Expert: Work needed to validate changes in diagnostic work-up for upper tract urothelial carcinoma

In this video, Jacob Taylor, MD, MPH, shares the take-home message from the study, “Diagnostic Imaging in the Evaluation of Asymptomatic Microhematuria: Systematic Review and Meta-Analysis.” Taylor is a fellow in urologic oncology at the University of Texas Southwestern Medical Center in Dallas.

Transcription:

Based on this study, are you likely to alter anything about your practice?

I think this study reinforces the [American Urological Association] guideline changes for imaging de-intensification. We know the prevalence of upper tract urothelial carcinoma is far lower than that of bladder and renal cell carcinoma. Therefore, recommending ultrasound rather than cross sectional imaging is likely valid, particularly in low- and intermediate-risk patients. But I think that it's important to know that you have to treat each patient individually and even somebody that maybe has high-risk microhematuria, potentially starting with a non-con CT scan, if you do have a shortage of contrast, or even starting with an ultrasound, might be a valid step. But certainly, there's much more data and work to be done in order to validate some of those further changes in diagnostic work-up.

What is the take-home message for the practicing urologist?

I think the take-home message from our paper is that further evidence is needed to really strengthen our confidence in some of these recommendations for particular imaging modalities in the work-up of microhematuria. We know that in screening populations, urologic malignancy overall is pretty low, and upper tract malignancy is even lower. It's probably around 3% and 1%, respectively. So in this specific population, we need to have more high-quality level data to increase our certainty that using any of these diagnostic modalities is really beneficial. And then there's obviously more work to be done as well in looking at this from a cost effectiveness perspective to see if one imaging modality is truly better than another.

Is there anything you would like to add?

I think clinicians can really take away that we have more work to be done in this space of evaluating patients with microhematuria, specifically when it comes to looking at assessments of upper tract urothelial carcinoma or renal cell carcinoma. Bladder cancer, obviously, is much more prevalent, and so we have better tools to investigate bladder cancer, particularly cystoscopy. So I think that when looking at the recommendations for the evaluation of microhematuria, it's important to keep some of these numbers in mind and especially looking at the certainty of the evidence and the whole body of evidence that we still have a lot more work to do to increase our certainty around these tests.

This transcription was edited for clarity.