Diagnostics

• Perform initial laboratory studies.

  • Identify and treat any benign causes of symptoms (e.g., infection) and then reassess.

  • For persistent abnormalities, assessment depends on the symptoms.

    • Gross hematuria or other clinical features of urinary tract cancer: Obtain imaging followed by direct visualization of the urinary tract (with biopsy if needed).

    • Microscopic hematuria: Perform a risk stratification for microhematuria; further workup depends on perceived risk.

• If the diagnosis is confirmed, perform staging studies for urinary tract cancer.

Evaluate the entire urinary tract if malignancy is suspected. Use imaging to assess the renal pelvis and ureters and perform cystoscopy to assess the bladder and urethra.

Gross hematuria or microhematuria with ≥ 3 RBCs per high-power field (HPF)

• Assess for common causes of hematuria ; repeat studies after treatment or cessation of any contributing factors.

• Persistent gross hematuria

  • Determine if glomerular causes are present; patients with glomerular causes should be additionally worked up by nephrology.

  • Evaluate the upper and lower urinary tract for malignancy with imaging and direct visualization.

Identification of dysmorphic RBCs, RBC casts, and/or significant proteinuria on urine microscopy indicates a glomerular cause of hematuria.

Assessment of urine tumor markers is not recommended, as their diagnostic value is uncertain.

• Renal function tests —> Used to establish a baseline and assess for impairment, which may affect the imaging study used.

• CBC and CMP —> Decreased cell counts, elevated alkaline phosphatase, and elevated liver chemistries may indicate metastases.

• Preferred: CT urography

• Alternative

  • MR urography

  • Renal bladder ultrasound

MR urography is typically obtained if CT urography is contraindicated (e.g., if there are contraindications to iodinated contrast)

Compared to CT urography, ultrasound has lower sensitivity for detecting carcinomas of the renal pelvis and ureters.

• Filling defects

• Hydronephrosis (suggestive of intraluminal tumor obstruction)

• Mural thickening

• Visualization of masses

• Evidence of disease spread (e.g., lymphadenopathy)

Bladder mass

CT urography (with contrast; axial plane) of a patient with transitional cell carcinoma

A hypodense mass (green overlay) is visible within the posterior bladder. Layering (red line) hyperdense contrast (C) outlines the mass.

Direct visualization (cystoscopy/ureteroscopy) —> Direct visualization is the gold standard for diagnosing urinary tract cancer

TURBT may be performed during cystoscopy if lesions are detected. During cystoscopy, TURBT can allow for simultaneous diagnosis and treatment.

• Single or multiple lesions

• Appearance may be a:

  • Papillary, sessile, or nodular mass

  • Flat erythematous area (carcinoma in situ)

• Areas of necrosis may be visible.

• Chest x-ray and/or CT chest with IV contrast

• CT abdomen/pelvis with and without IV contrast (if not already performed) ->MRI with and without IV contrast can be used as an alternative.

• Bone scan

• FDG-PET/CT scan

Indications include patients with bone pain, elevated alkaline phosphatase, signs of bone marrow infiltration (e.g., anemia, thrombocytopenia), and/or invasive disease.

• Biopsy

• Urine cytology

• Not routinely required: Histology is usually performed on tissue removed during TURBT.

• Image-guided or endoscopic biopsy may be used as an alternative.

• Indication: an adjunct study for patients with gross hematuria

• Findings: can detect sloughed malignant cells, especially from high-grade urothelial tumors