EAU 2018: Case-based Discussion: "My Patient Has A Normal Cystoscopy But A Positive Urine Marker: What Now”?
In this case, the two discussants were asked to present a patient that had a negative cystoscopy but a positive urine-based test (ie cytology, etc).
Dr. Maurizio Brausi presented first and highlighted several points to consider in this patient population.
1. Is the cystoscopy really negative? It is operator dependent.
- Cross-control cystoscopy with additional urologists demonstrated increased yield
- Bladder diagrams at the time of initial diagnosis and flexible cystoscopy can help the physician at the time of TURBT!
- Flexible cystoscopy should be used – enhanced BT identification and diagnosis!
2. Bladder cancer diagnosis if cysto negative
- Random bladder biopsy in 7 locations based on EORTC recommendations: retro-meatal x 2, lateral wall x 2, posterior, superior and prostatic urethra. The last one is key!
- 12-48% of patients with Bladder UC have prostatic duct involvement – may be a side of positive urine tests with negative cystoscopy!
- EAU guidelines also suggest utilization of photodynamic detection methods, such as NBI and Blue-light cystoscopy
3. Upper tract disease
- Recommend
a) CT Urogram
- gold standard. Has 88-100% sensitivity, 93-100% specificity
- Better sensitivity for renal pelvis tumors than ureteral tumors
b) Bilateral upper tract selective washings
- If the CT Urogram is negative by urine tests remain position, bilateral selective washings have a >85% predictive value
- If the CT Urogram is concerning: ureteroscopy
c) Ureteroscopy (flexible or semi-rigid)
- Flexible preferred over semi-rigid due to better ability to visualize all the calyces
- He also briefly put a plug in for a new technology called CellVizo® a unique optical based system that can be used during cystoscopy or ureteroscopy. US probe through the scope is placed right on the suspected tumor. Allows visualization of the tumor at the cellular level, similar to pathologic slides.
Professor James Catto followed with a brief response. He didn’t disagree with Dr. Brausi but added the following key points.
1) It is very possible that rather than the cysto being negative, the urine test was a false positive.
- Shariat 2011 – many of the urine tests had a specificity 75-90%. Hence, these are not perfect tests!
2) Assuming the urine test is correct, where is the missed cancer – 3 possibilities:
a) Bladder – but missed
b) Bladder – but macroscopically normal
c) Elsewhere in the urinary tract
3) Fluorescence cystoscopy (PDD) – Higher sensitivity than WLC, but lower specificity (57% vs. 72% WLC)
- So even a negative PDD does not rule out bladder cancer!
Therefore, always question the tests you use. His practice is to continue cystoscopy on schedule and repeat the urine test. Either the urine test will normalize (false positive) or cystoscopy will eventually become positive.
Presented by: Joan Palou, MD, Ph.D., FEBU, Fundació Puigvert, Department of Urology, Barcelona, Spain
Discussants:
Maurizio Brausi, Director Urology Ausl Modena, Chairman ESOU, Department of Urology, Azienda Unità Sanitaria Locale Modena, ASL Modena, Italy
Professor James Catto, Professor of Urological Surgery, Centre Clinical Co-director, Departments: Academic Units of Urology and Molecular Oncology, Sheffield Institute for Nucleic Acids
Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark