Evaluation of the New American Urological Association Guidelines Risk Classification for Hematuria.

PURPOSE: Microhematuria is a prevalent condition and the American Urological Association has developed a new risk-stratified approach for the evaluation of patients with microhematuria. Our objective was to provide the first evaluation of this important guideline. MATERIALS AND METHODS: This multinational cohort study combines contemporary patients from 5 clinical trials and 2 prospective registries who underwent urological evaluation for hematuria. Patients were stratified into American Urological Association risk strata (low, intermediate or high risk) based on sex, age, degree of hematuria, and smoking history. The primary end point was the incidence of bladder cancer within each risk stratum. RESULTS: A total of 15,779 patients were included in the analysis. Overall, 727 patients (4.6%) were classified as low risk, 1,863 patients (11.8%) were classified as intermediate risk, and 13,189 patients (83.6%) were classified as high risk. The predominance of high risk patients was consistent across all cohorts. A total of 857 bladder cancers were diagnosed with a bladder cancer incidence of 5.4%. Bladder cancer was more prevalent in men, smokers, older patients and patients with gross hematuria. The cancer incidence for low, intermediate and high risk groups was 0.4% (3 patients), 1.0% (18 patients) and 6.3% (836 patients), respectively. CONCLUSIONS: The new risk stratification system separates hematuria patients into clinically meaningful categories with differing likelihoods of bladder cancer that would justify evaluating the low, intermediate and high risk groups with incremental intensity. Furthermore, it provides the relative incidence of bladder cancer in each risk group which should facilitate patient counseling regarding the risks and benefits of evaluation for bladder cancer.

A Visual Scale for Improving Communication When Describing Gross Hematuria.

OBJECTIVE: To create and validate a grading scale that facilitates communication between providers managing gross hematuria (GH). METHODS: A blood simulant was used to create a spectrum of GH in 5 foley catheter tubes which were shown to a group of experienced urologists. The urologists were asked how they would adjust the continuous bladder irrigation rate if the samples represented the urine of hypothetical patients, and a 5-point scale was created by group consensus with pictures of the representative tubes printed onto a visual aid. Another cohort were then shown the 5 tubes at random and asked to describe the GH. Raters were then shown the visual aid and asked to assign a grade to the same samples. Fleiss' kappa analysis was used to measure inter-rater agreement, and therefore fidelity of the scale. RESULTS: Fourteen urologists were surveyed to determine the samples used to create the 5-point scale. After the scale was created, 43 raters (22 nurses, 16 urologists, and 5 advanced practice providers) attempted match the tubes to their corresponding images on the printout. When asked to describe the degree of GH for the samples as they would in clinical practice, 28 different descriptors were used (mean 8.6 per sample). When using the 5-point GH scale, however, raters exhibited near perfect agreement in matching each sample to its corresponding severity on the scale (κ = 0.93, P < .001). CONCLUSION: We created a clinically useful GH scale that improves communication and reduces ambiguous language among providers of varying levels of experience.

Multidetector Computed Tomographic Urography (MDCTU): Its Practical Role in Diagnosis of Upper Tract Urothelial Cancer in Patients 50 years and Older with Different Types of Hematuria.

MDCTU is a preferred method for the investigation of malignant lesions in the upper urinary tract. However, to decrease unnecessary radiation exposure the indications for the exam in different groups of patients should be assessed. In this study, we evaluated the role of MDCTU in patients older than 50 years who presented with different types of hematuria. In a retrospective manner, we assessed the radiologic reports of 173 patients ≥50 years who underwent MDCTU as a part of the evaluation for hematuria. To estimate the accuracy of MDCTU in the detection of upper urinary tract urothelial carcinoma (UUTUC) we compared MDCTU findings with the results of ureteroscopy. We also evaluated which factors can predict ureteroscopic confirmation of MDCTU-based diagnosis. In this list we also included diabetes mellitus and anticoagulant medications. As a result, 140 (103 males and 37 females) patients met the inclusion criteria. Mean patients' age was 69.7±16.98. Smokers and passive smokers comprised 38.6% and 26.4% of our patients, while 37.8% of our patients suffered from DM and 45% took anticoagulant medications. MDCTU suspected urothelial carcinoma in 17% (n=24) of our patients: UUTUC in eight and bladder urothelial carcinoma (BUC) in 16patients. Ureteroscopy had diagnosed UUTUC (with/without concurrent urothelial carcinoma of the bladder) in 9 patients: 6 with suspicious lesions in MDCTU and 3 additional patients with CIS/small low grade TCC. MDCTU had a sensitivity of 66.7%, specificity - 98.5%, positive predictive value - 75% and negative predictive value - 97.7%. The logistic regression model revealed five strong predictors for UUTUC: positive/atypical cytology, recurrent hematuria, MDCTU signs, age and Warfarin treatment. Finally a source of hematuria was diagnosed in 57% of patients, while MDCTU individual accuracy reached 42%. We found that MDCTU can effectively identify patients in whom further endoscopy is unnecessary. Otherwise, elder patients with positive/atypical cytology and recurrent microscopic hematuria, who have MDCTU signs and take Warfarin, should undergo endoscopic evaluation.

Hematuria en la infancia: Un dilema clínico / Hematuria in childhood: A clinical dilemma

La hematuria es un signo clínico sugerente de múltiples patologías nefrourológicas de diverso pronóstico renal y vital, siendo fundamental conocer su etiopatogenia en el niño para identificar de forma precoz su causa y establecer un adecuado tratamiento clínico y quirúrgico en algunas ocasiones. En la infancia la su etiopatogenia varía en tipo y frecuencia según la edad, siendo la causa más frecuente la infección urinaria. Como en toda patología será fundamental elaborar una historia clínica detallada y llevar a cabo una exploración física completa del paciente, lo cual nos proporcionará mucha información para orientar el caso. Hay que recordar que antes de solicitar pruebas complementarias más complejas debemos confirmar que nos encontramos ante una hematuria real, para lo cual necesitamos en primer lugar efectuar tres tipos de estudios seriados: observar el aspecto macroscópico, realizar una tira de orina y solicitar un sistemático/sedimento de orina. El screening de patología renal mediante tira de orina debe realizarse en pacientes con hematuria confirmada, sospecha de infección del tracto urinario o diagnosticados o en riesgo de desarrollar enfermedad renal crónica. El manejo del paciente y el tratamiento debe ser multidisciplinar, implicando a profesionales de las áreas de atención primaria y hospitalaria

Hematuria is a suggestive clinical sign of multiple nephrourological pathologies of diverse renal and vital prognosis, being essential to know its etiopathogenesis in the child to identify its cause early and establish adequate clinical and surgical treatment on some occasions. In childhood, its etiopathogenesis varies in type and fre-quency according to age, with urinary infection being the most frequent cause. As in all pathologies, it will be essential to prepare a detailed medical history and carry out a complete physical examination of the patient, which will provide us with a lot of information to guide the case. We must remember that before requesting more complex complementary tests, we must confirm that we are facing real hematuria, for which we first need to carry out three types of serial studies: observe the macroscopic appear-ance, perform a urine dipstick and request a systematic/urine sediment. Screening for kidney disease using a urine dipstick should be performed in patients with confirmed hematuria, suspected urinary tract infection, or diagnosed or at risk of developing chronic kidney disease. Patient management and treatment must be multidisciplinary, involving professionals from the areas of primary and hospital care

Fifteen-minute consultation: the management of microscopic haematuria.

Haematuria can be a troublesome symptom with various different methods of presentation and aetiologies. Microscopic haematuria is a common coincidental finding often found when the patient has presented for another reason. We will discuss the subject of haematuria but will focus the majority of this article on the discussion of microscopic haematuria, including a definition, the important features to cover in the history and examination, aetiologies to suspect in children and infants, and a suggested approach to assessing these patients in secondary care.

Haematuria: classification, causes and investigations.

The majority of patients who attend haematuria clinics for investigation of blood in their urine will be found to have either no cause or a benign cause. Between 20% and 25% of people with visible blood in their urine and 5-10% of people with non-visible blood in their urine will be diagnosed with a urological malignancy, i.e. bladder, kidney or prostate cancer. Haematuria is therefore a significant symptom that should be investigated promptly and thoroughly to exclude cancer as quickly as possible. This article gives an overview of the causes of haematuria and the investigations that patients will undergo when referred to a haematuria clinic.

Hematuria grading scale: a new tool for gross hematuria.

OBJECTIVE: To develop a new tool for gross hematuria, the Hematuria Grading Scale (HGS), and evaluate its consistency in assessing hematuria samples. METHODS: The HGS was developed on the basis of an evaluation of sample brightness and saturation using a cyan, magenta, yellow, key (black) color model. Thirty hematuria samples were prepared from human blood by diluting with saline using a standard method. Twenty examiners (5 in each group, including laypeople, nurses, general practitioners, and urologists) participated. Each scored 30 hematuria samples using the HGS under the same conditions without communicating with one another. The intraclass correlation coefficient (ICC) was calculated to assess the reliability of the datasets. Questionnaires for usefulness (Q1) and simplicity (Q2) were obtained from all examiners using a 5-point Likert scale. RESULTS: The ICC for pooled examiner scores showed a high agreement rate (99.7%, 95% confidence interval [CI] 0.996-0.999). ICC values by group were 99.3% (95% CI 0.989-0.997) for laypeople, 98.8% (95% CI 0.980-0.994) for nurses, 99.1% (95% CI 0.984-0.995) for general practitioners, and 99.2% (95% CI 0.987-0.996) for urologists. Mean Q1 and Q2 scores were 4.70 ± 0.66 and 4.30 ± 1.03, respectively, indicating general satisfaction with the HGS among all examiners. CONCLUSION: Evaluations of gross hematuria using the HGS were in high agreement among examiners of all types, and all examiners found the HGS simple and easy to use. The HGS should be a helpful tool for assessment and communication of gross hematuria.

Computed tomography-urography for upper urinary tract imaging: is it required for all patients who present with hematuria?

PURPOSE: To define in which patients who present with microscopic or macroscopic hematuria CT urography (CTU) is indicated as an imaging mode for the upper urinary tract (UUT). PATIENTS AND METHODS: We conducted a prospective study on consecutive patients who attended a modern protocol-driven hematuria clinic from January 2006 to February 2010. Standard tests (history taking, physical examination, urinalysis via dipstick method, ultrasonography of kidneys and bladder performed by urologists, cystoscopy, and cytology) were directed to all patients, whereas the mode of additional UUT imaging (ultrasonography by a radiologist or four-phase CTU/magnetic resonance (MR) urography (MRU) when CTU was contraindicated) was selected according to a risk factor-based management algorithm. The added value of cross-sectional urography (CTU/MRU) supplementary to ultrasonography (by urologists) to detect renal masses, UUT tumors, and stones was assessed. Univariate and multivariate analysis on predictive factors for cross-sectional urography result were performed. RESULTS: From the total of 841 patients, lesions that might account for hematuria could not be identified in 462 (54.9%), whereas in 250 (29.7%) and 124 (14.7%) patients, hematuria was from benign and malignant disease, respectively. Cross-sectional urography revealed relevant UUT lesions in 73 of 525 (13.9%) patients. Only result of ultrasonography (odds ratio [OR] 7.7, 95% confidence interval [CI] 4.0-14.9), P<0.001) and type of hematuria (OR 2.6, 95% CI 1.3-5.1, P=0.01) were significant predictors for cross-sectional urography result. In 44 of 456 (9.6%) patients with no abnormalities on ultrasonography, CTU/MRU revealed that these were false negatives, with most lesions missed being stones. In 253 of 309 (81.9%) patients with macroscopic hematuria, no lesions were detected in the UUT on CTU/MRU, in contrast to 199 of 216 patients (92.1%) with microscopic hematuria. CONCLUSION: For patients who present with microscopic hematuria, ultrasonography 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.

Clinical presentation & management of glomerular diseases: hematuria, nephritic & nephrotic syndrome.

Because the differential diagnosis for glomerulonephritis (GN) is broad, using a classification schema is helpful to narrow the causes of GN in a systematic manner. The etiology of glomerulonephritis can be classified by their clinical presentation (nephrotic, nephritic, rapidly progressive GN, chronic GN) or by histopathology. GN may be restricted to the kidney (primary glomerulonephritis) or be a secondary to a systemic disease (secondary glomerulonephritis). The nephrotic syndrome is defined by the presence of heavy proteinuria (protein excretion greater than 3.0 g/24 hours), hypoalbuminemia (less than 3.0 g/dL), and peripheral edema. Hyperlipidemia and thrombotic disease may be present. The nephritic syndrome is associated with hematuria and proteinuria and abnormal kidney function and carries poorer prognosis and is typically associated with hypertension. The predominant cause of the nephrotic syndrome in children is minimal change disease. The most common causes of nephritic syndrome are post infectious GN, IgA nephropathy and lupus nephritis. Chronic GN is slowly progressive and is associated with hypertension and gradual loss of kidney function. Treatment includes non-specific measure aimed at controlling hypertension, edema, proteinuria and disease modifying immunosuppression.

The modified Clavien classification system: a standardized platform for reporting complications in transurethral resection of the prostate.

PURPOSE: The aim of the study was to evaluate the applicability of the modified Clavien classification system (CCS) in grading perioperative complications of transurethral resection of the prostate (TURP). METHODS: All patients with benign prostatic hyperplasia submitted to monopolar TURP from January 2006 to February 2008 at a non-academic center were evaluated for complications occurring up to the end of the first postoperative month. All complications were classified according to the modified CCS independently by two urologists, and the final decision was based on consensus. If multiple complications per patient occurred, categorization was done in more than one grade. Results were presented as complication rates per grade. RESULTS: Forty-four complications were recorded in 31 out of 198 patients (overall perioperative morbidity rate: 15.7%), and their grading was generally easy, non-time-consuming and straightforward. Most of them were classified as grade I (59.1%) and II (29.5%). Higher grade complications were scarce (grade III: 2.3% and grade IV: 6.8%, respectively) There was one death (grade V: 2.3%) due to acute myocardial infarction (overall mortality rate: 0.5%). Negative outcomes such as mild dysuria during this early postoperative period or retrograde ejaculation were considered sequelae and were not recorded. Nobody was complicated with severe dysuria. There was one re-operation due to residual adenoma (0.5%). CONCLUSIONS: The modified CCS represents a straightforward and easily applicable tool that may help urologists to classify the complications of TURP in a more objective and detailed way. It may serve as a standardized platform of communication among clinicians allowing for sound comparisons.

The Oxford IgA nephropathy clinicopathological classification is valid for children as well as adults.

To study the predictive value of biopsy lesions in IgA nephropathy in a range of patient ages we retrospectively analyzed the cohort that was used to derive a new classification system for IgA nephropathy. A total of 206 adults and 59 children with proteinuria over 0.5 g/24 h/1.73 m(2) and an eGFR of stage-3 or better were followed for a median of 69 months. At the time of biopsy, compared with adults children had a more frequent history of macroscopic hematuria, lower adjusted blood pressure, and higher eGFR but similar proteinuria. Although their outcome was similar to that of adults, children had received more immunosuppressants and achieved a lower follow-up proteinuria. Renal biopsies were scored for variables identified by an iterative process as reproducible and independent of other lesions. Compared with adults, children had significantly more mesangial and endocapillary hypercellularity, and less segmental glomerulosclerosis and tubulointerstitial damage, the four variables previously identified to predict outcome independent of clinical assessment. Despite these differences, our study found that the cross-sectional correlation between pathology and proteinuria was similar in adults and children. The predictive value of each specific lesion on the rate of decline of renal function or renal survival in IgA nephropathy was not different between children and adults.

Hematúria / Hematuria

Hematúria é uma anormalidade urinária muito frequente na prática clínica. O diagnóstico da causa básica fica facilitado quando o paciente apresesenta outros sinais e sintomas que sugiram uma patologia específica. Contudo, a presença de hematúria microscópica isolada constitui um verdadeiro desafio diagnóstico. Na investigação da etiologia, além

[Hematuria]. / Hematúria.

Patients referred for hematuria work-up are frequently seen in the urologic practice. The initial evaluation does not require the participation of a urologist or nephrologist, due to the false sense of security in the evaluation of an asymptomatic and persistent hematuria. In fact, an adequate history and physical followed by urinalysis and radiologic tests, such as IVP and ultrasonography, must be made in the initial evaluation to exclude any serious urologic/nephrologic disease.

Hematuria: enfoque diagnóstico / Hematuria: diagnosis

La hematuria es un motivo de consulta o un hallazgo de laboratorio de relativa frecuencia que alarma a los pacientes y a sus padres. Para el pediatra es importante considerar los posibles diagnósticos diferenciales y solicitar los exámenes pertinentes, evitando la solicitud innecesaria de estudios, así como derivar los pacientes oportunamente al nefrólogo y velar por el cumplimiento de los controles posteriores y tratamientos para evitar consecuencias como daño renal irreversible

[Microscopic hematuria in children]. / Le ematurie microscopiche nel bambino.

Hematuria is a common finding on a urinalysis, with a prevalence rate between 1% and 2%. The execution of screening of hematuria in children is controversial. Once hematuria has been identified, it is useful to identify sources of bleeding, as either glomerular or non-glomerular. If microscopic hematuria is confirmed, investigations would include: hypercalciuria screen, blood examinations (full blood count, renal function tests, complement and autoantibody screen), renal tract ultrasound, urinalysis of family members, audiogram, if family history of deafness is present, or family members present a positive dipstick. If all these tests are negative and microscopic hematuria persists, then a renal biopsy is advocated.