ULTRASOUND FOR MICROSCOPIC HEMATURIA 1301 Findings in 80 patients with normal and 21 with abnormal detected and many clinically insignificant lesions

were detected, 30% of which required additional imaging Findings No. Pts. Followup Studies studies. Therefore, we recommend the continued reliance

upon IVP and cystoscopy for the evaluation of microscopic

ultrasound results

Determinate: Simple 4 4 - hematuria. co,-tical thinning 3 -

~~

Mild hydronephrosis, normal

column of Bertin small stone

rw

Indeterminate (compare with

Inadequate visualization on

possible abnormal collecting

rw): ultrasound

system finonnal ultrasound:

Interpolar mass Complex cyst Indeterminate cystic lesion

Normal IVP

Normal Ivp

CT normal CT simple cysts CT possible maas, repeat CT

cyst CT complex cyst, arteriogram

normal, repeat CT (appmsi- mately 6 and 8 m o d comolex cvst

indicated. The improved capability of modem ultrasono- graphic equipment to image the renal parenchyma and col- lecting system has spurred numerous studies ta compare upper urinary tract imaging by IVP and ultrasonography. These studies have questioned the cost-effectiveness and ac- curacy of diagnosis when NP is the primary imaging modal- ity of the upper urinary tracts. The superior capability of IVP to image the urothelium as part of a microscopic hematuria evaluation is not addressed in our study. We addressed only the mar@ use of ultrasonography in the face of a normal IVP.

Numerous reports support the contention that NP will occasionally miss anterior and posterior solid r e d mass- es.13 Curry et al reported that 3 of 9 solid renal masses smaller than 3 cm. were initially missed by W.1 Kass et al described 2 primary renal cell carcinomas and 2 cases of metastases to the kidney that were not found by IVP.4 Others have reported similar failings with renal tumors as large as 5 an. not visualized by Ivp.3.5 The frequency of this occur- rence is unknown. A disturbing report by Demos et al indi- cated that 3 renal cell carcinomas and 1 angiomyolipoma were missed on an initial IVP in a review of 65 consecutive primary renal neoplasms treated at 1 institution.2 Addition- ally, the benign nature of small solid renal lesions cannot be assumed, since distant metastases have been reported from renal masses less than 2 cm. in diameter.73 The use of ultrasonography or CT instead of IVP to image the kidneys would undoubtedly identify more renal neoplasms than IVP alone. However, the cost of identifying these additional masses must be considered. The cost of the scan itselfmay be 88 much as $500 more than Ivp alone. Additionally, the cost of an overly sensitive test (such as ultrasound), as manifested

the 6% of patients who required 11 additional imaging studies, may be unacceptable in financial and human terms (due to the additional anxiety and potential morbidity from testing).

CONCLUSlONS

our study demonstrates that the addition of ultrasonogra- PhY to IVP in the evaluation of microscopic hematuria is unnecessary. No additional renal masses of significance were

REFERENCES

1. Curry, N. S., Sehabel, S. I. and Betsill, W. L., Jr.: Small renal neoplasms: diagnostic imaging, pathologic features, and clin- ical course. Radiology, 1MI: 113. 1986.

2. Demos, T. C., Schiffer, M., Love, L., Waters, W. B. and Moncada, R.: Normal excretory urography in patients with primary kid- ney neoplasms. Urol. Rad., 7: 75,1985.

3. Glen, D. A, Gilbert, F. J. and Baylis, A. P.: Renal carcinomas missed by urography. Brit. J. Urol., 63: 457, 1989.

4. Kass, D. A., Hricak, H. and Davidson, A. J.: Renal malignancies with normal excretory urograme. AJR, 141: 731,1983.

5. Parvey, H. R., Thomas, J. L., Bernardino, M. E., Barnes, P. k and Lewis, E.: pitfalls in diagnosis of exophytic renal tumors. Urology, 20: 218, 1982.

6. Aslaksen, k, Gadeholt, G. and Gathlin, J. H.: Ultrasonography versus intravenous urography in the evaluation of patients with mimompic haematuria. Brit. J. Urol., 66: 144, 1990.

7. Evins. S. C. and Varner. W.: Renal adenoma-a misnomer. Urol- ogy; 13: 85,1979. '

8. Talamo. T. S. and shonnard, J. W.: Small renal adenocarcinoma with metastases. J. Urol.,~124.132,1980.

EDITORIAL COMMENT The authors review a total of 101 patients with micmseopic hema-

turia and a normal IVP who subsequently underwent renal ultra- sound. Renal ultrasound was abnormal in 20% of the patients but none had clinically signi6cant findings. They conclude that renal ultrasound is unnecessary in the patient with micmscopic hematuria and a normal IVP.

In the discussion, the authors cite several reports indicating that AT will miss amall solid renal tumors (references 1 to 5 in article). Renal cell carcinomas are more accurately diagnosed by renal ultra- sound than IVP. Renal cell adenocarcinomas are far more common than transitional cell carcinomas of the upper urinary tract (more readily diagnosed by IVP). The present military population may be somewhat younger and better screened than a similar group from the general population. Hematuria is also described as including 1 red cell per high power field. Might this population have been better classified inta Werent age groups and Merent levels of hematuria?

It could also be argued that in the patient with mierosropic hema- turia renal ultrasound should be the next diagnostic test and IVP should be reserved only for those with a possible suspicion of tran- sitional cell carcinoma. The initial cost-effective, efficient, best ex- aminations for mimmpic hematuria might include urinalysis, eye- toseopy, sonography and urinary cytology. IVP andlor Cl' would be better reserved for only patients with suspicious lesiona that would be better delineated by those radiographic studies Increaeingly. sonography is a commonly obtained examination and mauy patienta do not undergo M'. As many as a quarter to a third of d mil carcinomas are currently found by serendipity on studies obtained for vague abdominal pain or other unrelated symptoms. Not all of these patients have microscopic hematuria but the efficacy of renal ultrasound has clearly been demonstrated. The authors have dem- onstrated that sonography has minimal value only when a healthy population has been examined and the IVP already was normal. It may be more appropriate to consider sonography as a better initial examination than IVP in the evaluation of the patient with micro- scopic hemahuia.

Fray F. Marshall Department of U m l ~ The Johns Hopkins Hospital Baltimore, Maryland