Podcast: The IDENTIFY Study: The investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer; a multicentre observational study
Mr Sinan Khadhouri is a Specialty Registrar in Urology in the East of Scotland and currently doing his PhD at the University of Aberdeen. He is also the co-vice chair of BURST and the lead trainee on IDENTIFY.
The aim of the present study was to review major organizational guidelines on the evaluation and management of asymptomatic microscopic haematuria (AMH). We reviewed the haematuria guidelines from: the American Urological Association; the consensus statement by the Canadian Urological Association, Canadian Urologic Oncology Group and Bladder Cancer Canada; the American College of Physicians; the Joint Consensus Statement of the Renal Association and British Association of Urological Surgeons; and the National Institute for Health and Care Excellence. All guidelines reviewed recommend evaluation for AMH in the absence of potential benign aetiologies, with the evaluation including cystoscopy and upper urinary tract imaging. Existing guidelines vary in their definition of AMH (role of urine dipstick vs urine microscopy), the age threshold for recommending evaluation, and the optimal imaging method (computed tomography vs ultrasonography). Of the reviewed guidelines, none recommended the use of urine cytology or urine markers during the initial AMH evaluation. Patients should have ongoing follow-up after a negative initial AMH evaluation. Significant variation exists among current guidelines for AMH with respect to who should be evaluated and in what manner. Given the patient and health system implications of balancing appropriately focused and effective diagnostic evaluation, AMH represents a valuable future research opportunity.
This 61-year-old man presented with pelvic discomfort and haematuria. His PSA was 0.96ug/L. He had an abnormal prostate on DRE.
No such quiz/survey/poll
Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.
In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.
Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Archie Hughes-Hallett,, discussing his paper.
If you only have time to read one article this week, it should be this one.
To assess the impact on suspected cancer referral burden and new cancer diagnosis of Public Health England’s recent Be Clear on Cancer ‘blood in pee’ mass media campaign.
A retrospective cohort study design was used. For two distinct time periods, August 2012 to May 2013 and August 2013 to May 2014, all referrals of patients deemed to be at risk of urological cancer by the referring primary healthcare physician to Imperial College NHS Healthcare Trust were screened. Data were collected on age and sex and whether the referral was for visible haematuria, non-visible haematuria or other suspected urological cancer. In addition to referral data, hospital episode data for all new renal cell (RCC) and upper and lower tract transitional cell carcinoma (TCC), as well as testicular and prostate cancer diagnoses for the same time periods were obtained.
Over the campaign period and the subsequent 3 months, the number of haematuria referrals increased by 92% (P = 0.013) when compared with the same period a year earlier. This increase in referrals was not associated with a significant corresponding rise in cancer diagnosis; instead changes of 26.8% (P = 0.56) and −3.3% (P = 0.84) were seen in RCC and TCC, respectively.
This study has shown that the Be Clear on Cancer ‘blood in pee’ mass media campaign significantly increased the number of new suspected cancer referrals, but there was no significant change in the diagnosis of target cancers across a large catchment. Mass media campaigns are expensive, require significant planning and appropriate implementation and, while the findings of this study do not challenge their fundamental objective, more work needs to be done to understand why no significant change in target cancers was observed. Further consideration should also be given to the increased referral burden that results from these campaigns, such that pre-emptive strategies, including educational and process mapping, across primary and secondary care can be implemented.
In this month’s issue of the BJUI, Hughes-Hallette et al. [1] report on the impact of a mass media public health campaign for gross haematuria. The authors performed a retrospective analysis evaluating the effectiveness of the ‘Be Clear on Cancer: “Blood in the pee”’ campaign. Similar campaigns for colorectal cancer have shown increased referrals and cost, without increasing the number of cancer diagnoses [2, 3]. In the current study [1], cancer diagnosis similarly did not rise. The two questions that therefore needs to be asked are:
Recent data from large integrative datasets have shown that visible haematuria is a significant predictor for bladder cancer [4, 5]. If gross haematuria is a predictor for urological malignancy, however, why did the authors [1] fail to find an increase in diagnosis of urological malignancy in their study? While the authors indicate that the study may have been underpowered, and that the use of an unlinked dataset may have interfered with proper accounting of cancer incidence, one must also consider that mass media outreach may not be an effective method for cancer outreach.
The ‘Be Clear on Cancer’ campaign involved the use of television adverts, print media and ‘out of home’ advertisements. Using this method, patients who are at risk of renal and bladder cancer, i.e. men, those aged >50 years, and smokers, are targeted as frequently as non-smoking teenagers. This type of mass media outreach programme is analogous to traditional advertising, where the message is often diluted and ineffective. While the ‘Be Clear on Cancer’ campaign is a worthy endeavour, the data do not seem to support the use of taxpayers’ money given its ineffective nature. A novel approach to visible haematuria may be to encourage GPs to ask patients about visible, painless haematuria, much as they would ask about chest pain or blood pressure. This would create a more focussed and durable outreach programme that would reduce the number of non-oncological referrals. As stewards of taxpayers’ money, we must be careful of how public funds are spent. The next generation of mass media outreach may require a combination of traditional media in addition to, social media and targeted advertising [6]. Although the ‘Be Clear on Cancer’ campaign did not appear to achieve its intended goals at this time, we must continue to refine and create new interactive approaches to improve the diagnosis and treatment of urological malignancies.
To assess the impact on suspected cancer referral burden and new cancer diagnosis of Public Health England’s recent Be Clear on Cancer ‘blood in pee’ mass media campaign.
A retrospective cohort study design was used. For two distinct time periods, August 2012 to May 2013 and August 2013 to May 2014, all referrals of patients deemed to be at risk of urological cancer by the referring primary healthcare physician to Imperial College NHS Healthcare Trust were screened. Data were collected on age and sex and whether the referral was for visible haematuria, non-visible haematuria or other suspected urological cancer. In addition to referral data, hospital episode data for all new renal cell (RCC) and upper and lower tract transitional cell carcinoma (TCC), as well as testicular and prostate cancer diagnoses for the same time periods were obtained.
Over the campaign period and the subsequent 3 months, the number of haematuria referrals increased by 92% (P = 0.013) when compared with the same period a year earlier. This increase in referrals was not associated with a significant corresponding rise in cancer diagnosis; instead changes of 26.8% (P = 0.56) and −3.3% (P = 0.84) were seen in RCC and TCC, respectively.
This study has shown that the Be Clear on Cancer ‘blood in pee’ mass media campaign significantly increased the number of new suspected cancer referrals, but there was no significant change in the diagnosis of target cancers across a large catchment. Mass media campaigns are expensive, require significant planning and appropriate implementation and, while the findings of this study do not challenge their fundamental objective, more work needs to be done to understand why no significant change in target cancers was observed. Further consideration should also be given to the increased referral burden that results from these campaigns, such that pre-emptive strategies, including educational and process mapping, across primary and secondary care can be implemented.
Test yourself against our experts with our weekly quiz. You can type your answers here if you want to compare with our answers.
This patient presented with haematuria and was found to have stones.
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“It is my ambition to say in ten sentences what others say in a whole book.” – Friedrich NietzscheThe EAU guidelines on lower urinary tract symptoms have been published recently. These contain 36,000 words. It was pointed out to me that the American declaration of independence contained 1300 words and The Ten Commandments just 179 words.
The challenge was therefore to write ten commandments for urology in 179 words. The rules I set were that I should write them whilst keeping the spirit of the structure of the decalogue as closely as possible. (It may be worth rereading the original before reading on). So here goes.
1) I am a logical specialty. Thou shall investigate thoroughly prior to undertaking intervention for I am a specialty that avoids surprises.
2) Though interested in the whole of medicine thou will perform no other procedures other than urological.
3) Thou shalt not base intervention on old imaging for the clinical situation could have changed.
4) Remember that 80% of diagnoses can be made with history alone. Thou shalt listen carefully to your patient to this end.
5) Honour sound surgical principles. Urological tissue is forgiving but anastamoses under tension will not heal.
6) Thou shall not ignore haematuria.
7) Thou shall not leave a stent and forget it has been placed.
8) Thou shall not adopt new technology without proper clinical evaluation unless it is part of a trial.
9) Thou shall not fail to see the images yourself in assessing the patient before you.
10) Thou shall not fail to assess the potential for harm before embarking on a surgical procedure. If you would not do it to your family, your neighbour or friends, you will not do it to the patient who is in your clinic.
I put these out for discussion. Other offerings please.
Jonathan M. Glass @jonathanmglass1
The Urology Centre, Guy’s Hospital, London, UK.
The development of haematuria following bladder decompression is a well described phenomenon, but is usually transient, mild, and of little clinical consequence. We describe a case in which bladder decompression precipitated massive urinary tract haemorrhage requiring multiple blood transfusions and bilateral nephrostomy insertion
Authors: Spencer Chapman, Michael; Harber, Mark
Department of Nephrology, Royal Free Hampstead NHS Trust, London, UK
Corresponding Author: Spencer Chapman, Michael
Introduction
Urinary retention is a frequently encountered problem in everyday clinical practice. When chronic, the patient is able to urinate and may be asymptomatic, or may complain of lower urinary tract symptoms (LUTS) such as urinary frequency, urgency or hesitancy, poor urinary stream, post-micturition dribbling, nocturia or urinary incontinence. However the urinary tract is often subjected to high pressures which are required to allow voiding. Over time high pressures may damage the entire urinary tract: obstructive nephropathy resulting in renal failure and bladder changes such wall thickening, trabeculation, and loss of capillary and tissue integrity(1). The immediate management of urinary retention is urethral catheterisation to allow free drainage of urine from the bladder. The development of haematuria following bladder decompression is a well described phenomenon, but is usually transient, mild, and of little clinical consequence. We describe a case in which bladder decompression precipitated massive urinary tract haemorrhage requiring multiple blood transfusions and bilateral nephrostomy insertion.
Case report
A 58 year-old Caucasian man was transferred to our unit from a local hospital with massive urinary tract haemorrhage and renal failure.
He had presented to his GP five days previously complaining of dysuria. He was prescribed a course of antibiotics for a presumed urinary tract infection and blood taken for a full blood count and urea and electrolyte estimation. The results of his blood tests demonstrated a creatinine level of 958 μmol/l and haemoglobin of 5.2 g/dL. He was referred immediately to his local Accident & Emergency (A&E) department.
At his local A&E, he reported prostatic symptoms of urinary frequency, poor stream and nocturia. These had been present for the last twenty years but had worsened over the previous few weeks. The symptoms were accompanied by general lethargy, malaise and aching thoraco-lumbar back pain that radiated to his groin. In addition he had recently noticed bilateral numbness and dysaesthesiae in his fingertips. His past medical history was notable only for long-standing prostatic symptoms for which he had been investigated three years previously, at which time a serum prostate-specific antigen (PSA) level was measured at 5.4 μg/L. MRI of the prostate had showed an enlarged central lobe of the prostate and bladder changes consistent with chronic obstruction, but no evidence of malignancy (Figure 1a and Figure 1b). He had undergone urethroscopy and cystoscopy which were reportedly normal and he did not undergo any surgical intervention. He had been lost to follow up. There was no history of neurological disease. His medications included losartan, doxazosin and simvastatin. He reported no prescription or over-the-counter use of aspirin, clopidogrel or other anticoagulants. He had a 30 pack year smoking history, drank around 5 units of alcohol a week and did not use illicit drugs. He was afebrile and observations were within normal limits. General examination was reportedly unremarkable.
Initial blood tests showed a creatinine of 958 μmol/L, urea of 43.3 mmol/L, haemoglobin of 5.2 g/dL, corrected calcium of 2.06 mmol/L, phosphate of 3.29 mmol/L, and potassium of 5.8 mmol/L.
He was transfused and a urethral catheter was easily inserted which immediately drained 2.9L of clear urine. After a few hours the urine was noted to have become a pale red colour. Overnight this progressed to frank haematuria with clots. This persisted, and over the following 3 days he underwent bladder irrigation and required transfusion with 10 units of packed red blood cells, 7 units of fresh frozen plasma and 1 unit of platelets.
The patient’s haematuria and renal failure continued and on the fifth hospital day he was transferred to our unit. His haemoglobin was measured at 5.8 g/dL, urea 37.2 mmol/L, and creatinine 809 μmol/L. Bladder irrigation was continued and he was further transfused. CT of the abdomen and pelvis obtained with the administration of contrast material revealed hugely dilated renal pelvises bilaterally, measuring 10cm in maximal diameter on the right and 7cm on the left (Figure 2a). The catheterised bladder was diffusely thick-walled with a posterior diverticulum (Figure 2b). High attenuation material likely to represent haemorrhage was present throughout the bladder, ureters and renal pelvises. Both kidneys were hydronephrotic. No focal lesion or active bleeding was identified.
At this stage there was considerable discussion regarding the benefits of bilateral nephrostomy insertion to relieve back pressure on his kidneys. Renal failure was persisting with the need for dialysis under consideration, and imaging suggested obstruction at the level of the ureters due to insoluble blood clot. A consensus was reached that nephrostomy insertion would be likely to hasten renal recovery and potentially avoid the need for dialysis. On the eighth hospital day he underwent bilateral nephrostomy insertion. Serum creatinine levels fell and dialysis was not required.
Over the next two weeks he underwent bilateral antegrade stenting of his ureters, and by the twenty-fifth hospital day, both nephrostomies were removed. Shortly after he was discharged with a urethral catheter and right ureteric JJ stent in situ. His creatinine on discharge was 348 μmol/L. Two months later, at which time his creatinine was 241 μmol/L, he underwent successful transurethral resection of the prostate. Notably, no false passage was seen in the urethra. His LUTS were much improved and the urethral catheter was no longer required. He went on to have laparoscopic pyeloplasty of the right kidney and removal of the right JJ stent. Radioisotope renography with MAG-3 performed one month later demonstrated reasonable bladder emptying post-micturition, normal transit times, no evidence of obstruction, but ongoing dilatation of the right renal pelvis.
Discussion
Urinary retention is the inability to empty the bladder. When chronic, the patient is able to pass urine, but may experience voiding difficulties and bladder emptying is incomplete. The usual cause is bladder outlet obstruction, the aetiology of which may be enlargement of the prostate (benign or malignant), drugs (e.g. anticholinergics, antispasmodics), congenital deformities (e.g. meatal stenosis, posterior urethral valves) or urethral strictures (from trauma or infection). It largely affects men from middle-age onwards reflecting the increasing incidence of benign prostatic hypertrophy (BPH) in this group. Women are also affected however, around 50% of women are diagnosed with Fowler’s syndrome: a problem of inadequate urethral sphincter relaxation (2).
In order to facilitate emptying, the bladder is forced to hypertrophy so as to increase its contractile force. This results in bladder wall thickening, trabeculation and friability. It may also become increasingly sensitive (contributing to symptoms of urinary frequency, urgency and incontinence) and eventually become weakened thereby preventing complete bladder emptying. The structural changes within the bladder are thought to affect the integrity of capillaries and tissues within its wall.
Haematuria following bladder decompression by urethral catheterisation is well-recognized, and visible haematuria is estimated to occur in 2-16% of patients(3). However, though there are case reports of clinically significant haematuria, they are rare and we could find no reports in the literature of haemorrhage requiring multiple blood transfusions as in this case (4). Factors contributing to the severity of bleeding in this case include the significant structural damage to the urinary tract resulting from many years of urinary retention, and possible coagulopathy that is part of the “uraemic syndrome” associated with renal failure. Traditional teaching recommends a “clamping technique” to achieve step-wise gradual bladder decompression and supposedly reduce the risk of haematuria. Use of an IV giving set to achieve gradual decompression has also been advocated (5). However, these approaches are time consuming and presently there is scant evidence to support their use (8). We could find no randomized studies comparing gradual bladder decompression with quick, complete emptying, and other studies suggest that the risk of haematuria correlates with the severity of bladder wall damage prior to catheterisation, and not the rate of initial emptying (6). Furthermore, studies of changes in intravesical pressure following catheterisation for acute urinary retention show that the pressure drops to around 50% of the initial value after drainage of only 100mL (7)– hence clamping after 1000mL (a commonly adopted figure) might not be expected to significantly reduce risk of bleeding.
One question brought up by this case is whether the haemorrhage responsible for decompression haematuria is confined to the bladder, or if it occurs throughout the urinary tract. In our patient blood clot was seen to fill and distend both renal pelvises; did this blood track up from the bladder or did it originate from bleeding within the pelvis itself? A number of factors lead us to conjecture that the bleeding may well have originated from the wall of the renal pelvis itself. Firstly, the renal pelvises were filled with large volumes of clot in the absence of significant dilatation of the ureters (images not shown). Secondly, there is no reason to believe that the pathological process resulting from chronic urinary retention affecting the integrity of capillaries should be limited to the bladder. In the absence of a competent uretero-vesical valve, the ureters and collecting system of the kidneys are subjected to similarly high pressures and are likely to undergo similar pathological changes.
Given this, what can be done to minimise harm to the patient when considering urethral catheterisation for urinary retention? Most importantly, one must recognize patients who are at risk of clinically significant decompression haematuria. Risk correlates with the chronicity of symptoms and the degree of bladder wall damage. Hence, patients such as ours with a long history of LUTS are at increased risk and should have close monitoring post-catheterisation. It is currently unclear as to whether strategies facilitating “gradual decompression” should be advocated: further studies are required to assess the effectiveness and practicality of such strategies.
Teaching points
Fig. 1a
Fig. 1b
Fig. 2a
Fig. 2b
References
1. High pressure chronic retention. George NJ, O’Reilly PH, Barnard RJ, Blacklock NJ. Br Med J (Clin Res Ed). 1983 Jun 4;286(6380):1780-3.
2. Urinary retention in women: its causes and management. Kavia RB, Datta SN, Dasgupta R, et al; BJU Int. 2006 Feb;97(2):281-7.
3. Management of urinary retention: rapid versus gradual decompression and risk of complications. Nyman MA, Schwenk NM, Silverstein MD . Mayo Clin Proc. 1997 Oct;72(10):951-6.
4. Hematuria as a complication of sudden decompression of chronically distended bladder in a child with neurogenic bladder dysfunction. Soylu A, Kavukçu S, Türkmen M, Arici A, Aktud T. Pediatr Emerg Care. 2000 Jun;16(3):221.
5. Slow decompression of the bladder using an intravenous giving set. Perry A, Maharaj D, Ramdass MJ, Naraynsingh V. Int J Clin Pract. 2002 Oct;56(8):619.
6. Comparison of rapid versus slow decompression of the distended urinary bladder. Gould F, Cheng CY, Lapides J. Invest Urol. 1976 Sep;14(2):156-8.
7. Intravesical pressure changes during bladder drainage in patients with acute urinary retention. Christensen J, Ostri P, Frimodt-Møller C, Juul C. Urol Int. 1987;42(3):181-4.
8. Practical management of patients with dilated upper tracts and chronic retention of urine. George NJ, O’Reilly PH, Barnard RJ, Blacklock NJ. Br J Urol. 1984 Feb;56(1):9-12.
Date added to bjui.org: 11/12/2012
DOI: 10.1002/BJUIw-2012-092-web
We present a case of a young man referred to our hospital with severe haematuria, pre-renal lipoma and lumbar pain.
Authors: Navarro, Joaquin; Azua-Romeo, Javier; Tovar, Maria Teresa; Lpoez Lopez, Jose Antonio; Ernest Lluch Hospital, Urology, Calatayud, Zaragoza, Spain
Corresponding Author: Javier Azua-Romeo, Ernest Lluch Hospital, Urology, Calatayud, Zaragoza, Spain. Email: [email protected]
Date added to bjui.org: 27/01/2012
DOI: 10.1002/BJUIw-2011-092-web