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Urological Association Identifies Questionable Tests and Treatments
The American Urological Association (AUA) has released a new list of recommendations regarding specific tests or treatments that are commonly ordered but are not always necessary in urology, or urologic management that could be improved, as part of its Choosing Wisely campaign. The list, the third released by the AUA, identifies five targeted, evidence-based recommendations that can support conversations between patients and physicians about what care is really necessary. The AUA list was introduced during the association’s 112th annual meeting in Boston.
The AUA's 2017 list offers the following five recommendations:
- Don’t treat low-risk, clinically localized prostate cancer (e.g., the Gleason score is less than 7; prostate-specific antigen (PSA) is less than 10.0 ng/mL; and the tumor stage is T2 or less) without discussing active surveillance as part of the shared decision-making process.
The ultimate choice of treatment should be based on shared decision-making and individualized to the patient’s disease characteristics, his overall health, and his personal preferences. For men with newly diagnosed low-risk prostate cancer, an active surveillance program represents a valid option that should be discussed.
- Don’t treat uncomplicated cystitis in women with fluoroquinolones if other oral antibiotic treatment options are available.
Because of the potential serious adverse effects associated with the use of fluoroquinolone antibiotics, these drugs should not be prescribed as first-line therapy for uncomplicated cystitis in women. Their use should be reserved for situations in which recommended first-line antibiotic therapies, such as nitrofurantoin or sulfa-trimethoprim, are contraindicated.
- Don’t continue opioid analgesia beyond the immediate postoperative period; prescribe the lowest effective dose and number of doses required to address the expected pain.
Because of the emergence of opioid use disorder as a public health epidemic, the appropriate use of opioid therapy must begin with adherence to minimum prescribing in terms of dose, duration, and quantity.
- Don’t obtain urine cytology or urine markers as a part of the routine evaluation of the asymptomatic patient with microhematuria.
Insufficient evidence exists for the use of urine cytology and urine markers in the routine evaluation of asymptomatic patients with microhematuria, including bladder tumor antigen (BTA) assays, nuclear matrix protein (NMP) assays, and fluorescent in situ hybridization (FISH) assays to detect chromosomal alterations. The psychological stress and unnecessary diagnostic procedures that could result from a false positive test outweigh the potential benefits to these patients.
- Don’t routinely use computed tomography (CT) to screen pediatric patients with suspected nephrolithiasis.
Given the link between radiation exposure from computed tomography (CT) in children and an increased risk of cancer, the selection of an imaging test should adhere to the principle of ALARA (as low as reasonably achievable) to minimize radiation exposure. Ultrasonography is sufficiently sensitive and specific as an initial imaging test in pediatric patients with suspected urolithiasis. When ultrasound results are negative or indeterminate despite strong clinical suspicion or when proceeding with perioperative planning, computed tomography using a low-dose protocol is an appropriate next step.
Source: AUA; May 13, 2017.