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Keywords:

  • urothelial carcinoma;
  • urinary cytology;
  • bladder cancer;
  • tumour markers

Study Type – Diagnostic (non- consecutive case series)

Level of Evidence 3b

What’s known on the subject? and What does the study add?

Urinary cytology has been demonstrated to have high specificity and low sensitivity. Thus, a positive cytology result is generally considered an indicator of malignancy along the urinary tract. Clinically unconfirmed positive urinary cytology refers to the uncommon setting where the assay is repeatedly positive and tumor cannot be detected on cystoscopy and upper tract imaging. The clinical course of these patients remains elusive.

The results indicated that detection of overt urothelial carcinoma in these patients is time dependent. The bladder is most commonly involved, and usually with high-grade disease. The time interval from presentation to final diagnosis might often be protracted (>1 year) but the long-term outcome of patients in this setting appears to be favorable. Urologists should strive to reach a definitive diagnosis even if the primary workup is unremarkable.

OBJECTIVE

• To evaluate the natural history of patients presenting with positive urinary cytology in the absence of clinically identifiable disease.

PATIENTS AND METHODS

• A surgical database was queried to identify 48 patients with positive urinary cytology of undetermined source.

• All patients underwent a thorough urological evaluation consisting of random bladder biopsies, lateral montanal prostate biopsies, bilateral retrograde pyelography and selective urine cytology sampling from each ureter.

• Time from presentation to definitive diagnosis was estimated using the Kaplan–Meier method.

RESULTS

• In total, 27 patients (56%) had a history of bladder cancer and 21 (44%) were evaluated for irritative voiding symptoms or haematuria.

• At a median follow-up of 31 months, the source of the positive cytology was identified in 32 patients (67%): in 29 (61%) as bladder cancer, in two patients (4%) as upper tract tumour and in one patient (2%) as transitional cell carcinoma of the prostate; 29/32 (91%) had high-grade disease and the predominant clinical stage (53%) was carcinoma in situ.

• The median (interquartile range) interval from presentation to diagnosis was 19 (8–22) months, and was significantly shorter in naive patients than in those with a previous history of bladder cancer (13 vs 27 months, P < 0.05).

• Disease-free survival with an intact bladder at 4 years was 74% (95% CI, 63–85).

CONCLUSIONS

• Unconfirmed positive urine cytology often predates the development of high-grade urothelial carcinoma.

• The bladder is most commonly involved.

• The time to diagnosis is generally protracted, although the long0term outcome appears to be favourable.