Guideline of guidelines: asymptomatic microscopic haematuria

Abstract

The aim of the present study was to review major organizational guidelines on the evaluation and management of asymptomatic microscopic haematuria (AMH). We reviewed the haematuria guidelines from: the American Urological Association; the consensus statement by the Canadian Urological Association, Canadian Urologic Oncology Group and Bladder Cancer Canada; the American College of Physicians; the Joint Consensus Statement of the Renal Association and British Association of Urological Surgeons; and the National Institute for Health and Care Excellence. All guidelines reviewed recommend evaluation for AMH in the absence of potential benign aetiologies, with the evaluation including cystoscopy and upper urinary tract imaging. Existing guidelines vary in their definition of AMH (role of urine dipstick vs urine microscopy), the age threshold for recommending evaluation, and the optimal imaging method (computed tomography vs ultrasonography). Of the reviewed guidelines, none recommended the use of urine cytology or urine markers during the initial AMH evaluation. Patients should have ongoing follow-up after a negative initial AMH evaluation. Significant variation exists among current guidelines for AMH with respect to who should be evaluated and in what manner. Given the patient and health system implications of balancing appropriately focused and effective diagnostic evaluation, AMH represents a valuable future research opportunity.

Development and validation of a haematuria cancer risk score to identify patients at risk of harbouring cancer

“…Age is the main discriminating factor across guidelines and we show that the use of the HCRS may reduce the risk of missing cancers. In addition to age and type of haematuria, smoking history and gender are important risk factors for the development of bladder cancer . These variables are currently not used in the decision to refer for investigations but are collected as part of the standard assessment of patients.…”

“…The decision to guide who should have investigations following a presentation of haematuria varies between guidelines . Recommendations by the National Institute for Health and Care Excellence (NICE) suggest that patients aged ≥45 years with visible (VH) and ≥60 years with nonvisible haematuria (NVH) with either dysuria or a raised white cell count on blood test should be urgently investigated .…”

Imaging for the diagnosis and response assessment of renal tumours

“…An ultrasound (US) of the renal tract may be considered initially in low-risk young patients with non-visible haematuria as a cost-effective non-ionising technique for assessing the kidneys and bladder [24, 25]. However, US sensitivity is low for renal lesions < 1 cm (26%) [26] and it does not evaluate the collecting systems adequately; hence, CT urography (pre- and post-contrast) is recommended as a first-line tool for patients presenting with non-visible haematuria by a number of American associations [9, 11, 23, 27]. CT urography following contrast administration assesses the entire urinary tract [28] and has a better diagnostic yield for renal cancer than intravenous urography (IVU), with a sensitivity of 100%, specificity of 97.4% and accuracy of 98.3% [29].…”

Urothelial cancer rate in women with asymptomatic microhematuria. Is there a justification for full hematuria evaluation?

“…Significant variation exists among current guidelines for AMH with respect to who should be evaluated and in what manner [19]. Moreover, there is evidence that guidelines are not adhered to, and this reflects the necessity for introducing selection criteria and maybe variable levels of investigation for MH depending on the individual patient [20].…”