Routine urine cytology has no role in hematuria investigations

Purpose: Urine cytology has been a long-standing first line investigation for hematuria and is recommended in current major guidelines. We determined the contribution of urine cytology in hematuria investigations and its cost implications.

Materials and methods: Data were prospectively collected for 2,778 consecutive patients investigated for hematuria at a United Kingdom teaching hospital from January 1999 to September 2007 with final analysis in October 2010. All patients underwent standard hematuria investigations including urine cytology, flexible cystoscopy and renal tract ultrasound with excretory urogram or computerized tomography urogram performed in those with visible hematuria without a diagnosis after first line tests. Patients with positive urine cytology as the only finding underwent further cystoscopy, retrograde studies or ureteroscopy with biopsy under general anesthesia. Outcomes in terms of eventual diagnosis were cross-referenced with initial urine cytology results (classified as malignant, suspicious, atypical, benign or unsatisfactory). Costs of urine cytology were calculated.

Results: Of the patients 124 (4.5%) had malignant cells and 260 (9.4%) had atypical/suspicious results. For urothelial cancer cytology demonstrated 45.5% sensitivity and 89.5% specificity. Two patients with urine cytology as the only positive finding had urothelial malignancy on further investigation. For the entire cohort the cost of cytology was £111,120.

Conclusions: Routine urine cytology is costly and of limited clinical value as a first line investigation for all patients with hematuria, and should be omitted from guidelines.