Is Flexible Cystoscopy Necessary in the Investigation of Non-visible Haematuria?
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Background: Historic evidence suggests up to 16% (approximately) of non-visible haematuria (NVH) referrals result in Urological cancer diagnosis. The majority are bladder cancers, for which flexible cystoscopy is regarded the “gold standard” diagnostic procedure. Recent changes to suspected cancer referral guidelines, public information campaigns and reduced smoking prevalence may have changed this percentage. We retrospectively calculated cancer detection rates from NVH referrals to assess whether flexible cystoscopy,
an invasive and morbid procedure, remains necessary.
Patients and methods: All patients referred to our University teaching hospital on a suspected (“two-week”) cancer pathway with NVH over a 16-week period were included. Clinical and demographic data were collected for a series of 200 patients (96 male, age range 27–92, median 68).
Results: Only eight patients had urological malignancy found (two renal and six bladder cancers). Both renal, and four bladder cancers, were identified on imaging prior to flexible cystoscopy. Only two bladder cancers were therefore detected by cystoscopy; one low-risk non-muscle invasive (patient has already been discharged) and one in a patient that was unfit for treatment (died of heart failure). Only seven (3.5%) of the patients were offered the option of not undergoing flexible cystoscopy.
Conclusion: Our analyses suggest that flexible cystoscopy is rarely of benefit in patients with NVH. We suggest that patients should be given an accurate risk of bladder cancer diagnosis during the consent process. We advocate that flexible cystoscopy can be avoided for the majority of NVH referrals, particularly in patients without strong risk factors for urothelial cell carcinoma. Avoidance of flexible cystoscopy would reduce patient risks from procedural morbidity, reduce risks of acquiring coronavirus from hospital attendance, and there could be huge reductions in financial and service delivery demands in an overstretched secondary-care service.
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