Microhematuria: AUA/SUFU Guideline

Abstract

Purpose: Patients presenting with microhematuria represent a heterogeneous population with a broad spectrum of risk for genitourinary malignancy. Recognizing that patient-specific characteristics modify the risk of underlying malignant etiologies, this guideline sought to provide a personalized diagnostic testing strategy. Materials and Methods: The systematic review incorporated evidence published from January 2010 through February 2019, with an updated literature search to include studies published up to December 2019. Evidence-based statements were developed by the expert Panel, with statement type linked to evidence strength, level of certainty, and the Panel's judgment regarding the balance between benefits and risks/burdens. Results: Microhematuria should be defined as 3 red blood cells per high power field on microscopic evaluation of a single specimen. In patients diagnosed with gynecologic or non-malignant genitourinary sources of microhematuria, clinicians should repeat urinalysis following resolution of the gynecologic or non-malignant genitourinary cause. The Panel created a risk classification system for patients with microhematuria, stratified as low-, intermediate-, or high-risk for genitourinary malignancy. Risk groups were based on factors including age, sex, smoking and other urothelial cancer risk factors, degree and persistence of microhematuria, as well as prior gross hematuria. Diagnostic evaluation with cystoscopy and upper tract imaging was recommended according to patient risk and involving shared decision-making. Statements also inform follow-up after a negative microhematuria evaluation. Conclusions: Patients with microhematuria should be classified based on their risk of genitourinary malignancy and evaluated with a risk-based strategy. Future high-quality studies are required to improve the care of these patients.

Assessment of Diagnostic Yield of Cystoscopy and Computed Tomographic Urography for Urinary Tract Cancers in Patients Evaluated for Microhematuria

“…Therefore, the AUA updated its 2012 recommendation, 53 in which it endorsed upper urinary tract imaging using CT urography for all patients, to recommend restricting CT urography to high-risk patients (ie, women or men aged ≥60 years, >30 pack-years, >25 RBCs per HPF on a single urinalysis, or history of gross hematuria) in its 2020 guidelines. 4 …”

“…Ultrasonography as an alternative to CT urography is now recommended in the literature as well as the updated AUA recommendations as first-line imaging for low- and intermediate-risk patients with MH. 2 , 4 Ultrasonography has acceptable sensitivity for detection of KCC and a high negative predictive value for UTUC among patients with MH. 6 , 9 Furthermore, ultrasonography is cost-efficient and does not expose patients to harmful radiation.…”

“…The routine use of cystoscopy to evaluate all patients with MH also seems debatable. The use of an individual risk-stratified evaluation strategy based on personal risk factors, as recommended by recent AUA guidelines, 4 may be a better approach to assess whether further evaluation is necessary among patients with MH.…”

Current Concepts in Imaging Asymptomatic Hematuria

“…1 The prevalence of hematuria ranges from 0.19 to 31% in the literature, depending on the definition of hematuria, population demographics, and diagnostic testing approaches. 2,3 Hematuria can be classified as gross hematuria (also referred to as macrohematuria) or microhematuria. Gross hematuria is defined as red blood cells resulting in readily visible red or brown coloration of the urine.…”

“…The American Urological Association (AUA) defines microhematuria as ≥3 red blood cells per high-power field. 2 For this review, we will examine the clinical evaluation and diagnostic imaging pertaining to asymptomatic hematuria focusing closely on the controversies in microscopic hematuria.…”