology, 11 had atypia, and 5 had suspicious/malignant. No patient had a positive cytology and a negative biopsy. Overall the number of hematuric patients harboring bladder cancer was small (7%). Cytology #1 detected 4 cases of cancer, cytology #2 detected an additional case and cytology #3 did not detect any additional cancers.

Conclusion

Because of this low prevalence of bladder cancer in patients presenting with microscopic hematuria and the low sensitivity of detecting bladder cancers, the utility of urinary cytology in the initial evaluation of patients with hematuria may be minimal. The exact role of urinary cytology in the evaluation of hematuria is unknown.     

Should the presence of a culture positive urinary tract infection exclude patients from rapid evaluation hematuria protocols?

ObjectiveCurrent rapid evaluation protocols for patients with hematuria tend to exclude those with urinary tract infection since this is assumed to be evidence of a benign treatable cause. The likelihood of a urinary tract cancer in such patients is, however, uncertain, and we have therefore analyzed a prospective hematuria clinic database to determine risk.Patients and methodsA total of 1,740 patients were enrolled prospectively in this study at our unit's one stop fast track hematuria clinic between April 2003 and March 2006. Evaluation of patients consisted of basic demographics, history and examination, urinalysis, urine culture, urine cytology, and serum creatinine. All patients then underwent a renal ultrasound, intravenous urogram, and cystoscopy.ResultsA total of 1,067 males and 673 females with a mean (range) age of 60.8 (16–96) years were included in the study. One hundred sixty-one patients had a positive mid-stream urine (MSU) on a specimen collected at the hematuria clinic. Amongst this group 20% (32) patients had a urologic malignancy diagnosed, of whom 12% (4) had metastatic disease at presentation. Only 1% (3) of patients had a urologic malignancy with a previous history of a treated urinary tract infection (UTI) and negative MSU at the clinic. The risk of urologic malignancy was 24% (303) in the remaining 1,249 patients with no history of a UTI prior to presentation and a negative MSU on a specimen collected at the one stop fast track hematuria clinic.ConclusionDespite selection bias inherent in this analysis, it appears that the presence of UTI does not decrease the likelihood of having a urologic malignancy diagnosed. Hence, there is no indication to delay prompt evaluation in patients with hematuria and a positive urine culture collected at the hematuria clinic.     

The spectrum of colovesical fistula and diagnostic paradigm

BACKGROUND: Our experience with colovesical fistula (CVF) over a 12-year period was reviewed to clarify its clinical presentation and diagnostic confirmation. METHODS: Twelve patients with CVF were identified. Presenting symptoms, etiologic factors, diagnostic investigations, and subsequent treatment were reviewed. RESULTS: Underlying etiologies were diverticular disease (75%), colon cancer (16%), and bladder cancer (8%). Pneumaturia (77%) was the most common presentation, followed by urinary tract infections, dysuria and frequency (45%), fecaluria (36%), hematuria (22%), and orchitis (10%). The ability of various preoperative investigations to identify a CVF were: computed tomography (CT) (90%), barium enema (BE) (20%), and cystography (11%), whereas cystoscopy, intravenous pyelogram (IVP), and colonoscopy were nondiagnostic. All patients underwent single- or multiple-staged repair of the fistula. CONCLUSIONS: In patients with a suspected CVF, we recommend CT followed by a colonoscopy as a first-line investigation to rule out malignancy as a cause of CVF. Other modalities should only be used if the diagnosis is in doubt or additional information is needed to plan operative management.     

Asymptomatic Microscopic Hematuria in Women: Case Series and Brief Review

Recommendations for the work-up of asymptomatic microscopic hematuria (AMH) often derive from studies including both men and women. This study was undertaken to determine whether that work-up is appropriate for a female patient population. We studied 49 women referred to a urogynecologist for AMH. Patients underwent formal urinalysis, urine culture and cytology, cystoscopy, and either renal ultrasound or intravenous urography (IVU). Highly significant lesions diagnosed were one renal cell carcinoma and one acute tubular necrosis (ATN). Moderately significant lesions included one candidal urinary tract infection. Insignificant lesions included bladder inflammation in 46 patients and renal cysts in 5. Our findings confirm the importance of the work-up of AMH in women. Ultrasound was effective in diagnosing upper tract lesions, with less cost and morbidity than IVU. Larger studies are needed to determine who should be screened, whether the work-up should differ for younger women, possible treatments for benign findings, and appropriate follow-up.     

Cystoscopy for lower urinary tract symptoms in urogynecologic practice: the likelihood of finding bladder cancer

The objectives of this study were to estimate the detection rate of lower urinary tract malignancy among women evaluated with cystoscopy for lower urinary tract symptoms and to determine whether microscopic hematuria is a reliable predictor of cancer risk. The study population included 1,584 consecutive women undergoing office cystourethroscopy in a single urogynecology center between 1991 and 2001. The overall rate of biopsy-confirmed bladder cancer was 0.63%, including nine cases of transitional cell carcinoma and one superficial squamous cell carcinoma. Among women with initial microscopic hematuria, the rate of bladder cancer was 1.7%, significantly higher than 0.45% among those without hematuria (p = 0.03). However, in absolute terms, the majority of bladder cancer cases (60%; six of ten) presented with normal initial dipstick urinalysis. These findings suggest that outpatient cystourethroscopy is an integral tool for the evaluation of lower urinary tract symptoms, facilitating early recognition of both benign and malignant conditions. However, its expense and inconvenience must clearly be weighed against its potential yield.     

上尿路移行细胞癌的诊断与治疗（附39例报告）

目的探讨上尿路移行细胞癌的诊治方法。方法回顾性分析39例上尿路移行细胞癌患者的临床表现及诊治方法。结果39例患者均行手术治疗,术后病理检查证实29例为肾盂移行细胞癌,10例为输尿管移行细胞癌。通过B超、静脉尿路造影（IVU）、逆行肾盂造影、CT、尿脱落细胞学及输尿管镜等检查,术前诊断符合率为92.3%（36/39）。35例患者获得随访6个月-12年,6例术后出现膀胱移行细胞癌,5例死于肿瘤进展。结论B超、IVU、CT可作为上尿路肿瘤的常规检查,IVU显影不佳时逆行肾盂造影可作补充,输尿管镜配合组织活检准确性极高。根治性肾输尿管切除术效果较好,术后应行膀胱灌注治疗及定期膀胱镜检查。     

What is evaluation of hematuria by primary care physicians? Use of electronic medical records to assess practice patterns with intermediate follow-up

BackgroundTo determine whether patients found to have hematuria by their primary care physicians are evaluated according to best practice policy.Materials and methodsThe University of Texas Southwestern Medical Center maintains institutional outpatient electronic medical records (EMR) that are used by all providers in all specialties. We conducted an Institutional Review Board approved observational study of patients found to have more than 5 red blood cells/high power field between March 2009 and February 2010.ResultsThere were 449 patients of whom the majority were female (82%), Caucasian (39%), with microscopic hematuria (MH) (85%). Almost 58% of patients were initially symptomatic with urinary symptoms or pain. Evaluation for the source of hematuria was limited and included imaging (35.6%), cystoscopy (9%, and cytology (7.3%). Only 36% of men and 8% of women were referred to a urologist. No abnormality was found in 32% and 51% of patients with gross hematuria and MH, respectively (P = 0.004). There were 4 bladder tumors and 1 renal mass detected. Male gender, ethnicity and gross (vs. microscopic) hematuria were associated with higher rate of urological referral. Advanced age, smoking, provider practice type, and the presence of urinary symptoms were not associated with an increase rate of urological referral. No additional cancers were diagnosed with 29-month follow-up.ConclusionsWhile urinalysis remains a common diagnostic tool, most cases of both microscopic and gross hematuria are not fully evaluated according to guidelines. Use of cystoscopy, cytology, and upper tract imaging is limited. Further studies will be needed to determine the extent of the problem and impact on morbidity and survival.     

非肌层浸润性膀胱癌患者术前是否需要常规行IVU检查

目的 探讨非肌层浸润性膀胱癌患者术前是否需要常规行IVU检查.方法 病理确诊为非肌层浸润性膀胱癌患者1968例.男1021例,女947例.年龄16～84岁,平均57岁.病理分期均为Ta～T1,细胞分级G11541例、G2382例、G345例.术前均行双肾输尿管膀胱超声、膀胱镜、IVU检查.均行经尿道膀胱肿瘤切除术.统计学比较分析不同检查方法上尿路癌的检出率.结果 1968例患者中同时发生上尿路癌216例(11.0%).1582例血尿者IVU检查发现上尿路癌215例(13.6%),386例偶然发现膀胱癌患者IVU检查发现上尿路癌1例(0.3%),有无血尿者IVU检查发现上尿路癌比例差异有统计学意义(P＜0.01).超声检查示上尿路异常者120例IVU检查均发现上尿路癌(100.0%),1848例超声检查上尿路无异常者IVU检查发现96例(5.2%),组间比较差异有统计学意义(P＜0.01);1247例超声检查上尿路无异常的单发肿瘤患者IVU检查发现上尿路癌37例(3.0%),601例多发者IVU检查发现59例(9.8%),组间比较差异有统计学意义(P＜0.01);超声检查上尿路无异常的单发膀胱肿瘤直径＜1.0 cm者IVU检查发现上尿路癌2例(0.2%),肿瘤直径≥1.0 cm者IVU检查发现35例(8.2%),组间比较差异有统计学意义(P＜0.01).G1患者同时发生上尿路癌48例(3.1%),G2～G3168例(39.3%),组间比较差异有统计学意义(P＜0.01).结论 非肌层浸润性膀胱癌患者中有血尿症状、超声检查上尿路异常者、超声检查上尿路未见异常的膀胱肿瘤多发或单发但直径≥1.0 cm者、膀胱镜检查肿瘤可疑高级别者应行IVU检查;偶发病例、单发肿瘤且直径＜1.0 cm、肿瘤低级别者,术前可不行IVU检查.

Abstract：

Objective To discuss the need for performing intravenous urography(IVU) in patients with non-muscle invasive bladder cancer before surgery. Methods From 1997 to 2008,1968patients were diagnosed as non-muscle invasive carcinoma of the bladder with pathological confirmation. All patients underwent ultrasonography, cystoscopy and IVU prior to surgrey. The x2 test was used for statistical analysis. Results The incidence of upper urinary tract urothelial tumors (UUTUT) was 11. 0% (216 cases). Two hundred and fifteen (13. 6%) suffered simultaneous UUTUT detected by IVU in 1528 patients with bladder cancer who had intermittent painless gross hematuria, while only 1 (0.3 %) suffered simultaneous UUTUT in 386 non-symptomatic patients (P＜0.01). Among 120 patients with bladder cancer whose upper tract was abnormal detected by ultrasonography,120 (100. 0%) suffered simultaneous UUTUT detected by IVU, and of 1848 patients who were normal in upper tract by ultrasonography, 96 (5. 2%) suffered simultaneous UUTUT detected by IVU (P＜0. 01). Of the patients with no abnormalities in upper tract by ultrasound, 37(3. 0%) suffered simultaneous UUTUT detcted by 1VU in 1247 patients with single bladder tumor,and 59 (9.8%) suffered simultaneous UUTUT in 601 patients with multiple bladder tumors (P＜0.01). Of the patients with single bladder tumor who had no abnormalities in upper tract by ultrasonography, 2 (0.2%) suffered simultaneous UUTUT detected by IVU in 822 patients with the diameter of the tumor＜1.0 cm, and 35 (8. 2 %) suffered simultaneous UUTUT in 425 patients with the diameter≥1. 0 cm (P＜0.01). Of the 1541 patients with histological G1, 48 (3.1%) suffered simultaneous UUTUT detected by IVU, and of the 427 patients with histological G2- G3, 168 (39. 3%)suffered simultaneous UUTUT (P ＜ 0. 01 ). Conclusion Patients with the following characters should undergo IVU before surgery: hematuria, abnormal upper urinary tract by ultrasonography,multifocal tumours, the diameter of the single bladder tumor≥1. 0 cm and high gradc tumors.     

Urinary tract ultrasonography in the evaluation of haematuria--a report of over 1,000 cases

Over a 5-year period, 1007 patients with haematuria were investigated, using a protocol based on ultrasonography as the upper tract imaging modality of choice. Intravenous urography (IVU) was only used in selected individuals, including those patients with bladder cancer suspected on cystoscopy, suspicious or malignant cytology, previous investigation for haematuria, on-going haematuria at the time of their clinic visit, a history of flank pain or hydronephrosis on ultrasonography. Of this series, 840 (83%) had visible haematuria, 158 (15%) had microscopic or chemical haematuria and 9 (0.9%) had unspecified haematuria. A total of 133 bladder transitional cell tumours, 21 renal cell cancers and 2 upper tract transitional cell cancers (TCC) were diagnosed. The sensitivity of ultrasound with respect to bladder cancer was 63% and the specificity 99%. The odds ratio of diagnosing cancer in patients with visible haematuria compared to microscopic or unspecified haematuria was 3.3. No upper tract tumours were missed using this investigational protocol. An ultrasonography-based protocol could miss fewer upper tract TCCs than a standard IVU-based service would miss renal cell cancer. Provided there is no history of flank pain, no malignant cytology, no hydronephrosis and no previously investigated haematuria, IVU could be safely omitted.     

The outcome of patients on dialysis with upper urinary tract transitional cell carcinoma

PURPOSE: Transitional cell carcinoma is the most common upper urinary tract cancer in Taiwanese patients on dialysis. It is a unique finding compared with Western countries. Unfortunately, the long-term outcomes of patients with upper urinary tract transitional cell carcinoma on dialysis are largely unknown. This study presents clinical outcome of patients on dialysis with upper urinary tract transitional cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients with upper urinary tract transitional cell carcinoma who had end stage renal disease and underwent dialysis. Traditional prognostic factors including age, sex, tumor grade, stage and tumor location were analyzed with respect to disease recurrence and survival. RESULTS: A total of 73 patients were included in this study. The major complaints were painless gross hematuria and urethral bloody discharge. Disease relapsed in 40 (54.8%) patients at average time of 15 months (2 to 92). Univariate analysis failed to identify significant prognostic factors for recurrence. The average duration between primary and contralateral metachronous upper urinary tract transitional cell carcinoma recurrence was 36 months (range 5 to 96). Patients on dialysis with upper urinary tract transitional cell carcinoma who had previous or concurrent bladder tumor, or who had a history of recurrent bladder tumor, had high contralateral upper urinary tract transitional cell carcinoma recurrence. (p = 0.038) The statistically significant prognostic factor for disease-free survival was pT stage (p = 0.041). CONCLUSIONS: Patients on dialysis with painless gross hematuria or bloody urethral discharge must undergo detail urinary system evaluation. Since patients with upper urinary tract transitional cell carcinoma on dialysis have a high recurrence rate and metachronous or even multiple, early synchronous tumor characteristics that may be missed by imaging, total urinary tract exenteration is a recommended therapeutic option.     

Clinical study of asymptomatic microhematuria

A statistical survey was performed on 200 patients with asymptomatic microhematuria who visited our hospital between January 1986 and October 1989. Urinalysis, urinary cytology, urinary culture, IVP, echography and cystoscopy were carried out for the evaluation of the origin and nature of the microhematuria. In 92 patients (46%), urological abnormalities were observed. Among them, urological lesions requiring medical and surgical treatments were found in 28 patients (14%) including two malignant cases of bladder tumor. No urologic lesion could be identified in 108 patients (54%). The degree of hematuria was unrelated to the seriousness of its cause. Thirteen of 28 patients (46%) with diseases that required treatment had under 5 red blood cells per high power field on the microscopic urinalysis. Therefore, complete urologic investigation of all patients with any degree of asymptomatic microhematuria is recommended.