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UROLOGICAL
ONCOLOGY
doi: 10.1590/S1677-55382011000200027
Association
of hematuria on microscopic urinalysis and risk of urinary tract cancer
Jung H, Gleason JM, Loo RK, Patel HS, Slezak JM, Jacobsen SJ
Department of Urology, Kaiser Permanente Southern California, Los Angeles,
California, USA
J Urol. 2011; 185: 1698-703
- Purpose:
We determined the incidence of urinary tract cancer in patients with
hematuria, stratified risk by age, gender and hematuria degree, and
examined current best policy recommendations.
Materials and Methods: We performed a large, retrospective population
based cohort study of patients who underwent microscopic urinalysis
during 2004 and 2005 in a large managed care organization. Patients
were followed for 3 years for urinary tract cancer.
Results: We identified 772,002 patients who underwent urinalysis during
the study period. After exclusions due to previous hematuria, age less
than 18 years, pregnancy, urinary tract infection, inpatient status
and prior urinary tract cancer 309,402 patients were available for analysis,
of whom 156,691 had hematuria. The overall 3-year incidence of urinary
tract cancer in those with hematuria was 0.68%. Older age (greater than
40 years OR 17.0, 95% CI 11.2-25.7), greater hematuria (greater than
25 red blood cells per high power field OR 4.0, 95% CI 3.5-4.5) and
male gender (OR 4.8, 95% CI 4.2-5.6) were associated with a higher risk
of cancer. The American Urological Association definition of microhematuria
had 50% sensitivity, 84% specificity and 1.3% positive predictive value.
Conclusions: The incidence of urinary tract cancer is low even in individuals
with microhematuria. Thus, current best policy recommendations do not
perform well. Since older age, male gender and greater hematuria are
associated with a higher risk of cancer, future studies should evaluate
strategies that target these populations.
- Editorial
Comment
Although under review, the last AUA Best Practice Policy Recommendations
suggest evaluation in patients who have at least 2 urinalyses with 3
or more RBC/HPF within a 12-month period as well as those with gross
hematuria (1).
The authors have proposed an approach of evaluating patients older than
40 years with at least 1 urinalysis showing greater than 25 RBC/HPF.
Compared to the AUA method this alternative strategy could have spared
25,917 evaluations and detected 6 more cases of urinary tract cancer.
Compared to the CUA approach (AUA restricted to patients > 40 years)
it could have spared 11,584 evaluations and detected 16 more cases.
Older age, greater hematuria and male gender were predictors of urinary
tract cancer, in accordance to a more restrictive protocol based on
home dipstick testing to identify hematuria in a limited age spectrum
(> 50 years), including only men with a proved beneficial impact
on positive cases of bladder cancer (2).
However, future studies are to be greatly improved including evaluation
of known risk factors, such as smoking history, occupational exposure
to chemicals or dyes, gross hematuria, urological disease, irritative
voiding symptoms, urinary tract infection, analgesic abuse and pelvic
radiation in prospective, randomized trials of general population.
Furthermore, confounding clinical contexts, such as menstruation, vigorous
exercise and cases of recent urinary tract instrumentation should be
excluded and also the complete evaluation of urine cytology, upper tract
imaging and cystoscopy are necessary for all patients to provide the
best evidence for a safe actualization of the last recommendations that
age 10 years.
Reference
- Grossfeld
GD, Wolf JS Jr, Litwan MS, Hricak H, Shuler CL, Agerter DC, et al.:
Asymptomatic microscopic hematuria in adults: summary of the AUA best
practice policy recommendations. Am Fam Physician. 2001; 63: 1145-54.
- Madeb
R, Messing EM: Long-term outcome of home dipstick testing for hematuria.
World J Urol. 2008; 26: 19-24.
Dr.
Leonardo Oliveira Reis
Assistant Professor of Urology
University of Campinas, Unicamp
Campinas, São Paulo, Brazil
E-mail: reisleo@unicamp.br
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