The oncological assessment—for cancer of the kidneys, ureters, bladder, and urethra—is now comprised of two components. Cystoscopy, typically performed under local anesthetic in the office, is a brief and low-risk procedure utilized to visualize the bladder and urethra. Cystoscopy is recommended in all patients ages 35 years and older and in all those with risk factors for urinary tract malignancies regardless of age. The second component of the oncological evaluation is some form of radiologic imaging to visualize the upper tracts—the kidneys and ureters. Multiphasic CT urography—including noncontrast, arterial, parenchymal, and delayed excretory phase images—is the optimal imaging modality given its high sensitivity and specificity for identifying malignancies and other upper tract causes of microhematuria.8 Other imaging modalities that may be utilized in patients with contrast allergies and/or renal insufficiency include magnetic resonance urography (MRU) or retrograde pyelograms plus either MRI, noncontrast CT, or renal ultrasound. Finally, in a key departure from the prior Best Practice Statement, urine cytology is no longer recommended as part of the routine initial evaluation of microhematuria.
These guidelines are an important step towards an evidence-based approach to caring for patients with this very common—and most often benign—urinary finding. Unfortunately, with a complete absence of randomized data evaluating the workup of microhematuria, the new recommendations are not based on any level I data. With further research, we will hopefully gain a better ability to fine tune our diagnostic approach based on specific patient factors, enabling us to better adjust the intensity of our evaluation based on each individual’s likelihood of urologic malignancy.
1. Messing EM, Young TB, Hunt VB, et al. Hematuria home screening: repeat testing results. J Urol. 1995;154(1):57-61.
2. Messing EM, Young TB, Hunt VB, et al. The significance of asymptomatic microhematuria in men 50 or more years old: findings of a home screening study using urinary dipsticks. J Urol. 1987;137(5):919-922.
3. Hiatt RA, Ordoñez JD. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population-based sample. Cancer Epidemiol Biomarkers Prev. 1994;3(5):439-443.
4. Murakami S, Igarashi T, Hara S, Shimazaki J. Strategies for asymptomatic microscopic hematuria: a prospective study of 1,034 patients. J Urol. 1990;144(1):99-101.
5. Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy–part I: definition, detection, prevalence, and etiology. Urology. 2001;57(4):599-603.
6. Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy–part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up. Urology. 2001;57(4):604-610.
7. Davis R, Jones JS, Barocas DA, et al. Diagnosis, Evaluation, and Follow-up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. http://www.auanet.org/resources.cfm?ID=692. Updated May 2012. Accessed July 31, 2012.
8. Silverman SG, Leyendecker JR, Amis ES Jr. What is the current role of CT urography and MR urography in the evaluation of the urinary tract? Radiology. 2009;250(2):309-323.