Introducing a Software-Based Template for Standardized Structured Reports of Urinary Cytology and Its Impact on...

Standardized pathology reports enhance completeness and readability, contributing to the overall improvement in the management of patients. The standardization of urine cytology reporting has gained widespread acceptance with the use of the Paris system (TPS) for reporting urinary cytology, primarily focused on detecting high-grade urothelial carcinoma (HGUC). The next phase at the Institute of Pathology, Medical Faculty, University of Ljubljana, was the implementation of TPS, including standardized additional findings on non-neoplastic changes, into a software-based standardized structured reporting (SBSSR) system.

The implementation of SBSSR for urinary cytology at the Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia, began in March 2023. Before daily usage, the SBSSR template was tested and approved by all cytopathology team members. An informative briefing for clinicians was organized to facilitate inter-specialty communication. To assess the impact of the SBSSR system on reporting efficiency, the turnaround time was tracked from the receipt of the cytology sample in the lab to the time of digital signature on its diagnostic report during two consecutive 11-month periods (04/01/2022-03/01/2023 and 04/01/2023-03/01/2024).

All team members easily adopted the new SBSSR for urinary cytology. Reports are generated, costs are calculated, and they are digitally signed in a single step. The adoption of SBSSR for urinary cytology led to the replacement of dictation and administrative tasks. The average turnaround time for urine cytology has been reduced from 1,8 days (based on 2843 samples) to 1,5 days (based on 3438 samples).

The introduction of SBSSR for urinary cytology increased the quality of patient care with a shorter time to diagnosis and a higher level of report clarity.