Aims and objectives
The ‘red patch’ on cystoscopy is a cause of diagnostic uncertainty, mandating bladder biopsy to exclude underlying malignancy. We aim to identify the rate of malignancy in patients found to have a red patch on cystoscopy.
Methods
Retrospective case note review of all patients undergoing diagnostic rigid cystoscopy and bladder biopsy under general anaesthesia in our institution over a 1 year period (Jan – Dec 2016). Patients were excluded if they required any concomitant procedures (e.g. retrograde studies, stent insertion, transurethral resection, photodynamic diagnosis).
Results
204 patients with a mean age of 69 (30-92) years were studied, of whom 75% were male. 135 patients (66%) had a prior history of bladder TCC, and 69 had no prior history of TCC.
Of those with a history of TCC, 48 patients (35%) were found to have a ‘red patch’ and malignancy (high grade NMIBC or CIS) was found in 7 (15%) of these. Cytology was abnormal (≥C3) in 75%.
Of those with no prior history of TCC, 39 patients (57%) were found to have a red patch, of which only 1 was malignant (low-grade G1pTa TCC) (Table 1). Cytology was abnormal in 1 out of 10 patients. 18 (46%) had a history of recurrent UTI, and the majority (72%) were booked by trainees.
Of these 87 patients with a ‘red patch’, 27 (31%) had significant co-morbidity with an ASA grade of 3 or 4, and 18 (21%) were taking anticoagulants. An overnight stay was required by 10 patients and an inpatient stay of 2 days required by 2 patients. The total cost attributed to these procedures for this group of 87 patients, including pre-operative medical assessment, theatre time, and inpatient hospital stay, was estimated at £66,904.
‘Red patch’
|
Prior history of TCC
|
No prior history of TCC
|
Benign/ Resolved
|
41
|
38
|
Malignant
|
7
|
1
|
Total
|
48
|
39
|
Table 1. Diagnostic yield of ‘red patch’ biopsies
Conclusions
The risk of malignancy from a ‘red patch’ in patients with no prior history of TCC is very low, but the current diagnostic pathway puts patients at increased risk and is costly. Methods to improve outpatient-based diagnostics (such as narrow-band imaging) should be studied further in this setting.