Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria.

Abstract

223 Background: AMH in the general population is common, occurring in up to 9-18%. Even low degrees of AMH have been considered a risk factor for UTMT. Although the prevalence of UTMT is low (.01-3%), many asymptomatic patients undergo unnecessary and hazardous evaluations. In 2007, the Kaiser Permanente (KP) Urologists started a multi-year QI effort to research and develop a risk stratified evidence-based approach in the evaluation of AMH. Methods: The group first conducted a retrospective analysis to determine the incidence of urinary cancer, and stratify risk according to age, gender, smoking history, and degree of hematuria. A multi-regional prospective, observational study was then conducted over a two year period. We used a data collection tool embedded within an EMR to determine patients with AMH who are at greatest risk for UTMT, and patients who might benefit from urologic evaluation or safely avoid unnecessary workup and radiation exposure. Results: 4,414 patients had full urologic work up. Overall, 100 bladder cancers were diagnosed among 4,414 patients (2.3%), and only 11 renal cancers (0.2%) were pathologically confirmed. Multivariable logistic regression was conducted for 5 common parameters: age, gender, smoking history, degree of microscopic hematuria, and history of gross hematuria within the past 6 months. The two most important risk factors were age > 50, and prior history of gross hematuria. A hematuria risk index (HRI) was developed, which significantly improved predictability (AUC = .809-HRI vs .532-AUA guideline). Overall, 32% of the population was identified as low risk with only 0.2% cancer detected; 14% of the population was identified as high risk, of whom 11.1% had a cancer diagnosed. Conclusions: These results suggest that a considerable proportion of patients may safely avoid hazardous evaluation using multivariate risk stratification. An evidence-based algorithm was developed for the management of asymptomatic microscopic hematuria and implemented within KP. We expect to significantly improve patient safety and improve reliability of patient evaluation.

Lynch Syndrome: A Primer for Urologists and Panel Recommendations

“…In a large Kaiser study of 3,222,699 UAs performed in a total of 1,117,542 patients the MH rate was 41%. 46 While no patient was diagnosed with UTUC, only about 2% of patients underwent further evaluation.…”

Evaluation of Microscopic Hematuria: A Critical Review and Proposed Algorithm

“…1 The most recent estimates of GU cancer rates among patients with MH range from 0.68% to 15.7%, with the highest estimates coming from a study in which the authors acknowledge that the higher than expected rate was likely related to local referral patterns. [30][31][32][33][34] In another study, urologists at Kaiser Permanente reported on 4414 adults referred for evaluation of asymptomatic MH from 2009 to 2011. 31 GU cancer was found in 3.4% of subjects, including 100 cases of bladder cancer and 11 cases of kidney cancer.…”

“…[30][31][32][33][34] In another study, urologists at Kaiser Permanente reported on 4414 adults referred for evaluation of asymptomatic MH from 2009 to 2011. 31 GU cancer was found in 3.4% of subjects, including 100 cases of bladder cancer and 11 cases of kidney cancer. Using these data, the authors developed a "Hematuria Risk Index" to identify significant predictors of urologic malignancy.…”

Differenzialdiagnose der Hämaturie

“…3) mitberücksichtigt werden. Bei der individuellen Risikoabschätzung könnten sicher hierbei nach Meinung verschiedener Autoren in Zukunft auch hierfür gezielt entwickelte Risiko-Scores als hilfreich erweisen [23,24]. …”