A 77-year-old man is brought to the physician by his daughter with a 1-week history of gross hematuria. He has no frequency, urgency, hesitancy, or dribbling. His other medical problems include hypertension, chronic low back pain, and chronic renal insufficiency. The patient's medications include amlodipine, hydrochlorothiazide, and acetaminophen with codeine as needed. He has a 46-pack-year smoking history. Prostate examination shows no abnormalities. Laboratory results are as follows: Urine microscopy shows many normal-appearing red cells, but no dysmorphic red cells or casts. Urine culture shows no growth. Prostate-specific antigen is 3.2 ng/mL. Ultrasound of the kidneys shows bilateral cortical atrophy but no other lesions. Which of the following is the most appropriate next step in management of this patient?

Question

A 77-year-old man is brought to the physician by his daughter with a 1-week history of gross hematuria.  He has no frequency, urgency, hesitancy, or dribbling.  His other medical problems include hypertension, chronic low back pain, and chronic renal insufficiency.  The patient's medications include amlodipine, hydrochlorothiazide, and acetaminophen with codeine as needed.  He has a 46-pack-year smoking history.  Prostate examination shows no abnormalities.  Laboratory results are as follows:  Urine microscopy shows many normal-appearing red cells, but no dysmorphic red cells or casts.  Urine culture shows no growth.  Prostate-specific antigen is 3.2 ng/mL.  Ultrasound of the kidneys shows bilateral cortical atrophy but no other lesions.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c093_1dff_8f63_05848c44a6f2_MD0005_00 This patient has a high risk of urinary tract malignancy (eg, renal, bladder, or prostate cancer) in light of gross hematuria, age >40, male gender, and smoking history. Other potential risk factors include history of pelvic radiation or exposure to aniline dyes. Gross hematuria in such patients requires assessment of both the upper and lower urinary tracts. The lower tract is best visualized with cystoscopy, which is highly sensitive for bladder cancer and may identify other potential causes of hematuria as well. Urine cytology is less sensitive than cystoscopy for diagnosing bladder cancer, but it may be considered as an alternate test in low-risk patients (Choice E). The upper tract should also be evaluated. This is usually done with contrast-enhanced computed tomography (CT) urogram, but this test is relatively contraindicated in patients with underlying chronic kidney disease (Choice A). Alternatives to CT include renal ultrasound and magnetic resonance imaging. This patient's ultrasound shows no kidney lesions suggestive of malignancy. (Choice C) Intravenous pyelography has largely been replaced by CT imaging, which has higher sensitivity and specificity in evaluating hematuria. It also requires intravenous contrast, which is contraindicated in this patient. If additional imaging of the upper tract is needed, a retrograde pyelogram can be performed at the time of cystoscopy. (Choice D) Renal biopsy is indicated if there is evidence of glomerular bleeding (eg, red cell casts, dysmorphic red cells) with worsening renal function. It would not be advised in this patient with nonglomerular hematuria. Educational objective: Gross hematuria warrants evaluation of both the upper and lower urinary tracts. Computed tomography urogram is recommended for the upper tract; ultrasound is an alternate test, especially for patients with chronic kidney disease. Cystoscopy is recommended for evaluation of the lower tract, with urine cytology as an alternate test for low-risk patients. References: Diagnostic tests and algorithms used in the investigation of haematuria; systematic reviews and economic evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/16729917) Assessment of hematuria. (http://www.ncbi.nlm.nih.gov/pubmed/21095418)

A 77-Year-Old Man Is Brought to the Physician by His