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2012 AUA Guidelines
ASYMPTOMATIC MICROSCOPIC HEMATURIA:
2012 AUA GUIDELINES
Andrew James Tompkins, M.D.Clinical Instructor in Surgery (Urology)The Warren Alpert School of Medicine at Brown UniversityUrologic Specialists of New [email protected]
I’m not actually 5’11 I don’t usually wear a suitDidn’t get much sleepNothing to disclose
DISCLOSURES
To define asymptomatic microscopic hematuria (AMH).
Identify patients that require urologic referral.
Discuss the ideal evaluation of AMH.
What should I send to the urologist that would be helpful? Focus less on “data” and more on evaluation process.
OBJECTIVES
58 yo female with history of smoking, HTN, DM, and recurrent UTI’s presents for evaluation of urinary frequency.
Urine Dipstick: + 2 Blood, + LE, - Nit, - Protein
Does this patient need a hematuria evaluation?
Lets find out.
CASE
“3 or greater RBC per high power field on a properly collected urinary specimen in the absence of obvious benign cause”
Dipstick is insufficient! Sensitive not specific 35% false positive
Obvious Benign Cause Infection Menstruation* Vigorous exercise Viral illness Trauma Recent urologic procedure
AMH - DEFINED
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012Rao, PK et. al.: Dipstick Pseudohematuria: Unnecessary Consultation and Evaluation. Journal of Urology. 2010. Vol. 183. 560-565
Change from 2001 guideline “2 of 3 urine specimens with 3 or more RBC.”
Indirect evidence supports 1 positive sample Microhematuria caused by malignancy is highly intermittent…
multiple samples may lead to missed diagnosis
Studies show malignancy rate of 3.3% (95% CI 2.2-5%) with one sample. Not significantly different from multiple samples.
Patients “benefit” from active management of frequently diagnosed conditions during AMH evaluation.
AMH - DEFINED
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
Stone Disease – 6.0% (95% CI 3.8-9.2%)
Benign Prostate Enlargement – 12.9% (95% CI 6.3-24.6%) 30%-40% in my patient population
Urethral Stricture – 1.4% (95% CI 0.6-3.2%)
GU Malignancy - 3.3% (95% CI 2.2-5%)
AMH - DIAGNOSIS
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
58 yo female with history of smoking, HTN, DM, and recurrent UTI’s presents for evaluation of urinary frequency.
Urine Dipstick - + Blood, + LE, - Nit
Microscopy – 3 RBC, 10 WBC, Urine Culture - > 100,000 E. Coli
Does this patient need a hematuria evaluation?
Repeat UA with Micro in 4 weeks.
CASE CONTINUED
Retrospective chart review of two urologists at Cleveland Clinic between 2006-2008
91 patients met inclusion criteria as referral for AMH 59.3% - referred on + dipstick only 16.5% - referred + dipstick and micro <3rbc 24.2% - referred on + dipstick and micro > 3rbc
57% (52/91) consults had “pseudohematuria” 52% (27/52) – patients deferred evaluation c counseling on
guidelines 48% (25/52) – patients requested evaluation despite urologist
counseling against additional evaluation Cost $26,792 based on 2009 Medicare reimbursements
AMH - REFERRAL
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012Rao, PK et. al.: Dipstick Pseudohematuria: Unnecessary Consultation and Evaluation. Journal of Urology. 2010. Vol. 183. 560-565
25% of inappropriate referrals were found to have
AMH on urology evaluation
AMH - REFERRAL
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012Rao, PK et. al.: Dipstick Pseudohematuria: Unnecessary Consultation and Evaluation. Journal of Urology. 2010. Vol. 183. 560-565
Prevalence
Rate of AMH range from 2.4% to 31% in health screening studies.
Highest rates in Men ≥ 60 yo
Smokers/former smokers.
AMH - BACKGROUND
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012Loo, RK et. al.: Stratifying Risk of Urinary Tract Malignant Tumors in Patients With Asymptomatic Microscopic Hematuria. Mayo Clinic Proceedings. 2013
Male genderAge ≥ 35Past/Current
smokingChemical exposureAnalgesic abuseHx gross hematuriaHx irritive voiding
symptoms
AMH – AUA RISK FACTORS FOR MALIGNANCY
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
Hx pelvic irradiationHx chronic utiHx of
cyclophosphamide*Chronic indwelling
foreign body
2630 patients referred for AMH in southern California between 2009 & 2011 (prior to 2012 guidelines)
> 3 RBC on 2/3 properly collected specimens
Renal or Bladder Cancer – 1.9% (3.3% on meta-analysis)
RF – Age > 50 yo, hx gross hematuria, male sex.
Hematuria Risk Index Low Risk (32%) – 0.2% risk of cancer High Risk (14%) – 11.1% risk of cancer
AMH – MALIGNANCY RISK
Loo, RK et. al.: Stratifying Risk of Urinary Tract Malignant Tumors in Patients With Asymptomatic Microscopic Hematuria. Mayo Clinic Proceedings. 2013
58 yo female with history of smoking, HTN, DM, and recurrent UTI’s presents for evaluation of urinary frequency.
Microscopy – 3 RBC, 10 WBC, Urine Culture - > 100,000 E. Coli,
Repeat UA with Micro in 4 weeks 3 RBC, 5 WBC Urine Culture - No Growth
Should I refer to urology? Yes!
CASE CONTINUED
Urinalysis & Microscopy – dysmorphic RBC, proteinuria, cellular casts, renal insufficiency → nephrology consult
GFR – (BUN, Cr) → Impaired renal function → nephrology consult
Imaging - CTU
Cystoscopy - All patients ≥ 35 years old & < 35 years old with risk factors
AMH - EVALUATION
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
Midstream Clean Catch UA dipstick and Microscopy If contaminated – repeat Send UA dipstick and microscopy with referral
Urinalysis – dysmorphic RBC, proteinuria, cellular casts Nephrology consult
Continue Urologic Evaluation
AMH - URINALYSIS
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
GFR – (BUN, Cr) → Impaired renal function → nephrology consult *Send recent BMP with referral GFR has implications with CTU & MRU
Continue Urologic Evaluation
AMH - GFR
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
CTU – without, with, & with delayed imaging w/o – stones, backdrop for enhancement W – renal masses, renal artery stenosis, assess for
enhancement Delayed – assess collecting system for filling defects
ASYMPTOMATIC MICROSCOPIC HEMATURIA - IMAGING
Chlapoutakis K, et al: Performance of computed tomographic urography in diagnosis of upper urinary tract urothelial carcinoma, in patients presenting with hematuria: Systematic review and meta-analysis. Eur J Radiol 2010; 73: 334
AMH- IMAGING
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012
58 yo female with history of smoking, HTN, DM, and recurrent UTI’s presents for evaluation of urinary frequency.
Microscopy – 3 RBC, 10 WBC, Urine Culture - > 100,000 E. Coli,
Repeat UA with Micro in 4 weeks 3 RBC, 5 WBC Urine Culture - No Growth Serum Cr 1.7 eGFR 39ml/min/1.73m2
You want to get the ball rolling and order imaging. What imaging test should you order? CTU! Hold metformin, IVF 500cc-1L D5NS prior to scan
CASE CONTINUED
1. CT Urogram
2. MR Urogram – If allergic to IV contrast
3. MR & Retrograde Pyelograms – If poor renal function
What about Renal Ultrasound? Not sensitive – 50% sensitive Not specific – 95% specific (RCC) Technician/body habitus dependent Not sufficient
AMH – ALTERNATIVE IMAGING
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012El-Galley R, Abo-Kamil R, Burns JR et al: Practical use of investigations in patients with hematuria. J Endourol 2008; 22: 51
If you refer microscopic hematuria frequently… Find urologist you trust. Ask them their preferences on imaging.
Modality Preferred imaging location?
Referrals to me? Don’t image please – let me discuss with patient I send prior imaging to my radiologists for comparison I show patients their imaging I give them a copy of their report If you do image, obtain study at RIMI & cc results to me. Care New England…in process of bringing reporting/image
viewing up to speed. CTU is preferred modality If ever any question text me or call my cell phone 585-315-4853
AMH –IMAGING SUMMARY
“Use of urine cytology and urine markers (NMP22, BTA-stat, & FISH) is NOT recommended” Cytology – Specific, Finds High Grade Tumors FISH/ Urovision (False Positive)
Chromosome 3,7, and 17 centromere gain. Loss of 9P21.
NMP 22 (False Positive) Detects nuclear matrix protein
BTA-Stat (False Positive) Detects compliment factor H-related protein
AMH – TUMOR MARKERS
Diagnosis, evaluation and follow-up of AMH in adults: AUA guideline, 2012Lotan, Y and Shariat, S.: Urinary Markers for Bladder Cancer Detection and Follow-up. AUA Update Series. Lesson 21 Volume 30, 2011
Any questions before I need to run?
THANK YOU
ASYMPTOMATIC MICROHEMATURIA VS. GROSS HEMATURIA
Initial supportive care: correct coag, consider transfusion, medical evaluation (in case OR requrired), stop all anticoagulation
Consider placing a Foley2 way minimum 20 Fr- hand irrigation3 way minimum 22 Fr
Must hand irrigate all clot free before starting CBI Start CBI with normal saline - titrate to light pink
GROSS HEMATURIA TREATMENT
Additional therapies
Amicar- IV, PO or intravesical
Must have no clot in bladder
Intravesical: Amicar, alum, formalin, silver nitrate.
Hyperbaric Oxygen
Cystoscopic evaluation with clot evacuation and fulguration.
GROSS HEMATURIA TREATMENT
The pregnant female AMH patient requires special consideration. The majority of AMH cases are associated with non-life threatening conditions, and less than 5% are associated with malignancy. Further, the incidence of AMH in pregnant and non-pregnant women is similar (approximately 4%).176 Brown177 reported that women with and without AMH during pregnancy had offspring of similar birth weight and gestational age at delivery, and similar rates of gestational hypertension and pre-eclampsia. Given that malignancies in this low risk group (typically < 40 years of age) are rare, the Panel recommends use of MRU, MRI with RPGs, or US to screen for major renal lesions with a full workup after delivery once gynecological bleeding and persistent infection have been ruled out.
SPECIAL CONSIDERATIONS IN THE PREGNANT FEMALE
The use of urine cytology and urine markers (NMP22, BTA-stat, and UroVysion FISH) is NOT recommended as a part of the routine evaluation of the asymptomatic microhematuria patient. Recommendation
Twenty-five studies reported sensitivity and/or specificity values for urine cytology.25-26, 32, 36, 42, 53, 59, 65, 178-194 Sensitivity values ranged from 0% to 100%; specificity values ranged from 62.5% to 100%.
For NMP22, sensitivities ranged from 6.0% to 100% and specificities ranged from 62% to 92%.
Three studies reported on UroVysion FISH;25, 191-192 sensitivities ranged from 61% to 100%, and specificities ranged from 71.4% to 93%.