New Guidelines for the Work-up of Hematuria

Educational Objectives

The goals of this program are to highlight changes and trends in urology. After hearing and assimilating this program, the clinician will be better able to:

1. Sketch a treatment algorithm for a patient with hematuria based on his or her risk factors.

Summary

Guideline: 2002 AUA guideline stipulated 2 of 3 urines and ≥3 red blood cells (RBCs) per high power field (HPF) as criteria for obtaining intravenous pyelography (IVP) or multiphasic CT; new 2012 guideline recommends work-up for patients ≥35 yr of age with 1 positive urinalysis with ≥3 RBCs/HPF, using multiphasic CT and cystoscopy; transition from IVP to CT understandable due to enhanced sensitivity and specificity of CT for diagnosing renal tumors and upper tract transitional cell cancers; AUA found no comparative data on magnetic resonance urography for hematuria; recognizing lower risk for cancer in women, 2006 Kaiser Permanente guideline recommended ultrasonography (US) instead of CT for nonsmoking women <40 yr of age, and multiphasic CT for all other patients

Risks related to radiation: multiphasic CT of abdomen and pelvis fairly hazardous, with moderate risk of causing fatal cancer; risk for fatal cancer inversely related to age; fatal cancer expected in ≈1 of 460 women age 40 yr; risk slightly higher in men; with >70 million CTs performed in United States, ≤2% of future cancers likely related to CT; one-third of currently performed CT probably unnecessary

Kaiser study: retrospective analysis of patients with hematuria showed that AUA guidelines result in evaluation of large numbers of patients to identify few cancers; based on this finding, prospective study designed to assess common risk factors, including patient report of hematuria within previous 6 mo, age, sex, smoking history, and detection of microscopic hematuria; simple hematuria risk index constructed from observed odds ratios; to calculate risk index, add 4 points for history of gross hematuria, 4 points if ≥50 yr of age, and 1 point each for other 3 variables; stratifies patients into low-, moderate-, or high-risk cohorts

Comparison with current guideline: area under curve 0.850 for Kaiser hematuria index and 0.53 for AUA guideline; AUA analysis of >35 studies included ≈10,000 patients; cohort used to create Kaiser index included 4500 patients, comprising largest published cohort; age — Surveillance Epidemiology and End Results (SEER) data show risk for renal or bladder cancer double in patients ≥50 yr of age; in AUA studies reviewed for guideline, age of patient reported for only 22 of 415 cancers studied; in Kaiser study, age ≥50 yr statistically significant and second most important risk factor; sex — in SEER data, incidence of and mortality from bladder and renal cancers in males more than twice that in females; AUA could not assess sex as risk factor because of poor data quality; in Kaiser study, sex third most important risk factor and statistically significant; smoking — AUA could not evaluate smoking because of inadequate data; smoking data available for 99.9% of patients in Kaiser study; data show risk in smokers slightly higher but not statistically significant; gross hematuria — most important risk factor; >6 times greater risk for malignancy in patients with self-reported hematuria; AUA did not examine effect of gross hematuria due to incomplete reporting of this variable

Multiphasic CT: used to detect renal cancer or upper tract transitional cell cancer and to assess clinical stage of bladder cancers; no correlation exists between microscopic hematuria and renal cancer; in 4500-patient Kaiser cohort, incidence of renal cancer in patients with microscopic hematuria 0.3%; study evaluating 6000 normal people 50 to 79 yr of age found renal cancer in 0.33%, same rate as in people with microscopic hematuria; in patients <50 yr of age, risk for renal cancer ≈1 in 1000, but risk for iatrogenic fatal cancer from CT higher

Kaiser treatment algorithm: divides patients into no-, moderate- and high-risk; screening urinalysis — not recommended in asymptomatic patients; this recommendation already in AUA guideline and not controversial; gross hematuria — ask patients whether blood observed in urine; AUA noted that 2 of 3 positive urines no more accurate than 1 positive urine; for patient with single positive urine, if no evidence of urinary tract infection or nephrologic cause, treat based on risk factors; asymptomatic, nonsmoking female <50 yr of age has no risk and requires no further evaluation; if any risk factor present, refer to urologist for renal US; only patients with gross hematuria evaluated with CT; for gross, painless hematuria, perform CT urography and refer to urologist; for gross, painful hematuria suspicious for urinary tract stone, perform single-phase CT of kidneys, ureters, and bladder, thereby exposing patient to lower dose of radiation than multiphasic CT, and refer to urologist; multiphasic CT likely reserved for staging patients with cancer

Other national practices: Canada — in 2009, based on same data evaluated by AUA, concluded that no patients should receive CT urography because quality of available data poor; patients evaluated with renal US if >40 yr of age; Netherlands — uses multivariable predictive risk model; recommends renal US in low- and medium-risk patients and CT urography in high-risk patients; lower age limit 50 yr

Kaiser cutoffs: 50 yr of age cutoff for determining moderate vs low risk; however, 35 yr of age used as cutoff for evaluating hematuria, as in AUA guidelines, since 20% of patients nonsmoking females <50 yr of age

Readings

AGS Guidelines and Recommendations. Available at: http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/; American Geriatrics Society: Geriatrics at your fingertips. Available at: www.geriatricsatyourfingertips.org/; American Urological Association: Health Policy Brief. September 5, 2012. Available at: www.auanet.org/eforms/hpbrief/view.cfm?i=1258&a=2933; Barnett SR: Polypharmacy and perioperative medications in the elderly. Anesthesiol Clin. 2009;27(3):377-89; Bortz W: Understanding frailty. J Gerontol A Biol Sci Med Sci. 2010;65(3):255-6; discussion 257; Boyd CM et al: From bedside to bench: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Comorbidity and Multiple Morbidity in Older Adults. Aging Clin Exp Res. 2008;20(3):181-8; Centers for Medicare & Medicaid Services Web site: Physician Quality Reporting Services. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs. Accessed January 22, 2013; Centers for Medicare and Medicaid Services: Electronic Prescribing Incentive Program. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html. Accessed January 22, 2013; Centers for Medicare & Medicaid Services: Medicare Physician Fee Schedule. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/medcrephysfeeschedfctsht.pdf. Accessed January 22, 2013; Fajkovic H et al: Impact of gender on bladder cancer incidence, staging, and prognosis. World J Urol. 2011;29(4):457-63; Griebling TL: Reconstructive urology and geriatrics: issues in older adults. Curr Opin Urol. 2009;19(6):577-81; Henning A et al: Do differences in clinical symptoms and referral patterns contribute to the gender gap in bladder cancer? BJU Int. 2013 Jan 15. [Epub ahead of print]; Jung H et al: Association of hematuria on microscopic urinalysis and risk of urinary tract cancer. J Urol. 2011;185(5):1698-703; Lokken RP et al: Diagnostic yield of CT urography in the evaluation of young adults with hematuria. AJR Am J Roentgenol. 2012;198(3):609-15; Loo RK et al: Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc. 2013 Jan 5. [Epub ahead of print]; Nepple KG et al: Population based analysis of the increasing incidence of kidney cancer in the United States: evaluation of age specific trends from 1975 to 2006. J Urol. 2012;187(1):32-8; Pessis DA: Comment Letter 2013 MPFS. American Urological Association Web site. Available at: www.auanet.org/content/media/AUA_Comment_Letter_2013_MPFS.pdf. Accessed January 19, 2013; Shariat SF et al: The effect of age and gender on bladder cancer: a critical review of the literature. BJU Int. 2010;105(3):300-8; Sieber FE and Barnett SR: Preventing postoperative complications in the elderly. Anesthesiol Clin. 2011;29(1):83-97; Tognoni P et al: Preoperative risk factors for postoperative delirium (POD) after urological surgery in the elderly. Arch Gerontol Geriatr. 2011;52(3):e166-9.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Loo was recorded at 2012 Urology Symposium, sponsored by Kaiser Permanente Medical Group and held November 2-3, 2012, in Las Vegas, NV. Information about upcoming meetings from the Southern California Permanente Medical Group can be found on Facebook at “kpmeetingsandevents”. You can also learn about upcoming events from sponsoring organizations by visiting our website, audio-digest.org, and clicking the “upcoming meetings” tab at the bottom of the page. The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR360602

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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