Study: CT urogram leads to costly follow-up imaging

Birmingham, AL-Findings from an initial cost analysis support further research and reconsideration of the role of computed tomography urography (CTU) for imaging evaluation in patients with asymptomatic microhematuria (AMH), according to urologists from the University of Alabama at Birmingham.

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The study, which was presented at the AUA annual meeting in San Diego and subsequently published in Urology (2016; 95:34-8), focused on determining costs stemming from the evaluation of incidental extra-urinary findings. It included data for 202 patients who underwent CTU for AMH from 2012 to 2014. A genitourinary malignancy-renal cell carcinoma-was identified on CTU in only two patients (0.99%), whereas 150 patients (74.3%) had an incidental extra-urinary finding and 36 of those patients underwent further evaluation.

Considering costs for follow-up imaging, specialist referral, and additional procedures, the total cost for further follow-up was $140,290 or $694.50 per patient screened. The additional workup identified only one extra-urinary malignancy, a T3N1aM0 colonic adenocarcinoma.

“The AUA guideline on AMH states that multi-phasic CTU is the imaging procedure of choice for the initial evaluation because it has the highest sensitivity and specificity for imaging the upper tracts. The actual incidence of a urologic cancer found on CTU performed for AMH is quite low, however, whereas multiple non-genitourinary findings are detected incidentally due to the wide area of coverage,” said first author Win Shun Lai, MD, a urology resident who worked on the study with Mark E. Lockhart, MD, MPH, and colleagues.

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“Our study shows how CTU for AMH can lead to expensive and invasive evaluations for suspicious lesions, the results of which are usually negative. Therefore, we believe future studies are warranted to investigate whether the costs are worth the benefits and if ultrasound can be recommended as an alternative to CTU that will limit the cost and invasiveness of evaluation for AMH,” added Dr. Lai.

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Cirrhosis among high-significance findings

The incidental findings were categorized based on clinical significance. Among the findings judged as having high clinical significance, cirrhosis (n=6) and other liver lesions (n=6) were the most common. Lung nodules and an adnexal mass were each found in four patients, and three patients had an aortic aneurysm >3 cm.

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Additional costs associated with further evaluation and management occurred in relation to follow-up imaging that was done in 36 patients ($17,242) and referral to a specialist for 13 patients ($2,705). In addition, 12 patients underwent a total of 20 procedures for diagnosis and treatment that cost $54,655 and involved 28 inpatient days resulting in an additional $65,688 of hospital costs.

According to the literature, imaging fails to find a cause for AMH in 45% to 77% of patients, and a urologic malignancy is identified no more than 5% of the time.

Dr. Lai noted that the Canadian Urological Association guidelines recommend ultrasound as first-line imaging for AMH whereas the European Society of Urogenital Radiology guidelines state that ultrasound may be used alone in low-risk patients but CTU is warranted in high-risk patients.

“According to the literature, ultrasound is as good as CTU for detecting renal masses >1 cm but not very good for diagnosing transitional cell carcinoma. However, the incidence of transitional cell carcinoma in patients with microscopic hematuria is only 0.1%,” he said.

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