Urologist Use of Cystoscopy for Patients Presenting With Hematuria in the United States

Objective To evaluate the prevalence of cystoscopy and factors associated with use among hematuria patients presenting to urologists, based on results from a nationally representative survey. Methods Using the National Ambulatory Medical Care Survey (2006-2012), we identified outpatient visits to urologists for hematuria, and excluded visits associated with benign diagnoses (eg, urinary tract infection). Our primary outcome was performed or planned cystoscopy. We hypothesized that major risk factors (ie, gross hematuria, tobacco use, age >50, male gender) would be associated with increased cystoscopy use. We used multivariable logistic regression to evaluate the relationship between available patient, provider, and practice setting factors and use of cystoscopy. Results Among an estimated 10.8 million hematuria visits to urologists, cystoscopy was planned or performed after 34.7% of visits (95% confidence interval [CI] 30.7-39.0). Patients with gross hematuria (adjusted odds ratio 2.17, 95% CI 1.28-3.69) and current tobacco users (adjusted odds ratio 2.48, 95% CI 1.40-4.39) had over twice the odds of undergoing cystoscopy compared to patients without those risk factors. We estimated that there are over 20,000 missed cancer cases annually among moderate- and high-risk hematuria patients, and nearly 230,000 excess cystoscopy cases annually for patients with near-zero cancer risk. Conclusion Despite guidelines emphasizing the importance of cystoscopy in hematuria evaluations, just over one-third of patients diagnosed with hematuria by urologists undergo this procedure. There also appears to be considerable misallocation of cystoscopy for hematuria patients, with excessive use among low-risk patients and significant potential for missed cancer cases among those at higher risk of malignancy.