Non-visible Haematuria Research Articles

Investigation of Non-visible Haematuria in a Tertiary Urology Service: Can We See the Reward?

Investigation of Non-visible Haematuria in a Tertiary Urology Service: Can We See the Reward?

Are We Over Investigating Non-Visible Haematuria, Time to Change Imaging Strategies?

Are We Over Investigating Non-Visible Haematuria, Time to Change Imaging Strategies?

#5827 MYCOPHENOLATE MOFETIL AS IMMUNOSUPPRESSIVE THERAPY IN IGA NEPHROPATHY

Abstract Background and Aims IgA Nephropathy is the commonest cause of primary Glomerulonephritis in developed countries. It is characterised by IgA-dominant deposits in the mesangium on renal biopsy. Classically presenting with asymptomatic non-visible haematuria or episodic visible haematuria 24-48 hours after an upper respiratory tract infection, raised BP and Proteinuria. End-stage renal disease (ESRD) can occur in up to 20-50% of patients. Treatment with ACEI/ARB has strong evidence in managing IgA. If there is evidence of progression, steroids and immunosuppression are recommended. Mycophenolate Mofetil's effectiveness in IgA nephropathy is controversial. KGIGO guidelines authors suggest not to use it. In this work, we reviewed immunosuppression with mycophenolate Mofetil (MMF) retrospectively in IgA nephropathy patients managed at Sussex Kidney unit – Brighton -UK. Method We retrospectively reviewed 25 patients who had a diagnosis of IgA nephropathy and were treated with mycophenolate mofetil as immunosuppression for IgA nephropathy under the care of the Sussex Renal Unit at University Hospitals Sussex. Patients reviewed, had been diagnosed between 2011-2020. Data collected from our department's electronic system, including laboratory results, histopathology reports, clinic letters and medications. Data were collected until January 2023 for patients who had renal survival. For patients who started on renal replacement therapy (RRT), data were collected until the start of RRT. The work aimed at looking at MMF efficacy in IgA nephropathy. The primary measures were renal survival without the need for RRT and proteinuria reduction to > 50% of the baseline at diagnosis. Results We reviewed 25 patients, 13 male and 12 female. Twenty-four patients (96%) were of white Caucasian ethnicity while one patient (4%) was Asian. The mean age was 42.4± 16 years. All the patients were diagnosed with both clinical pictures and renal biopsies. Oxford classification score showed M1 (21) patients, E (5 patients), S (19 patients), T (1 = 10 patients, 2 = 4 patients), and C (1 = 15 patients, 2 = 4 patients). On presentation, 5 patients presented with a sore throat, 8 with skin rash and 7 with macroscopic haematuria. Seventeen patients (60%) presented with AKI. Eleven patients (44%) had nephrotic range proteinuria on presentation. The average duration of the disease was 6.1 years at the time of assessment. MMF was used in the 25 patients, five of them had prednisolone and cyclophosphamide for 3 months followed by MMF maintenance. Twenty patients were treated with MMF alone or in combination with steroids (17 patients) from the start. The average duration of treatment was 2 years, and the average dose was 1 gm twice daily. Five patients (20%) progressed to ESRD and three of them had renal transplantation while twenty patients (80%) maintained renal survival. For the 80% who maintained renal survival the mean eGFR at diagnosis was 45.6± 34.1 and at the time of assessment was 56.1±26.6. Of the 17 patients presented with AKI, five patients (29.4%) recovered to normal renal function, five patients had ESRD (29.4%) and four had improvements of eGFR while three patients showed a decrease of eGFR (Mean 45.6± 1.1 ml/min) to eGFR (Mean 32± 8.2 ml/min). In total, 70.6% of AKI patients recovered either to normal or to CKD level and 80% of the total patients had renal survival without RRT during the time of review. Twenty patients (80%) achieved more than 50% reduction of proteinuria, with five patients (20%) having proteinuria less than 0.3 g/24 hours and 9 (36%) patients less than 0.5 g/24 hours. Comparison between the proteinuria at diagnosis and at the time of assessment was significant (P<0.001). Conclusion Mycophenolate mofetil was effective in maintaining renal survival and improving proteinuria in IgA nephropathy patients who were indicated for immunosuppression based on histopathology and risk of progression. It was well tolerated by patients. A randomised controlled trial is needed to compare the MMF effect in comparison with currently available therapies.

Renal stone disease

Renal stone disease (urolithiasis, nephrolithiasis) covers many conditions causing kidney, ureteric or bladder stones. These include metabolic and inherited disorders, anatomical defects of the upper or lower urinary tract, and chronic urinary infection. However, most cases of renal stones are idiopathic. They present with loin or abdominal pain, and visible or non-visible haematuria; this is followed by the eventual passage of a stone and resolution, or the need for further investigation and intervention. Renal stones often recur, and it is important to identify the underlying cause, particularly because the risk can be related to diet and lifestyle, and is often associated with hypertension and/or diabetes mellitus. Although clinical management is largely surgical and can seem straightforward, the increasing prevalence of renal stone disease in developed countries is becoming a significant health and economic burden.

Intra-Diverticular Bladder Tumours: How to Manage Rationally

Objective To report changing practice in the management of intra-diverticular bladder tumours. Methods We undertook a review of all intra-diverticular bladder tumours in our prospectively maintained institutional database. Results A total of 28 patients (male = 27, female = 1) with a median age of 71 years (IQR 61 to 76) were diagnosed with intra-diverticular bladder tumours (IDBT) between March 2013 and February 2021. Fourteen had visible and 3 had non-visible haematuria, while 11 patients had lower urinary tract symptoms. Median axial diameter of the diverticula was 46 mm (IQR 35 to 69), and median neck diameter was 9 mm (IQR 7 to 11). All patients had CT-urography and 5 patients also had an MRI. Surgical treatment consisted of diverticulectomy (n = 11), diverticulectomy and ipsilateral ureteric reimplantation (n = 11), radical cystectomy and ileal conduit (n = 4), or radical cystectomy and orthotopic bladder (n = 2). Eleven patients had open procedures, and 17 had robotic assisted surgery. Final pathological stages were T0 (n = 2), Ta (n = 5), T1 (n = 7), T3a (n = 8) and T3b (n = 6). Twenty-four patients had urothelial carcinoma (including one nested variant and 4 with squamous differentiation) and 2 had small cell carcinoma. Three patients had neoadjuvant systemic chemotherapy, 2 had intravesical bacillus Calmette-Guerin (BCG) with mitomycin, and one had BCG monotherapy preoperatively. Five patients had adjuvant systemic chemotherapy while 7 had adjuvant intravesical therapies. Mean follow-up period was 37.8 months (±25.3). Mean recurrence-free survival was 61.5% (CI 45.7 to 77.4) and mean overall survival 71.6 % (CI 57.4 to 85.8). Ten patients (37%) died of cancer. Conclusion Management of intra-diverticular bladder tumours is evolving. Bladder-sparing approaches are gaining popularity. Robot-assisted diverticulectomy is preferable as it reduces the morbidity resulting from treatment.

Optimizing Upper-Tract Imaging for Non-Visible Haematuria

Introduction: Non-visible haematuria (NVH) is associated with a small risk of upper-tract urothelial carcinoma (UTUC), though there is little consensus on its investigation, particularly with regard to upper-tract imaging. This study aimed to determine whether the presentation of UTUC can guide investigation of NVH in patients under 60 years old. Methods: All patients investigated at our one-stop haematuria clinics under a cancer pathway were reviewed during a 5-year period, with all patients undergoing cystoscopy and upper-tract imaging. Retrospective analysis of all UTUC cases from our urological cancer multidisciplinary team meeting database over a 10-year period was also undertaken. Results: 2,129 patients with a median age of 67 years underwent urgent investigation for haematuria between March 2015 and February 2020. 449 cases presented with NVH, of whom 124 (27.6%) were under 60. Out of 21 cases of UTUC, only 2 presented with NVH; both were over the age of 60 years. Factors that independently predicted diagnosis with urinary-tract malignancy were age ≥60 (OR 3.70, p < 0.001), visible haematuria (OR 2.50, p = 0.006), and suspicious cystoscopic findings (OR 58.06, p < 0.001). Review of all 119 UTUC cases over 10 years found 6 cases (5.0%) presenting with NVH, with one (0.8%) also presenting under 60 years. Conclusion: Diagnosis with UTUC is rare in patients presenting with NVH under the age of 60 years. Routine use of CTU in this low-risk group is best avoided, with ultrasonography constituting a safer first-line upper-tract imaging modality. Guidelines that risk-stratify NVH patients may be effective in reducing unnecessary investigations.

AKT question relating to non-visible haematuria

AKT question relating to non-visible haematuria

AKT answer relating to non-visible haematuria

AKT answer relating to non-visible haematuria

Haematuria in adults

Haematuria in adults is a common complaint, whether it be visible (macroscopic, previously called frank) haematuria or non-visible (microscopic) haematuria and may be either symptomatic or asymptomatic. Haematuria is a non-specific symptom generated by a wide range of medical and surgical causes. Determining the cause requires thorough history, examination and investigation. Visible haematuria and symptomatic non-visible haematuria always require investigation.

Simple Cysts of the Kidney: A Review and Update

Simple Cysts of the Kidney: A Review and Update

1284 Comparison of British Association of Urological Surgeons (BAUS) 2008 and NICE 2015 Guidelines for Patients with Suspected Urinary Tract Cancer: An Audit of Haematuria Referrals

Abstract Introduction BAUS guidelines for the investigation of haematuria were replaced by NICE guidelines in 2015. However, both criteria are currently used to refer patients to our Haematuria Clinic. We audit the haematuria referrals made to our unit and compare cancer yield. Method A retrospective review of all two-week wait haematuria referrals to a single UK teaching hospital between October 2019 and April 2020 was performed. Referrals were stratified into two groups: BAUS 2008 and NICE 2015 referral criteria. The outcomes of haematuria investigations were analyzed and the incidence of urinary tract cancer (UTC) compared between groups. Results 316 referrals were analyzed. Of these, 123 (39%) and 193 (61%) referrals were made using BAUS and NICE criteria respectively. 233 (74%) patients were investigated for visible haematuria of which 68 (29%) were referred using BAUS criteria and 165 (71%) using NICE. UTC was identified in 20% of patients referred using NICE criteria and 4.4% using BAUS criteria. 83 (26%) patients were referred with non-visible haematuria. Of these, 55 (66%) were referred using BAUS criteria and 28 (34%) using NICE. UTC was identified in 2.5% of patients referred using BAUS criteria. No UTC was identified in referrals using NICE criteria. Conclusions Despite BAUS haematuria guidelines being superseded by NICE guidelines in 2015, these older guidelines still account for 40% of our two-week wait referrals. Furthermore, NICE guidelines have a higher cancer yield for visible haematuria compared to BAUS guidelines and should therefore take precedence to avoid subjecting patients to unnecessary and costly investigations.

545 Assessing the Impact Of COVID-19 On the Diagnosis and Management of Bladder Cancer in The United Kingdom – The West Midlands Experience

IntroductionThe British Association of Urological Surgeons (BAUS) issued an interim strategy for the management of bladder cancer as a contingency measure during the COVID-19 pandemic. We aim to assess the actual implementation of these recommendations and deviation from the standard of care in the West Midlands.MethodA questionnaire was devised and sent to bladder cancer leads of 12 NHS Trusts in the region in June 2020. Responses were analysed and compared with the BAUS COVID-19 strategy.Results11 centres were aware of the BAUS COVID-19 strategy. 2 centres were offering teleconsultations only for 2-week-wait referrals, and 6 centres had changed their practice for non-visible haematuria referrals. All centres were offering TURBTs for new and high-risk tumours. 8 centres had clear MDT documentation of NICE risk-stratifications of all bladder tumours and 10 centres were also documenting any changes in treatment. Only 7 centres continued to give BCG to newly diagnosed NMIBC. All centres continued with staging CT for newly diagnosed MIBC. Patients were still being referred for cystectomies, however few were performed. Radiation as curative and palliative intent continued. Of the 5 regional cancer centres, only 1 continued with cystectomies as normal, whereas 2 performed the procedure on a case-by-case basis, and the procedure was delayed/deferred in the other 2 centres.ConclusionsDiagnostics, and definitive management of bladder cancer has been severely affected by COVID-19. In particular, deferred intravesical BCG and delayed radical treatment can have a dire impact on the long-term outcomes of the patients presenting during the pandemic.

Risk prediction models for symptomatic patients with bladder and kidney cancer: a systematic review.

BackgroundTimely diagnosis of bladder and kidney cancer is key to improving clinical outcomes. Given the challenges of early diagnosis, models incorporating clinical symptoms and signs may be helpful to primary care clinicians when triaging at-risk patients.AimTo identify and compare published models that use clinical signs and symptoms to predict the risk of undiagnosed prevalent bladder or kidney cancer.Design and settingSystematic review.MethodA search identified primary research reporting or validating models predicting the risk of bladder or kidney cancer in MEDLINE and EMBASE. After screening identified studies for inclusion, data were extracted onto a standardised form. The risk models were classified using TRIPOD guidelines and evaluated using the PROBAST assessment tool.ResultsThe search identified 20 661 articles. Twenty studies (29 models) were identified through screening. All the models included haematuria (visible, non-visible, or unspecified), and seven included additional signs and symptoms (such as abdominal pain). The models combined clinical features with other factors (including demographic factors and urinary biomarkers) to predict the risk of undiagnosed prevalent cancer. Several models (n = 13) with good discrimination (area under the receiver operating curve >0.8) were identified; however, only eight had been externally validated. All of the studies had either high or unclear risk of bias.ConclusionModels were identified that could be used in primary care to guide referrals, with potential to identify lower-risk patients with visible haematuria and to stratify individuals who present with non-visible haematuria. However, before application in general practice, external validations in appropriate populations are required.

PD10-07 UPPER TRACT IMAGING IN PATIENTS WITH HAEMATURIA

You have accessJournal of UrologyImaging/Radiology: Uroradiology I (PD10)1 Sep 2021PD10-07 UPPER TRACT IMAGING IN PATIENTS WITH HAEMATURIA Shanmugasigamani Kannan, Ashok Bhuvanagiri, Ashok Kailasa, Kyriacos Alexandrou, Mohanarangam Thangavelu, and Jason Walker Shanmugasigamani KannanShanmugasigamani Kannan More articles by this author , Ashok BhuvanagiriAshok Bhuvanagiri More articles by this author , Ashok KailasaAshok Kailasa More articles by this author , Kyriacos AlexandrouKyriacos Alexandrou More articles by this author , Mohanarangam ThangaveluMohanarangam Thangavelu More articles by this author , and Jason WalkerJason Walker More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001978.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To evaluate the range of pathologies identified in patients attending the One Stop Haematuria Clinic (OSHC) and to examine the value of Ultrasound Urinary tract (USS KUB) and CT Urogram in these patients. METHODS: This was a prospective study of 2110 patients (Males 1,112 (52.7%) Females 998(47.3%)) referred to OSHC with visible haematuria (VH, n = 1163 (55.1%)) or non-visible haematuria (NVH, n = 947 (44.9%)) between April 2017 and Jan2021. The mean age was 68.4 years (range 45-92). All patients were investigated by flexible cystoscopy and USS KUB, 1154/2110 (54.6%) had a CT Urogram. Data were collected from Welsh Clinical Portal, Welsh Clinical Communications Gateway and Synapse Radiology system. RESULTS: In Low Risk Group (NVH and Age <50, Non-smoker, Sex – Male <40 yrs, Female <50yrs) 315 USS KUB were normal except 1 patient had complex cyst confirmed as Bosniak2f cyst on CT scan. All renal masses were diagnosed on Ultrasound Scan. There were 33/2110 (1.5%) patients diagnosed as Upper Tract Transitional cell Carcinoma (UTTCC) on CTU. Mean age of this group was 71.2 (SD - 10.7) years and there was no statistical difference in Low and high risk group for UTTCC (p-Value 0.19). CONCLUSIONS: On the basis of these results there is no need for CT Urogram for assessment of non visible haematuria patients unless other risk factors (Age >65 years, Visible Haematuria, abnormal USS) are present. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e129-e129 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shanmugasigamani Kannan More articles by this author Ashok Bhuvanagiri More articles by this author Ashok Kailasa More articles by this author Kyriacos Alexandrou More articles by this author Mohanarangam Thangavelu More articles by this author Jason Walker More articles by this author Expand All Advertisement Loading ...

Coronavirus Infection of the Urinary Bladder and Lower Urinary Tract: A Review and Update

COVID-19 infection does affect males and females. Even though the commonest manifestations of COVID-19 infection tend to be related to symptoms associated with the respiratory tract, many other organs of the body also tend to be affected and COVID-19 infection of these other organs could manifest contemporaneously with symptoms of the respiratory tract system in addition to symptoms of the affected organs. At times COVID-19 may initially manifest solely related to non-respiratory tract organs and because the symptoms are non-specific without a high index of suspicion, the diagnosis of COVID-19 infection may be missed initially or there may be delay in the diagnosis which would tend to lead to spreading of the disease. Some of the manifestations of COVID-19 infection of the urinary bladder may include: Lower urinary tract symptoms of urinary frequency, and or urinary urgency, and or nocturia, and or urinary incontinence, or on rare occasions non-visible or visible haematuria, or acute retention of urine. The aforementioned symptoms may occur as De novo (new-onset) symptoms alone or they may be associated with or without fever, with or without respiratory tract symptoms. Some individuals who already have lower urinary tract symptoms could experience worsening of their previous lower urinary tract symptoms and if the clinician does not have a high index of suspicion for the possible development of COVID-19 infection, and the clinician does blame the symptoms on benign prostatic hyperplasia then the diagnosis could be missed or delayed. If the COVID-19 cystitis is associated with COVID-19 infection of the male genital tract then some of the patients could experience scrotal discomfort, swelling of the scrotum, erythema of the scrotum, or low-flow priapism or clinical and radiology imaging features of acute orchitis, or acute epididymitis, or acute epididymo-orchitis. However, if the lower urinary tract symptoms are associated with respiratory tract symptoms all clinicians globally are aware of the fact that a high index of suspicion for COVID-19 infection should be exercised. What is important is that every clinician and every individual should be made aware of the fact that the development of De novo lower urinary tract symptoms or sudden onset of worsening lower urinary tract symptoms should be regarded as possibly due to COVID-19 infection and appropriate tests should be undertaken to confirm or negate the diagnosis of COVID-19 infection quickly. Diagnosis of COVID-19 infection of the urinary bladder can be confirmed the undertaking of various COVID-19 infection tests but COVID-19 PCR test has tended to be a common test that most people use globally.

Upper tract imaging modality to investigate haematuria: cancer detection rates and changing guidelines

BackgroundTo assess the imaging modalities used to investigate both visible haematuria and non-visible haematuria along with their detection rate of malignancy at two hospitals and the corresponding radiological workload produced.MethodsA retrospective study was conducted across two hospitals. All CT urograms and ultrasound scans investigating haematuria in the outpatient setting over a 12-month period were evaluated.ResultsThe detection rate for upper tract urothelial cancer with visible haematuria was 0.97% and for renal cell carcinoma was 0.64%. Of all the CT urograms performed for non-visible haematuria 4.9% had suspicious findings but none of these represents an underlying malignancy. Of all the ultrasound scans performed for either visible or non-visible haematuria, none were shown to have an underlying malignancy. The detection rate was thus zero for an upper tract urinary cancer or renal cell carcinoma in the non-visible haematuria group. A CT urogram was performed in 27% and 67% of cases in each respective hospital to further investigate non-visible haematuria. CT urography makes up 2.3% and 5.2% of each hospitals overall respective workload in the CT department. CT urography to investigate non-visible haematuria could be replaced by ultrasound in low-risk patients.ConclusionsRadiological investigations are a limited resource and better rationalisation of upper tract imaging is needed in the setting of haematuria. Risk stratification of patients would be of benefit to help prevent a significant delay in timely diagnostics for higher risk individuals presenting with haematuria.

Is Flexible Cystoscopy Necessary in the Investigation of Non-visible Haematuria?

Background: Historic evidence suggests up to 16% (approximately) of non-visible haematuria (NVH) referrals result in Urological cancer diagnosis. The majority are bladder cancers, for which flexible cystoscopy is regarded the “gold standard” diagnostic procedure. Recent changes to suspected cancer referral guidelines, public information campaigns and reduced smoking prevalence may have changed this percentage. We retrospectively calculated cancer detection rates from NVH referrals to assess whether flexible cystoscopy, an invasive and morbid procedure, remains necessary. Patients and methods: All patients referred to our University teaching hospital on a suspected (“twoweek”) cancer pathway with NVH over a 16-week period were included. Clinical and demographic data were collected for a series of 200 patients (96 male, age range 27–92, median 68). Results: Only eight patients had urological malignancy found (two renal and six bladder cancers). Both renal, and four bladder cancers, were identified on imaging prior to flexible cystoscopy. Only two bladder cancers were therefore detected by cystoscopy; one low-risk non-muscle invasive (patient has already been discharged) and one in a patient that was unfit for treatment (died of heart failure). Only seven (3.5%) of the patients were offered the option of not undergoing flexible cystoscopy. Conclusion: Our analyses suggest that flexible cystoscopy is rarely of benefit in patients with NVH. We suggest that patients should be given an accurate risk of bladder cancer diagnosis during the consent process. We advocate that flexible cystoscopy can be avoided for the majority of NVH referrals, particularly in patients without strong risk factors for urothelial cell carcinoma. Avoidance of flexible cystoscopy would reduce patient risks from procedural morbidity, reduce risks of acquiring coronavirus from hospital attendance, and there could be huge reductions in financial and service delivery demands in an overstretched secondary-care service.

813 Risk of Death Following Pulmonary Complications After Surgery with And Without SARS-Cov-2 Infection: A Pooled Analysis of Individual Patient Data from Pre-Pandemic and Pandemic International Cohort Studies

Risk of death following pulmonary complications after surgery with and without SARS-CoV-2 infection: a pooled analysis of individual patient data from pre-pandemic and pandemic international cohort studiesIntroductionDiagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.MethodThe IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.Results8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.ConclusionsWe suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

IntroductionDiagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.MethodThe IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.Results8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.ConclusionsWe suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

O6 Reshaping the diagnostic pathways for investigation of haematuria during and after the COVID-19 pandemic: Diagnostic accuracy of strategies for the detection of bladder cancer from the IDENTIFY cohort study

BackgroundHaematuria often requires investigation with an imaging test and flexible cystoscopy to rule out urinary tract cancers. With a reduction in diagnostic services due to the COVID-19 pandemic there is a risk of compromise in the care of patients referred with haematuria. We aimed to provide a pragmatic strategy that optimises the use of scarce resources by reducing patient visits to hospital and allocating the appropriate diagnostic tests according to risk of bladder cancer.MethodsThe IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of newly suspected urinary tract cancer. Patients underwent cystoscopy, imaging tests, urine cytology and transurethral resection of bladder tumour (TURBT), where indicated. We developed strategies using combinations of imaging and cytology as triage tests to flexible cystoscopy. These strategies aimed to maximise cancer detection within a pragmatic pathway in a resource-limited environment.Findings8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Amongst all patients, 1474 (18·2%) had bladder cancer; 1333 (23·2%) in VH group and 141 (5·94%) in NVH group. Diagnostic test performance was used to determine optimal age cut-offs for each proposed strategy. We recommended proceeding directly to TURBT for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients (threshold of 60-years-old with VH, or 70-years-old with NVH) to capture high risk bladder cancer.InterpretationWe suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.