Is intravenous urography indicated in a young adult with hematuria?

CME

ARTICLE

ELSEVIER

IS INTRAVENOUS UROCRAPHY INDICATED ADULT WITH HEMATURIA? SCOTT

I. ZEITLIN,

ABRAHAM AND

LEVITIN, RICHARD

OMID HAKIMIAN, J. MACCHIA

IN A YOUNG

JOSHUA

A. BECKER,

ABSTRACT Objectives. Published reports are devoid of U.S. studies investigating the role of the intravenous urogram (IVU) in adult patients of differing ages with hematuria. To evaluate the efficacy of the IVU in patients less than 55 years old, a retrospective analysis was performed. Methods. The records of all patients (n = 800) undergoing IVU in an inner city hospital from January 1991 through October 1994 were reviewed for age, gender, race, urinalysis data, and cystoscopic and biopsy findings. Age greater than 55 years, recent trauma, and known malignancy were exclusion criteria. Hematuria was the indication for IVU in 128 of 800 patients. Eight (6.2%) of 128 patients had inadequate chart information, leaving a total of 120 evaluable charts. Results. We stratified the 120 patients by age, degree of hematuria (gross versus microscopic), and gender. The younger group (17 to 40 years old) included 64 patients (53%) and the older group (41 to 55 years old) 56 patients (47%). Gross hematuria was reported in 65 patients (54%), whereas 55 (46%) had microscopic hematuria. Men accounted for 78 patients (65%) and women for 42 (35%). The majority of patients were African-Americans ( 100 [83%] of 120). Abnormal findings were seen in 17 ( 14%) of 120 patients. The IVU alone provided no diagnosis of immediate consequence. There was no significant difference in findings between the age groups (P = 0.611, gross and microscopic hematuria (P = 0.281, and men and women (P = 0.59). Contrast reactions occurred in 3 (2.5%) of 120 patients. Conclusions. In this inner city population younger than 55 years of age, the usefulness of the IVU for the evaluation of hematuria is questionable. It did not establish a diagnosis, modify the subsequent evaluation, or change the therapy in any of our patients. UROLOGY 48: 365-368, 1996.

o quote from the 6th edition of Campbell’s Urology, “Hematuria of any degree should never be ignored and, in adults, it should be regarded as a symptom of urologic malignancy until proven otherwise.” Additionally, it states that, “The urogram remains the primary modality for visualizing the pyelocalyceal system and the ureter and, all else being equal, it is the study of first choice in patients with unexplained gross hematuria.“la2 The published reports are devoid of U.S. studies investigating the role of the intravenous urogram

T

From the Departments of Urology and Radiology, State University of New York Health Science Center at Brooklyn, Brooklyn, New York Reprint requests: Scott I. Zeitlin, M.D., Department of Uralogy, Box 79, State University of New York at Brooklyn, 470 Lenox Road, Brooklyn, NY 11203 Submitted: March 26, 1996, accepted: March 26, 1996 COPYRIGHT 1996 BY ELSEVIER ALL RIGHTS RESERVED

SCIENCE

INC.

(IVU) ages.

for hematuria MATERIAL

in adult patients AND

of differing

METHODS

The IVUs of all patients (n = 800) from January 1991 through October 1994 were evaluated. To ensure completeness of data collection, patient names and medical record numbers were obtained from the file logbooks that prospectively recorded all procedures. Patient ages were identified by computer, and all patients older than 55 years were immediately eliminated. The charts of the patients were then requested from the medical records department. Data regarding gender, race, urinalysis data, indications for and final report of the IVU, and cystoscopic and biopsy findings were sought from each chart. Patients were excluded from the study if the IVU was done for anything other than hematuria. Microscopic hematuria was defined as one red blood cell per high-power field. Recent trauma or a known urologic malignancy also prompted exclusion. Of the remaining 128 patients, 8 were excluded for inadequate chart information. The patients were categorized by age, degree of hematuria (gross and microscopic), and gender. The Fisher exact test was used to test for statistical significance. 0090-4295/96/$15.00 PII SOO90-4295(96)00162-8

365

TABLE

I.

Abnormal

radiologic

540 Yr Old (n = 64) Gross Hematuria Microscopic Hematuria (n = 39) (n = 25)

Abnormality Calculus Standing column Hydroureter Papillary necrosis Bladder cancer Atrophic kidney Prostatic hypertrophy Papillary KC bladder Invasive adenoma Renal artery aneurysm Total

3 1 2 1

findings

*

41-55 Cross Hematuria (n = 26)

Yr Old (n = 56) Microscopic Hematuria (n = 30)

1

1

1

1 1 1 1

1

7

1 1 1 4

5

KEY: TCC = transitional cell carcinoma. * Data presented are number of patients.

TABLE

II.

Gender and racial characteristics

Cross Hematuria (n = 65) Male Female African-American Hispanic Arabic Indian * Data presented

are number

48 17 57 7 1 0

Total (n = 120)

30 25 43 9 2 1

78 42 100 16 3 1

of patients

The patients were classified into two age groups: 17 to 40 years old (64 [ 53.3%1 of 120) and 41 to 55 years old (56 [ 46.7%] of 120). Sixty-five patients (54.2%) presented with gross hematuria and 55 (45.8%) with microscopic hematuria. There were 78 men (65%) and 42 women (35%). Of the 64 patients younger than 40 years, 39 (60.9%) had gross and 25 (39.1%) microscopic hematuria. Of the 56 patients older than 40 years, 26 (46.4%) had gross and 30 (53.6%) microscopic hematuria. The age of 55 years was chosen as the upper limit for the study because the peak incidence of upper tract urothelial malignancy is greatest in the sixth and seventh decade.3 In addition, the majority of studies evaluating patients for hematuria report 55 years or older to be the average age. Our review of published reports on IVU and hematuria failed to reveal definitive evidence to either support or rebuke its use in the younger adult population.

RESULTS Eight (12.5%) of 64 patients in the younger group and 9 (16.1%) of 56 in the older group had abnormal findings on the IVU (Table I). Abnormal findings were noted in 10 (12.8%) of 78 men, and 7 (16.7%) of 42 women, and 12 (18.5%) of 65 patients with gross and 5 (9.1%) of 55 with microscopic hematuria. These differences were not statistically significant (P = 0.61 and P = 0.28, respectively). No patient required immediate 366

*

Macroscopic Hematuria (n = 55)

modification of the subsequent workup or treatment based solely on the result of the IVU. No upper tract malignancies were identified. The 3 patients with dilated ureters were known to have this finding before their IVU. The bladder cancers were diagnosed by cystoscopy, as was the hypertrophied prostate. The renal artery aneurysm was less than 1 cm and was asymptomatic. The patient with papillary necrosis had sickle cell trait. She had papillary necrosis as her working diagnosis and was treated expectantly. All calculi in the present study were seen on the kidney, ureters, and bladder radiograph (KUB) before the IVU. The race and gender characteristics of all patients are shown in Table II. The racial distribution is representative of our hospitals population. Gender was not significant (P = 0.59). Three patients had a reaction to the contrast medium, of which two were minor. One patient developed pulmonary edema requiring a 3-day hospital stay. COMMENT Until recently, the IVU was the radiologic procedure of choice in patients with suspected nonUROLOGY

48 (3)) 1996

uremic urologic tract disease. In 1979 Mellins et aL4 questioned its use as newer technologies evolved. The routine use of IVU in adults with hypertension, those scheduled for prostatic surgery or hysterectomy, and female patients with recurrent urinary tract infections has been discouraged in recent years.5,6 In patients presenting with renal colic, Haddad et 61.’ failed to show a significant increase in clinically important findings when IVU was compared with ultrasound and KUB. The role of IVU needs continued investigation as more accurate, less invasive procedures become readily available. The reported incidence of moderate and severe reactions after IVU ranges from 0.175%* to 1.78°b.9 Severe reactions are defined as those requiring urgent therapy (ie, hypotensive shock, pulmonary edema, respiratory arrest, and convulsions ) . ’ The mortality rate after IVU is 1 in 117,0009 to 1 in 14,000.9 The use of nonionic/ low-osmolar contrast media versus conventional contrast media lessens the associated complication rate but significantly increases the cost.1°-12 In our retrospective study of 120 patients younger than 55 years of age with hematuria, none had IVU findings of clinical importance. Aslaksen et ~21.~~reviewed 193 patients 16 to 85 years old (median age 66) with microscopic hematuria from British published reports and concluded that it was not justified to recommend a routine IVU for asymptomatic patients with microscopic hematuria.13 Another British study involved young male Israeli soldiers. Froom et ~1.‘~ concluded that microscopic hematuria in men 40 years old or younger does not warrant an IVU. Our results concur with these findings. CONCLUSIONS We continue to utilize the IVU as the imaging procedure of choice for hematuria. However, in this inner city population, the usefulness of the IVU in adult patients younger than 55 years of age with hematuria is questionable. The IVU did not establish the diagnosis, modify the subsequent evaluation, or change the therapy in any of our patients. Our findings suggest that a prospective study of IVU for hematuria in this cohort is warranted. Discontinuance of clinically unnecessary investigations would minimize complications, lower medical costs, and eliminate potential litigation. REFERENCES 1. Lowe FC, and Brendler CB: Evaluation of the urologic patient, in Walsh PC, Retik AB, Stamey TA, and Vaughan ED Jr (Eds) : Campbell’s Urology, 6th ed. Philadelphia, WB Saunders, 1992, vol. 1, p 309. UROLOGY

48 (3), 1996

2. Pollack HM: Imaging of the urinary tract, in Walsh PC, Retik AB, Stamey TA, and Vaughan ED Jr (Eds) : Campbell’s Urology, 6th ed. Philadelphia, WB Saunders, 1992, vol. 1, pp 412, 431. 3. Catalona WJ: Urothelial tumors of the renal pelvis and ureter, in Walsh PC, Retik AB, Stamey TA, and Vaughan ED Jr (Eds) : Campbell’s Urology, 6th ed. Philadelphia, WI3 Saunders, 1992, vol. 2, p 1137. 4. Mellins HZ, McNeil BJ, Abrams HL, Van Houten FX, Murphy MA, and Korngold E: The selection of patients for excretory urography. Radiology 130: 293-296, 1979. 5. Mushlin AI, and Thornbury JR: Intravenous pyelography: the case against its routine use. Ann Intern Med 111: 58-70,1989. 6. Lieberman E, and Macchia RJ: Excretory urography in women with urinary tract infection. J Urol 127: 263-264, 1982. 7. Haddad MC, Sharif HS, Shahed MS, Mutaiery MA, Abdullah MS, Sammak BM, Southcombe LA, and Crawford AD: Renal colic: diagnosis and outcome. Radiology 184: 83, 1992. 8. Ansell G, Tweedie MCK, and West CR: The current status of reactions to intravenous contrast media. Invest Radiol 15: S32-S39, 1980. 9. Shehadi WI-I: Adverse reactions to intravascularly administered contrast media. A comprehensive study based on a prospective survey. Am J Roentgen01 Radium Ther Nucl Med 124: 145-152, 1975. 10. Bush WH, and Swanson DP: Acute reactions to intravascular contrast media. Types, risk factors, recognition, and specific treatment. AJR Am J Roentgen01 157: 1153-1161, 1991. 11. Pendergrass HP, Tondreau RL, and Pendergrass EP: Reactions associated with intravenous urography. Historical and statistical review. Radiology 71: l-12, 1958. 12. Palmer FJ: The RACR survey of intravenous contrast media reactions. Final report. Australas Radio1 32: 426-428, 1988. 13. Aslaksen A, Gadeholt G, and Gothlin JH: Ultrasonography versus intravenous urography in the evaluation of patients with microscopic hematuria. Br J Urol 66: 144-147, 1990. 14. Froom P, Ribak J, and Benbassat J: Significance of microhemaeturia in young adults. BMJ 288: 20-22, 1994. EDITORIAL COMMENT Zeitlin et nl. present a concise retrospective summary of their experience, which coincides with the impressions expressed by many in busy urologic practices. However, defining microscopic hematuria as greater than one red blood cell (RBC) per high-power field is, in our opinion, somewhat strict and would tend to bias the data toward less significant intravenous urographic (IVU) results. Of interest would be the actual RBC count per patient in the study. Although none of the authors’ 120 patients had an alteration of therapy on the basis of IVU study results, several (notably 6 with stones and 3 with dilated ureters> did have pathologic abnormalities that would have been readily diagnosed by an IVU, which also would have provided functional and anatomic information sufficient to serve at least as a preliminary guide to appropriate management. It is probably true that each of the aforementioned 9 patients could have been diagnosed by kidney, ureters, and bladder radiography (KUB) and ultrasound and then proceeded to IVU, if needed. Assuming accurate readings and negating the value to the patient of reporting a normal study result, the other 111 IVUs were apparently unnecessary. As with so much we do, the difficulty is in establishing parameters by which we can determine who will and will not benefit from an IVU. In the present report, the small number 367

of patients studied precludes statistically from the patient pool those patients ( 2%) under age 55 years with upper tract transitional cell carcinoma (TCC) Each time I think that I can skip the IW and rely on just KUB and ultrasound in the younger population, I recall the 14-year-old black male patient with sickle cell trait who came to us from the inner city with intermittent, mild gross hematuria. He was asymptomatic, and the concensus was that his bleeding was probably secondary to his sickle cell trait. The KUB was negative; however, the IW showed normal renal outlines but suggested amputation of an upper calyx. This finding was confirmed by retrograde pyelography and angiography. His nephrectomy specimen revealed a 3-cm TCC! It is highly unlikely that this TCC would have been picked up by ultrasound. Admittedly, this is one anecdotal case, but it is cases like this that we remember.

368

The IW continues to be our best screening modality for hematuria. Even normal study results provide guidance. Despite the costs and potential risks, most urologists, like Zeitlin et al., will continue to use it to avoid missing the unusual-at least until a better, more cost-effective technique comes along. I do not agree that discontinuing the IW in the evaluation of hematuria will eliminate potential litigation. In Texas, there have been only 31 malpractice claims in the past 14 years for “failure to diagnose.” Elimination of what is now probably our most sensitive initial study for upper tract TCC would be unlikely to improve those figures.

Thomas P. Ball, jr., M.D. University

Division of Urology of Texas Health Science Center

San Antonio, TX 78284-7804

UROLOGY

48 (31, 1996