Siobhán Hartigan: Thanks so much, Sam. So today I'm just going to go over a few things related to this article, Positive Urinalysis: Do we need to cancel the procedure? So just to set the scene for everybody, this is a common conundrum. How often are you in the middle of a busy clinic? You're running between rooms, and all of a sudden one of your clinical staff comes up to you and says, "Hey, doc, the urinalysis is positive. Do you want to cancel the procedure?" And what do you do? And there's not really a standard answer. So let's take a look at some of the data. For urodynamic studies, the AUA/SUFU best practice statement recommends a urinalysis prior to urodynamics procedures. But if you have a positive urinalysis, that doesn't necessarily mean you have an active UTI. Asymptomatic bacteriuria is extremely common, especially in a large portion of the patients that are here in the urology office, like females and the geriatric population. So when you have an active urinary tract infection, oftentimes you want to think about canceling that urodynamics procedure because it can falsify some cystometric findings. So typically we would reschedule and treat the urinary tract infection. Why? Well, urodynamics is invasive and often uncomfortable, and if we're going to put a patient through this testing, we want reliable and informative results, which sometimes can be altered with an active urinary tract infection.
But if the patient has asymptomatic bacteriuria, it is appropriate to give a single dose of antibiotics and proceed. For cystoscopy, there are retrospective studies that have supported the safety of diagnostic cystoscopy even in patients with asymptomatic bacteriuria, with or without the prophylactic antibiotic treatment at the time of the procedure. But we also know that hospitalization can occur in 1.2% of patients that have a positive urine culture following cystoscopy. And what about the diagnostic accuracy of a cystoscopy in a patient with an active urinary tract infection or a positive urinalysis? You might see something like erythema or bullous lesions. It may be hard to differentiate if this is inflammation or malignancy. Here are some examples of cystoscopic findings. Now, what do you do with this? It's not definitively cancer, but would you recommend a biopsy? Would you put a patient through another procedure if it's really just inflammation? Oftentimes we might give antibiotics and then repeat a cystoscopy, and all of this can lead to increased testing. For chemodenervation and bulking, there really isn't a ton of data to support either way. We know, as I said, that a urinalysis can look the same in asymptomatic bacteriuria and an acute urinary tract infection, and data is mixed on whether onabotulinumtoxinA injection in the setting of asymptomatic bacteriuria increases the risk of UTI or any adverse events.
Patients typically know when they have an active urinary tract infection versus just their baseline lower urinary tract symptoms. If you're doing chemodenervation on a patient, typically they already have frequency and urgency, and so it may be difficult to discern if you're just going based on those baseline symptoms. So performing chemodenervation or urethral bulking during a urinary tract infection is actually technically contrary to FDA labeling and manufacturer recommendations, so it's important to just keep that in mind as you're trying to interpret a positive urinalysis on the day of the procedure. And then, of course, we need to talk about safety, cost, and access. We all know urinary tract infections are expensive. In the United States, this is billions of dollars annually spent on urinary tract infection, and UTIs have increased in prevalence and the risk of mortality over the last 30 years. This is a big problem. But there's also an unprecedented problem in the US regarding access of appointments, especially with specialists. Many patients can travel a great distance for specialty care, and rescheduling procedures also has cost like lower patient satisfaction, wasted resources, and we know that almost half of patients who are canceled do not actually reschedule those procedures.
So if you're a patient and you've just driven 3 or 4 hours to get to a specialist only to have a positive urinalysis without symptoms and then your procedure's canceled, that could be very disheartening. So the take-home message here really is stay tuned. There is a SUFU best practice policy statement on antibiotic usage in these procedures, which is coming soon, so keep an eye out for that. And until then, it's really important to just use patient risk stratification and clinical judgment based on patient factors and symptoms. That may be more important than the urinalysis dipstick result itself.
Sam Chang: Siobhán, that was fantastic in terms of laying out the field of the different things that we try to consider for each of these procedures. Let me ask you a couple of questions about your determination of that patient, because knowing how hard you work and the number of patients you see, I am sure that you have that conundrum where someone comes in and says, "Okay, do we want to do this?" And there are definitely some procedures that you're much more likely to be concerned about, just like the bulking agent's denervation, versus a cystoscopy. Let's focus on cystoscopy. I think that's one of the most common procedures that we do. Tell me how you determine symptoms versus an asymptomatic patient. What are the factors that you take into play and how do you then determine if this patient is asymptomatic versus symptomatic?
Siobhán Hartigan: Yeah, great question. My practice is ERPs-focused, and so a ton of my patients have baseline lower urinary tract symptoms. And when I'm thinking about a positive urinalysis at the time of cystoscopy, I'm really thinking about an exacerbation of their symptoms, an elevation from baseline, so a change, an acute change. And if they tell me, "For the last 48 hours, my nocturia has been significantly worse," or, "I've seen blood in my urine," and it's associated with dysuria, those are active urinary tract symptoms that might lead me more to get a urine culture, treat appropriately, and reschedule a cystoscopy. If it's just their typical frequency, urgency, and there's some leukocytes in their urine, I'm way less concerned.
Sam Chang: Yeah. So then you have this situation where someone is referred to you with this history, in the past, of urinary tract infections. I'm going to focus on women, because clearly in the oncology field, there is so much data regarding the delay in diagnosis of bladder cancer in women that have had either gross hematuria or microscopic hematuria or both. I perform cystoscopy and I have exactly the findings that you showed on your PowerPoint slides regarding, what do you do with these edematous changes, inflammatory changes, et cetera, in someone who has asymptomatic bacteriuria. Tell me your strategies at this point.
Siobhán Hartigan: Yeah. So in asymptomatic bacteriuria, if I have those cystoscopic findings and a urine culture that's positive, if it's concerning for a malignancy, I'll biopsy it. Not in the office, not actively like that. And if they've got persistently positive cultures, I'll make sure that we pretreat to ensure that they've got a sterile urine on the day of a more invasive procedure. But sometimes if I have those changes and there's a urine culture or urinalysis that we're worried about, we send it out for a culture, I might just repeat a cystoscopy in a couple of weeks, 2, 3, 4 weeks and see what it looks like, and that might lead me down the path of whether we biopsy or not.
Sam Chang: Great.
Siobhán Hartigan: Yeah.
Sam Chang: I think I say that's great because that's akin to what I do, so obviously I'm quite supportive of it. But a question that is a follow-up to that is, I've got someone that, just as you say, has driven a long, long way, it's difficult for them to get there, they've already, say, perhaps missed one appointment, et cetera. They're there, they have some mild symptoms. Their UA does show nitrite and it's LE, et cetera, and you're concerned there's white cells. You decide to go ahead and do the procedure and you do the in-office cystoscopy, and lo and behold, you have inflammatory changes. You're not surprised by that, but you do. We tend to knee-jerk and get a cytology, it comes back a couple of days later, it's negative, but you see these changes. Do you think they're due to urinary tract infection, but you're not sure? And they've got risk factors for cancer, smoking history, et cetera. Tell me what your algorithm is. Is it, "Let's see you back in a month. Let's see you back in 2 weeks. Let's see you back in 6 weeks. Let's book you for surgery"? Tell me what you do with that. So mild symptoms, have risk factors for cancer, you see these changes.
Siobhán Hartigan: If they have risk factors for cancer, I'm a little bit more inclined to book them for a biopsy. That's kind of the way that I go with that. If they've never been a smoker, if they're on the younger side, if they're low risk, then I'm more inclined to treat based on culture results and repeat a cystoscopy. Typically in about a month is when I usually repeat it. But because of everything you just said, women are diagnosed later, and I get on a soapbox about that too with my patients that come in with recurrent urinary tract infections and gross hematuria, and then you look in their bladder and they've got a big tumor and they've just been diagnosed with UTIs for 6 months. And so for a patient with risk factors, I'm a little bit more inclined to just biopsy in a short-term interval. The other thing is, if I look in the bladder and there is cloudy, gross-looking urine, I tend to think that that's a little bit more inflammatory in nature versus you look in the bladder and there's just these erythematous changes and doesn't seem quite as infectious, then I'm a little bit more worried about that.
Sam Chang: Yeah. Now, Siobhán, thank you so much. The pearls that you gave, I think really are quite ringing regarding the concerns about misdiagnosis, no question, the evaluation of risk, very similar to the new AUA/SUFU guidelines regarding microscopic hematuria, the importance of determining risk factors, age, as you stated, other clinical risk factors in terms of tobacco use, exposures, et cetera, all those come into play as you determine what to do next. Because I agree with you, you have this tightrope of concern for not missing something, but then avoiding excess or unnecessary procedures. So risk stratification, understanding patient symptoms, all that, I think, are incredibly important. Tell me, the last question to ask is the importance of that urine culture. So say you have these changes and the urine culture ends up being negative, are you more likely to say, then, "Oh, we definitely need to do a biopsy?" Tell me your thoughts about the role of the culture results.
Siobhán Hartigan: Yeah, no, I find the culture results really critical. I try to treat urinary tract infections only based on culture results, and so I'll put in my notes that if we get a picture like that and we're worried about this being due to infection and then their urine culture comes back negative, then we're going to biopsy.
Sam Chang: Yeah, no, really, really important work, and I think that AUA news article is actually really, really helpful. I wanted to share that, especially from an oncology side, we struggle with all the things that you just described, and so very much appreciate your expertise and it's always great to see a superstar. So thank you so much, Siobhán. Let's do it again the next time you come up with some important findings.
Siobhán Hartigan: Sounds great. Thanks so much for having me.