US in micro- and gross Hematuria Athina C. Tsili, MD Department of Clinical Radiology, Medical School University of Ioannina, Greece XV th Balkan Congress of Radiology October 12-14, 2017 Budapest
Hematuria most common presentations of patients with urinary tract • diseases and for urology referrals can originate from any site in the urinary tract • wide range of causes, roughly divided into renal, • urothelial, or prostatic causes potential relation to urinary tract malignancy : RCC • or urothelial carcinoma the initial decision to be made is whether all • patients with any degree of hematuria need imaging evaluation
Hematuria macroscopic (gross) hematuria • miscroscopic asymptomatic hematuria (MAH), or • non-visible hematuria or ‘ dipstick positive hematuria ’ risk of malignancy among patients with • macroscopic hematuria: 3-6% (as high as 19%)
Microscopic Hematuria Definition: findings of a number of RBCs on urine • microscopy or the presence of a positive dipstick test for hematuria in the absence of symptoms and visible hematuria cut-off values: variable, from as few as 2 RBCs/HPF to • > 5 RBC/HPF in a centrifuged midstream urine specimen • Prevalence: 2.5% of adults (often found incidentally, • routine health screenings), as high as 20% potential relation to urinary tract malignancy • risk of malignancy: does not exceed 5% •
Microscopic Hematuria risk of malignancy [AUA guideline authors’ • meta-analysis] 2.6%, screening � 4.0%, initial MAH workup; and � 2.8%, additional workup after an initially negative � exams High-risk groups • males >50y � women aged >40y with>25 RBC/HPF � previous history of gross hematuria � However, rates of malignancy: 0.68-2.3% •
American College of Radiology ACR Appropriateness Criteria Clinical Condition: Hematuria [Last review date: 2014] Summary of Recommendations • thorough evaluation of gross hematuria is recommended, usually with a combination of clinical examination, cystoscopic evaluation, and urinary tract imaging • most adults with gross or persistent microhematuria require urinary tract imaging : CTU • in patients with risk factors such as cigarette smoking, occupational exposure to chemicals, irritative voiding symptoms , a full urologic evaluation for urothelial carcinoma is recommended if even one urinalysis documents the presence of at least 3 RBCs/HPF • specific circumstances in which complete radiologic workup of microscopic hematuria is unnecessary
American College of Radiology ACR Appropriateness Criteria Multidetector CTU: best overall imaging modality � due to its widespread availability, ability to detect a range of possible causes including small renal masses, calcifications and stones and ability to image the upper tract collecting system MRU is a reasonable alternative for detection of small � renal masses but is poor for detection of calcifications and small stones
American College of Radiology ACR Appropriateness Criteria: Role of US US still has a role in the initial workup of hematuria in radiation-sensitive populations , such as children • and pregnant or child-bearing age women , to detect renal calculi and renal masses when glomerular disease is the cause of hematuria • assess renal parenchyma, follow disease progression � renal length, quantitative echogenicity, cortical � thickness, parenchymal thickness
American College of Radiology ACR Appropriateness Criteria: Role of US US was a significant predictor of the final CTU/MRU • result ; that is, US can be used as an initial screening tool and can triage patients who need further cross-sectional urography [Unsal A Eur J Radiol 2011] in patients with contraindications to CTU • a very low risk of malignancy • medullary sponge kidney disease, papillary • necrosis: initial imaging study and subsequent follow-up study for progression
prospective study, consecutive patients attending a modern • protocol-driven hematuria clinic Standard tests: history taking, physical examination, • urinalysis via dipstick method, US performed by urologists, cystoscopy, and cytology: all patients additional UUT imaging: US by a radiologist or four-phase • CTU/MRU was selected according to a risk factor-based management algorithm added value of cross-sectional urography (CTU/MRU) • supplementary to US (by urologists) to detect renal masses, UUT tumors, and stones was assessed for patients who present with AMH, US is sufficient to • exclude significant UUT disease for patients with macroscopic hematuria, the • likelihood of finding UUT disease is higher, and a CTU as a first-line test seems justified Cauberg EC J Endourol 2011
American Urological Association (AUA)- Guidelines for MAH in adults (2012) thorough urologic evaluation of all asymptomatic patients • ≥35y who have a single urinalysis result with 3 RBC/HPF or more, or any patient with risk factors for malignancy regardless of age multiphasic CTU and cystoscopy • if CTU is contraindicated • RPGs + MRI � RPGs + non-contrast CT/ US � Davis R J Urol 2012
Canadian Urologic Association (MAH) cystoscopy recommended in patients without other risk • factors >40 years recommends ultrasound as the initial imaging • modality Wollin T Can Urol Assoc J 2009
National Kidney Foundation recommendations (MAH) cystoscopy recommended for all patients >50y • US or MRI • patients with low likelihood of malignancy : young age, � known stone formers sensitive to radiation exposure : pregnant women, � children known CKD � Oncology Bso BJU Int 2016
2010 ESUR guidelines: Summary low-risk patients: US and cystoscopy • medium-risk patients: US and cystoscopy • CTU, if only those tests are negative high-risk patients: CTU and cystoscopy •
2010 ESUR guidelines Characteristics Risk of malignancy Low Medium High Hematuria Micro- Micro- Macroscopic Macroscopic Age < 50 >50 < 50 >50 First Line US or US or cystoscopy US or cystoscopy CTU or cystoscopy cystoscopy Second Line If first line negative and If first line If first line negative and If first line negative persistent hematuria, negative, risk or persistent and risk or persistent urine cytology stop hematuria, CTU hematuria, CTU Third Line If second line positive If secondary line If secondary line retrograde negative and risk or negative and risk or ureteropyelography or persistent hematuria, persistent hematuria, ureteroscopy urine cytology urine cytology Fourth Line If third line positive If third line positive retrograde retrograde ureteropyelography or ureteropyelography or ureteroscopy ureteroscopy
Ultrasonography: Advantages avoidance of exposure to ionizing radiation • widely available • inexpensive • does not require iv contrast administration • unlimited scan planes • urinary bladder and kidneys • renal parenchymal and vascular diseases • US can reliably identify renal masses >2.5 cm, detection • rates similar to CT very sensitive in Dd solid from cystic renal lesions • in comparison with IVU, US showed a higher sensitivity for • bladder tumors and equal (i.e., moderate) sensitivity for upper urinary tract tumors
Wilms’ tumor in a 27-year-old woman
Ultrasonography: disadvantages sensitivity of US is variable depending on the skill and • experience of the operator and on the body habitus of the patient low spatial and contrast resolution • renal US: is less sensitive in detecting causes of • hematuria like urothelial lesions, small renal masses, and urinary calculi detection of renal pelvis carcinoma is moderate (82%) but • sensitivities as low as 12% have been reported for the detection of urothelial carcinoma of the ureter. US can often identifies secondary signs of ureteric tumors such as hydronephrosis and hydroureter difficult to Dd between blood clots, fungus balls, or small • urothelial lesions
Ultrasonography: disadvantages a high specificity but moderate sensitivity for the • diagnosis of bladder tumors renal masses <1 cm, sensitivity: 21% (60% for CT) • only moderately sensitive for the detection of renal calculi � (67-77%) indeterminate findings that will result in additional • imaging and costs
Conclusion guidelines have been introduced by different societies • actually differ both in the extent and the intensity of the • proposed imaging and invasive tests depending on the individual patient •
Conclusion US still has a role in the initial workup of hematuria low and medium-risk patients (MAH) • US can be used as an initial screening tool and can • triage patients who need further cross-sectional urography (MAH) relative or absolute contraindications to CTU/MRU (MAH) • in radiation-sensitive populations , such as children • and pregnant or child-bearing age women when glomerular disease is the cause of hematuria •
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