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Three Part Question

In [adults with haematuria] is [cytology testing alone as good as cytology testing with cystoscopy] at [detecting significant underlying pathology]?

Clinical Scenario

A 63 year old lady presents to the Emergency Department with a 3 week history of intermittent dark urine. She says it has become worse over the last 2 days and is now convinced that she is passing blood. You wonder if cytology testing will detect significant underlying pathology or if cystoscopy is necessary as well.

Search Strategy

Medline using the OVID interface - 1966 to June Week 1 2005
Embase - 1980 to 2005 Week 24
CINAHL - 1982 to June Week 1 2005
Cochrane Library - Issue 2 2005
(exp. HEMATURIA OR haematuria.mp) AND (cytology testing.mp. OR exp CYTODIAGNOSIS/ OR exp Cytological Techniques OR cytolo$ test$.mp.) AND (exp. CYSTOSCOPY/)
Limit to (Humans, English language, Adults (19 and over))

Search Outcome

Medline - 124 papers found of which 5 were relevant
Embase - no additional papers found
CINAHL - no additional papers found
Cochrane Library - no additional papers found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hong et al 2001 Korea	213 (79 male, 134 female) patients visiting an outpatient clinic due to asymptomatic microscopic haemturia from Mar 1994 to Nov 1998. Average age was 49.7 years. All patients had at least 2 consecutive demonstrations of haematuria in microscopic examinations. All patients had no positive findings detected by means of physical examination, IVP, urine cytology and other nephrologic evaluations.	Retrospective cohort study	Abnormality detected by cystoscopy alone following negative urine cytology	55 patients (27.6%)	Small-sized study. Microscopic haematuria only considered. Findings of statistical significance not observed.
			Significant lesions detected by cystoscopy alone following negative urine cytology	31 patients (17.6%) including 3 patients with histologically confirmed bladder tumour
Chahal et al 2000 UK	285 patients with mean age 62.4 years and male:female ratio 2:3. 65% with gross and 35% with microscopic haematuria. Evaluated in a haematuria clinic between Jan 1998 and Jan 2000. Examinations carried out were urine cytology (performed on freshly voided speciemn), flexible cystoscopy, ultrasonography and/or IVU.	Prospective cohort study	Number of tumours discovered	55 (19.2%) (47 of which were TCC)	Patients under 50 years with microscopic hameaturia not included. Not stated how microscopic haematuria was detected.
			Number of tumours detected by cystoscopy	47 (100% of TCC)
			Number of positive urine cytologies	18 (of which 17 were TCC also detected by cystoscopy and 1 carcinoma of the renal pelvis not detected by cystoscopy)
			Number of 'suspicious' urine cytologies	19 (of which 6 were TCC also detected by cystoscopy and 13 were confirmed normal following further investigation)
			overall sensitivity and specificity of urine cytology	42.4% sensitivity 94.3% specificity
Murakami et al 1990 Japan	1034 adults with asymptomatic microhaematuria noted after annual health checks. Average patient age 53.4 years. Male:female ratio approx. 1:3. All patients initially examined by urine culture, urine cytology and cystoscopy. Followed by IVP or abdominal ultrasound. CT and renal biopsy were performed in selected cases.	Prospective cohort study	Efficacy of urine cytology in detecting significant lesions	Sensitivity of 3.3% specificity of 99.5%	Predominance of women in this study may be significant since the findings showed a higher incidence of significant lesions in the men.
			Efficacy of cystoscopy in detecting significant lesions	Sensitivity of 9.5% specificity of 100%
			Detection rate of urine cytology when only bladder cancer is considered	53.8%
Suzuki et al 1999 Japan	263 patients (83 males and 180 females) between Jan 1993 and March 1996 showing haematuria on dipstick on annual health screening examination. Average age was 54.7 years (range 16-92). 79 patients were younger than 40 years. Patients underwent history, examination, microscopic urinalysis, urine cytology, renal and vesical ultrasound, cystoscopy, IVU. In selected cases CT, renal biopsy, urine culture and blood chemistry were performed in selected cases.	Prospective cohort study	Of the 8 cases in which bladder cancer (TCC) was found cytology testing detected	5 (62.5%)	Sensitivities and specificities not recorded for any outcome other than bladder cancer.
			cystoscopy detected	8 (100%)
Zippe et al 1999 USA	146 patients referred to the urology clinic due to microscopic or gross haematuria or another indication of risk for bladder cancer. All patients underwent urine cytology and cystoscopy. Histology was used to confirm diagnoses.	Prospective cohort study	Of the 8 histologically confirmed cases of bladder cancer	urine cytology detected 2/8 (25% sensitivity) and had specificity of 100%	Only bladder cancer is considered as a significant pathologic finding.
				cystoscopy detected 8/8 (100% sensitivity) and had specificity of 100%

Comment(s)

Two of these papers consider only bladder cancer as a noteworthy outcome. In these cases cytology testing does not seem to be of additional use to cystoscopy. However, when all pathological outcomes are considered it can be.

Clinical Bottom Line

A combination of cytology testing and cystoscopy can be an appropriate initial investigation for pathology in adult patients with haematuria presenting to the Emergency Department.

References

1. Hong SJ, Ahn C, Hyeon HK The value of cystoscopy as an initial diagnostic modality for asymptomatic microscopic hematuria J Korean Med Sci 2001; 16: 309-12
2. Chahal R, Gogoi NK, Sundaram SK Is it necessary to perform urine cytology in screening patients with haematuria? Eur Urol 2001;39:283-286
3. Murakami S, Igarashi T, Hara S, Shimazaki J Strategies for asymptomatic microscopic hematuria: a prospective study of 1034 patients Journal of Urology 144(1):99-101, 1990 Jul
4. Suzuki Y, Sasagawa I, Abe Y, Suzuki H, Kubota Y, Nakada T, Ohji H Indication of cystoscopy in patients with asymptomatic microscopic haematuria Scandanavian Journal of Urology & Nephrology 34(1):51-4, 2000 Feb
5. Zippe C, Pandrangi L, Potts JM, Kursh E, Novick A, Agarwal A NMP22: A sensitive, cost-effective test in patients at risk for bladder cancer Anticancer Research 19:2621-2624 (1999)