IS FLEXIBLE CYSTOSCOPY NECESSARY IN THE INVESTIGATION OF NON-VISIBLE HAEMATURIA?
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Original Article
DOI:10.22374/jeleu.v4i2.124
IS FLEXIBLE CYSTOSCOPY NECESSARY IN THE INVESTIGATION OF NON-
VISIBLE HAEMATURIA?
Jennifer Nowers1, Mark O. Kitchen1,2*, Sneha Rathod1, Caroline Lipski1, Sharbathana Nageswaran1,
Shahjahan Aslam1, Anurag Golash1
1
Urology Department, University Hospitals of North Midlands NHS Trust, Staffordshire, UK; 2School of
Medicine, Keele University, Staffordshire, UK
*Author for correspondence: Mark O. Kitchen: m.o.kitchen@keele.ac.uk.
Abstract
Background: Historic evidence suggests up to 16% (approximately) of non-visible haematuria (NVH) refer-
rals 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 pro-
cess. 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 atten-
dance, and there could be huge reductions in financial and service delivery demands in an overstretched
secondary-care service.
INTRODUCTION despite improvements in technology and vision/resolu-
tion, FC remains a user-dependent procedure, with poor
Flexible cystoscopy (FC) has been considered the
sensitivity for flat urothelial lesions such as carcinoma-
“gold standard” to visualize the bladder for several de-
in-situ (CIS).4 Therefore, it comprises only part of a
cades.1 As such, it is recommended in the investigation
multi-modal approach to haematuria investigation.
of haematuria by the National Institute for Health and
FC can be a morbid procedure, causing considerable
Care Excellence (NICE) and European Association of
(but temporary) irritative lower urinary tract symptoms
Urology (EAU) Bladder Cancer guidelines.2,3 However,
J Endolum Endourol Vol 4(2):e7–e12; June 22, 2021.
This article is distributed under the terms of the Creative Commons Attribution-
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Is Flexible Cystoscopy Necessary in the Investigation of Non-Visible Haematuria?
for a significant number of patients.5 It also has at- pathway for investigation of NVH, was identified at
tributable risks of infection (up to 10%) and sepsis our tertiary cancer centre and University teaching
(Is Flexible Cystoscopy Necessary in the Investigation of Non-Visible Haematuria?
Table 1. Patient Demographics
Total Age Median Current Occupational risk Family
number range age smokers Ex-smokers factors history
Male 96 27–92 67 10 28 11 1
Female 104 31–88 68 11 20 7 2
Figure 1. Cancers found. (a) Pie-chart representation of the number of bladder cancers found in our NVH
case series: the orange segment represents no cancer found (n = 194, 97%) and the blue segment represents
bladder cancers found (n = 6, 3%). (b) Pie-chart representation of all cancers found by site: the blue segment
represents bladder cancers (n = 6) and the orange segment represents renal cancers (n = 2). (c) Pie-chart
representation of cancers identified by imaging prior to FC (bladder cancers orange segment, n = 6, and
renal cancers blue segment, n = 2).
No prostate cancers were suggested by screening Regression analyses
PSA and/or DRE (that were subsequently proven on Multivariate regression analyses did not find any
mpMRI and/or prostate biopsy). significant correlation with age, gender, smoking
Two bladder tumours were identified only by FC: in status, or occupational or family risk factors to blad-
these cases, one was a sub-centimetre solitary G1pTa der cancer diagnosis.
(patient already discharged from follow-up), and the DISCUSSION
other was a solitary 2 cm pedunculated papillary tu-
mour, however, the patient was unfit for trans-urethral There are multiple conflicting factors regarding
resection and has since died of heart failure. the need for FC in NVH patients. The risk of bladder
J Endolum Endourol Vol 4(2):e7–e12; June 22, 2021.
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cancer missed by preliminary investigations and pa- Reassuringly, if a cancer is missed initially by US, the
tient choice (FC may be wanted for “peace of mind”), patient is likely to represent with further episodes of
compete with user-dependence, poor sensitivity, as- NVH, or with new VH, but the very low rate (Is Flexible Cystoscopy Necessary in the Investigation of Non-Visible Haematuria?
clear discussion of the low risks of finding bladder Final approval of the version to be published: JN,
cancer would prompt patients to decline FC on a risk MK, AG
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