US in micro- and gross Hematuria Athina C. Tsili, MD Department of - - PowerPoint PPT Presentation

US in micro- and gross Hematuria

Athina C. Tsili, MD Department of Clinical Radiology, Medical School University of Ioannina, Greece XVth 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
• r 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%

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,
• ccupational 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
• f microscopic hematuria is unnecessary

American College of Radiology ACR Appropriateness Criteria

American College of Radiology ACR Appropriateness Criteria

• Multidetector CTU: best overall imaging modality

due to its widespread availability, ability to detect a range

• f 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

• r 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 Age First Line Second Line Third Line Fourth Line Micro- < 50

US or

cystoscopy If first line negative, stop Micro- >50

US or cystoscopy

If first line negative and risk or persistent hematuria, CTU If secondary line negative and risk or persistent hematuria, urine cytology If third line positive retrograde ureteropyelography or ureteroscopy Macroscopic < 50

US or cystoscopy

If first line negative and risk or persistent hematuria, CTU If secondary line negative and risk or persistent hematuria, urine cytology If third line positive retrograde ureteropyelography or ureteroscopy Macroscopic >50 CTU or cystoscopy If first line negative and persistent hematuria, urine cytology If second line positive retrograde ureteropyelography or 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

• ften 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)
• nly 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