concomitant underlying urological pathology.

eGFR should also be measured as an indicator

Patients symptomatic of a urinary tract infection

of renal impairment.

should receive a course of antibiotics and the flex-

ible cystoscopy should be postponed for a couple

Flexible Cystoscopy

of weeks in order to allow the urinary tract infec-

tion to be fully treated.

Flexible cystoscopy under local anesthetic is prob-

The use of routine urinalysis as a screening

ably the ideal way to investigate the lower urinary

tool for urological malignancy remains the sub-

tract for hematuria. It combines good patient tol-

ject of debate.While the detection of microscopic

erability with safety and low cost, and the views

hematuria at urinalysis may predict the develop-

are usually as good as those obtained with a rigid

ment of bladder cancer,19 there is also evidence

instrument.23 Cystoscopy reportedly has a 5% risk

that patients testing positive and negative for

of causing urinary infection.37 Of note, the ability

microscopic hematuria have an equal chance of

of flexible cystoscopy to detect CIS of the bladder

developing a urological malignancy.24 A routine

may be more limited than with rigid instrumen-

screening program for urological malignancy

tation.38 If a bladder or urethral tumor is found at

based on urinalysis and the detection of hematu-

flexible cystoscopy, the patient should undergo

ria is therefore not currently advocated.

examination under anesthesia and formal tran-

Cytology

surethral resection, together with upper tract

evaluation (see below) including an intravenous

Urine cytology can detect atypical or malignant

urogram (IVU) or, increasingly commonly, a con-

trast-enhanced computer tomography urogram

cells but its sensitivity depends upon numerous

(CTU), in order to detect a synchronous urothe-

factors including the grade of the urothelial

lial lesion elsewhere within the urinary tract.

malignancy and the experience of the reporting

pathologist.5 It has a high specificity for the

detection of high-grade urothelial tumors and

Upper Urinary Tract Evaluation

CIS,25 but can be positive with nonmalignant

Evaluation of the upper urinary tract is complex

conditions such as chronic infection or inflam-

mation and urinary calculus disease.23

and requires a balance between the number of

radiological investigations required to detect

Molecular Tests

significant pathology and the low detection rate

of each test (Fig. 26.1). This balance varies

Recently, numerous molecular tests have been

between institutions (reflecting that no single

designed to detect urothelial malignancy using

protocol is ideal), and depends upon the indi-

urine analysis.25 The most developed of these are

vidual patient’s pathological risks (established

the detection of bladder tumor antigen (BTA),26-28

from history and examination) and their medi-

nuclear matrix protein 22 (NMP22),29-32 and fluo-

cal comorbidity. For example, unfit patients

rescence in-situ hybridization for chromosomal

may not benefit from investigations that would

anomalies (UroVysion). The NMP22 test is one of

not alter their management even if pathology

the best evaluated and detects the NMP22 protein

was found. Many urologists adopt a pragmatic

which is present at significantly greater con-

approach and utilize a renal ultrasound (USS)

centration in the urine of patients with bladder

scan in order to detect renal parenchymal

cancer as compared with normal controls.25

lesions and a plain abdominal x-ray for calculi.

NMP22 detection has a sensitivity between 58%

If flexible cystoscopy and these radiological

(specificity 84%) and 91% (specificity 76%) in

tests are normal, then patients with macro-

reported studies.32-36 Data suggest that it should

scopic or persistent microscopic hematuria

be used to complement a flexible cystoscopy.

should probably undergo additional upper tract

imaging in the form of either an IVU or CTU. If

Blood Tests

these investigations are negative and the patient

continues to have frank hematuria, additional

A full blood count should be considered in

investigations may be required,depending upon

patients with heavy or long-standing hematuria

the index of suspicion of a malignant cause of

to detect anemia, while plasma creatinine and

hematuria.