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. 2018 Sep;33(5):374-379.
doi: 10.5001/omj.2018.70.

Upper Tract Imaging in Patients with Initial or Terminal Hematuria Suggestive of Bleeding from the Lower Urinary Tract: How Often is the Upper Urinary Tract Responsible for the Hematuria?

Omar W S Al-Mula Abed  1 , Shalom J Srirangam  1 , Guy D Wemyss-Holden  1
Affiliations

Upper Tract Imaging in Patients with Initial or Terminal Hematuria Suggestive of Bleeding from the Lower Urinary Tract: How Often is the Upper Urinary Tract Responsible for the Hematuria?

Omar W S Al-Mula Abed et al. Oman Med J. 2018 Sep.

Abstract

Objectives: Visible hematuria (VH) is a common urological complaint. A history of initial or terminal VH in men is indicative of a lower urinary tract (LUT) source. A careful clinical history could limit unnecessary extensive upper tract imaging in this group of patients with VH. We conducted a single-center prospective study to examine the usefulness of investigating the upper tract in patients with a history of VH likely from a LUT source (initial and/or terminal VH) with specific reference to the incidence of demonstrable significant upper tract abnormalities.

Methods: We conducted a single-center prospective study of consecutive male patients presenting with VH over eight months. All patients underwent standard investigations including physical examination, flexible cystoscopy (FC), and radiological imaging (ultrasound scan (USS) and/or computed tomography urogram (CTU)). Those with a clear history of initial or terminal VH were identified for further scrutiny with regards to detectable upper tracts abnormalities.

Results: In total, 57 patients (aged 23-95 years) with initial or terminal VH were identified. Of these, 56 had FC and nine patients were subsequently diagnosed with a LUT malignancy. With regards to upper urinary tract (UUT), 35 patients (61.4%) had an USS, 46 (80.7%) underwent a CTU, and 25 (43.9%) patients had both. In this group, no UUT malignancy was identified on upper tract imaging.

Conclusions: Initial or terminal VH patients may not need extensive upper tract imaging. FC is recommended, but a non-invasive USS can be a safe initial investigation for the UUT, with a CTU subsequently considered in those with abnormalities on USS and those with ongoing bleeding. Further combined multicenter analysis will help corroborate these findings and could have several beneficial outcomes including a reduction in investigations cost, patient inconvenience, and ionizing radiation.

Keywords: Cystoscopy; Hematuria; Malignancy; Ultrasound; Urinary Tract; Urogram.

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Figures

Figure 1
Figure 1
Age distribution of male patient cohort who presented with initial and/or terminal visible hematuria (n = 57; range 23–95 years; median 64 years).
Figure 2
Figure 2
Flexible cystoscopy findings in the 56 patients who presented with visible hematuria (initial and/or terminal).
Figure 3
Figure 3
Summary of results of the hematuria investigations (VH: visible hematuria; USS: ultrasound scan; CTU: computed tomography urogram; TCC: transitional cell carcinoma, BN: bladder neck;AML: angiomyolipoma).
See this image and copyright information in PMC

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