Evaluation Of Asymptomatic Microscopic Hematuria Research Articles

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 May 2021Editorial CommentThis article comments on the following:Evaluation of the New American Urological Association Guidelines Risk Classification for Hematuria Richard S. Matulewicz Richard S. MatulewiczRichard S. Matulewicz Departments of Urology and Population Health, NYU Langone Health, New York, New York More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001550.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 205(5), pp. 1392–1393 Reference 1. : Cost-effectiveness of common diagnostic approaches for evaluation of asymptomatic microscopic hematuria. JAMA Intern Med 2017; 177: 800. Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyDec 24, 2020, 12:00:00 AMEvaluation of the New American Urological Association Guidelines Risk Classification for Hematuria Volume 205Issue 5May 2021Page: 1392-1393 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Richard S. Matulewicz Departments of Urology and Population Health, NYU Langone Health, New York, New York More articles by this author Expand All Advertisement PDF DownloadLoading ...

Current Concepts in Imaging Asymptomatic Hematuria

Hematuria is a very common clinical condition that most clinicians will encounter. Hematuria is divided into gross and microscopic hematuria with a wide variety of etiologies. The imaging evaluation of asymptomatic hematuria is generally tailored to identifying a common cause (urinary tract stones) and the most worrisome cause (carcinoma). The workup for asymptomatic gross hematuria is generally agreed upon and includes both CT and cystoscopy. However, the imaging evaluation of asymptomatic microscopic hematuria is controversial due to the much lower risk of urinary tract malignancies. The purpose of this article is to review the imaging of the upper urinary tract focusing on CT, MRI, and ultrasound. Current European and North American society guidelines, imaging techniques, typical imaging findings, diagnostic accuracy, and risks will all be addressed highlighting the current knowledge gaps, particularly between CT and ultrasound.

Re: Evaluation of Asymptomatic Microscopic Hematuria by Renal Ultrasound to Detect Upper Tract Malignancy: A 20-Year Experience in a Community Hospital.

Re: Evaluation of Asymptomatic Microscopic Hematuria by Renal Ultrasound to Detect Upper Tract Malignancy: A 20-Year Experience in a Community Hospital.

Asymptomatic microscopic hematuria in women.

The purpose of this review is to summarize the problem of asymptomatic microscopic hematuria (AMH) in women and the most recent publications on the topic. Urologic malignancy is rarely associated with AMH in low-risk women. Screening for urologic malignancy includes upper urinary tract imaging and cystoscopy. Renal ultrasound is a cost-effective first-line imaging modality in patients with AMH. Multiphasic computed tomography (CT) urography increases healthcare costs, the risk of secondary malignancy due to cumulative radiation exposure, and the discovery of incidental benign findings resulting in additional work-up. Cystoscopy is universally recommended as a diagnostic test in the evaluation of AMH but it is not without harm. Reliable risk factors for urologic malignancy in women are age, smoking, and possibly the presence of visible blood in the urine. Given the infrequency of these cancers and the performance characteristics of diagnostic testing in this context there is a need for better diagnostic strategies incorporating these risk factors in estimating the woman's risk. There is a need for sex-specific guidelines to risk stratify diagnostic evaluation for urologic malignancy in women with AMH. The low prevalence of these malignancies in women render diagnostic testing (e.g., cystoscopy and multiphasic CT urography) less impactful and pose unwarranted risk and significant healthcare costs.

Referral Patterns for the Evaluation of Asymptomatic Microscopic Hematuria in Women in a Single Health Care System: Room for Improvement.

To identify patterns of care for women referred for asymptomatic microhematuria in a single, hospital-based health care system and estimate the cost of unindicated evaluation. We conducted a retrospective study of 100 women with a diagnosis of asymptomatic microhematuria referred to a tertiary female pelvic medicine and reconstructive surgery practice. Our analysis focused on referral patterns by obstetrician-gynecologists and primary care physicians. Data analyzed included whether asymptomatic microhematuria was documented using urine microscopy (vs urine dipstick) and whether the urine microscopy correctly identified asymptomatic microhematuria with three red blood cells (RBCs). Forty-six patients were referred who met the American Urological Association's guidelines for asymptomatic microhematuria with a workup estimated at $8,298 per patient. Fifty-four were referred to a female pelvic medicine and reconstructive surgery specialist despite clearly not meeting the American Urological Association's definition of asymptomatic microhematuria. Of these, 33 patients were referred based on dipstick-positive results only, 11 were referred based on microscopic urinalysis demonstrating fewer than three RBCs per high-power field (HPF), and the remaining 10 patients were referred with urine microscopy demonstrating at least 3 RBC/HPF but in the setting of a clearly benign cause, such as infection or menstruation. The total estimated cost of the unnecessary asymptomatic microhematuria workup in patients who did not meet American Urological Association criteria for referral was $1,213 per patient. Fewer than half of the referrals for asymptomatic microhematuria were appropriate, leading to wasted and entirely preventable health care expenditures. This study highlights the need for education of health care providers making these referrals.

Evaluation of Asymptomatic Microscopic Hematuria by Renal Ultrasound to Detect Upper Tract Malignancy: A 20-Year Experience in a Community Hospital

To evaluate the sensitivity of ultrasound imaging in detecting upper urinary tract malignancy in patients with asymptomatic microscopic hematuria (AMH) in an outpatient community setting. A list of all patients who received renal ultrasound for hematuria in our health care system between January 1, 1997 and July 1, 2015 was obtained, and electronic health records were retrospectively reviewed. Patients were excluded for age (<18 years), <3 years follow-up, prior upper tract malignancy, recent urinary tract catheterization, inpatient status, pregnancy, insufficient data, or gross hematuria. The initial ultrasound was considered positive if suspicious findings led to a subsequent diagnosis of an upper tract malignancy. False negatives were determined by electronic medical record follow-up for at least 3 years. Of the 2138 patients with AMH who met inclusion criteria, ultrasound imaging detected suspicious findings in 9 of 9 patients with renal cell carcinoma and 3 of 3 patients with upper tract urothelial cancer, indicating a sensitivity of 100% and 100%, respectively. Four additional malignancies were diagnosed more than 3 years after the initial evaluation for an incidence rate of 1.6 cases of upper tract malignancy per 10,000 person-years. The prevalence of upper urinary tract malignancy was low in patients with AMH. Ultrasonography is an appropriate modality for upper tract imaging in the initial evaluation of patients with AMH. Practice guidelines should be updated to reflect the high sensitivity of ultrasound and low risk of upper tract malignancy in patients with AMH.

Could Nonenhanced Computer Tomography Suffice as the Imaging Study of Choice for the Screening of Asymptomatic Microscopic Hematuria?

ObjectiveTo compare the diagnostic accuracy of the noncontrast and contrast-enhanced phases of computed tomographic urography for detection of upper urinary tract findings in adults undergoing initial evaluation of newly diagnosed asymptomatic microscopic hematuria to determine if less-intensive noncontrast imaging has the potential to become a suitable imaging alternative in the work-up of this common condition. Materials and MethodsRetrospective review from 2010-2015 for adults who underwent computed tomographic urography for initial evaluation of asymptomatic microscopic hematuria. Three nonblinded physicians independently categorized the upper urinary tract findings described in the computed tomography reports into one of three groups: normal, benign, or suspicious for malignancy. The noncontrast images of a randomized portion of the studies categorized as normal and all studies categorized as suspicious and benign were submitted to two blinded radiologists who independently classified each study into one of the aforementioned categories. ResultsThe noncontrast images for 475 subjects were blindly reviewed. When compared to the computed tomographic urography reports, the negative predictive values of noncontrast images were 97.25% and 94.92% for radiologist 1 and radiologist 2, respectively, with an associated specificity of 88.6% and 97.95%. Of the 5 true upper tract malignancies, both blinded radiologists correctly identified 4 of the 5. ConclusionContrast imaging added little diagnostic value when compared with noncontrast imaging for most subjects undergoing initial evaluation for asymptomatic microscopic hematuria. Less-intensive imaging with nonenhanced computed tomography could reduce the nontrivial risks associated with multiphasic contrast imaging but further work is necessary to identify risk-stratifying criteria.

Risk of Radiation from Computerized Tomography Urography in the Evaluation of Asymptomatic Microscopic Hematuria

The AUA (American Urological Association) guidelines for asymptomatic microscopic hematuria recommend that patients undergo computerized tomography urography, which is associated with high doses of ionizing radiation. To our knowledge the associated risk of secondary malignancy and mortality remains unknown. We modeled the risk of malignancy and associated mortality due to ionizing radiation from computerized tomography urography relative to the additional diagnostic benefit offered over renal ultrasound. We performed a PubMed® based literature search to identify model inputs. We obtained estimates of age and gender specific radiation induced secondary malignancy and mortality rates from the BEIR (Biologic Effects of Ionizing Radiation) VII Phase 2 report with dose extrapolation using the linear no threshold model. Patients with asymptomatic microscopic hematuria had a 0.053% and 0.48% prevalence of upper tract urothelial carcinoma and renal cell carcinoma, respectively. Ultrasound had 77% sensitivity for upper tract urothelial carcinoma and 82% sensitivity for renal cell carcinoma. The effective radiation dose of computerized tomography urography was 31.7 mSv. Based on these inputs a population of 100,000 patients with asymptomatic microscopic hematuria would include 53.1 and 478 patients with upper tract urothelial carcinoma and renal cell carcinoma, respectively. On ultrasound alone 98.2 cases of upper urinary tract malignancy would be missed. An additional 149 cases of secondary malignancy would be caused by computerized tomography urography associated radiation with 101 fatalities. A total of 1,018.3 computerized tomography urography studies would need to be performed to detect an additional case of upper tract malignancy. Based on current risk models computerized tomography urography for asymptomatic microscopic hematuria may be associated with a small but significant risk of secondary malignancy relative to the additional diagnostic benefit offered.

What Is New in Evaluation of Asymptomatic Microscopic Hematuria in Women?: Best Articles From the Past Year.

This month we focus on current research in asymptomatic microscopic hematuria. Dr. Kenton discusses four recent publications, which are concluded with a "bottom line" that is a take-home message. A complete reference for each can be found on on this page along with direct links to abstracts.

Asymptomatic microscopic hematuria as a predictor of neoplasia in the urinary tract

Objective: The Danish hematuria guidelines were revised in January 2016. Before revision, it was recommended that asymptomatic microscopic hematuria in patients more than 40 years old should be routinely urologically investigated. In the revised guidelines, patients with asymptomatic microscopic hematuria are not recommended to be investigated, irrespective of age. The purpose of this study was to investigate whether asymptomatic microscopic hematuria was predictive of neoplasia of the urinary tract in a referred cohort of patients.Methods: All patients older than 40 years referred from primary care to private clinics and public hospitals in the Central Denmark Region for evaluation of asymptomatic microscopic hematuria in a 2 year period from January 2014 to December 2015 were included retrospectively. All patients had been routinely investigated with computed tomography urography and outpatient flexible cystoscopy. Patients’ age and gender were recorded and the final diagnosis after full investigation was retrieved.Results: In total, 1305 patients (492 males and 813 females) were included. Eleven patients (0.8%) were diagnosed with neoplasia in the urinary tract, including non-invasive Ta bladder tumor (n = 6), benign tumors in the kidney (n = 2), invasive bladder cancer (n = 2) and carcinoma in situ in the urinary bladder (n = 1). None of the patients had renal cancer or upper urinary tract tumors as the final diagnosis.Conclusion: A minority of patients with malignancies or non-invasive tumors would have been missed based on the revised Danish hematuria referral pathways.

Cost-effectiveness of Common Diagnostic Approaches for Evaluation of Asymptomatic Microscopic Hematuria

Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary (GU) malignant abnormality. Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of GU malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach. To estimate the effectiveness, costs, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH. A decision-analytic model-based cost-effectiveness analysis using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included adult patients with AMH on routine urinalysis with subgroups of high-risk patients (males, smokers, age ≥50 years) seen in the primary care or urologic referral setting. Four diagnostic approaches were evaluated relative to the reference case of no evaluation: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined. At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH. Of the 4 diagnostic approaches analyzed, CT alone was dominated by all other strategies, detecting 221 cancers at a cost of $9 300 000. Ultrasound and cystoscopy detected 245 cancers and was most cost-effective with an ICCD of $53 810. Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6 480 484. Ultrasound and cystoscopy remained the most cost-effective approach in subgroup analysis. The model was not sensitive to any inputs within the proposed ranges. Using probabilistic sensitivity analysis, ultrasound and cystoscopy was the dominant strategy in 100% of simulations. The combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the initial evaluation of AMH. The use of ultrasound in lieu of CT as the first-line diagnostic strategy will optimize cancer detection and reduce costs associated with evaluation of AMH. Given our findings, we need to critically evaluate the appropriateness of our current clinical practices, and potentially alter our guidelines to reflect the most effective screening strategies for patients with AMH.

Assessing the Costs of Extraurinary Findings of Computed Tomography Urogram in the Evaluation of Asymptomatic Microscopic Hematuria

To assess the costs associated with incidental extraurinary findings on computed tomography urogram (CTU) in patients with asymptomatic microscopic hematuria. A retrospective review was performed to identify all CTUs performed for asymptomatic microscopic hematuria at our institution from 2012 to 2014. All genitourinary (GU) and incidental extraurinary findings were documented. Further clinical follow-up to May 2015 was reviewed to determine if any referrals, tests, imaging, and/or procedures were ordered based on the initial CTU. Cost estimates were determined using the Medicare physician reimbursement rate. Two hundred two patients were evaluated with CTU for asymptomatic microscopic hematuria. GU malignancy was documented in 2 patients (0.99%), both renal masses suspicious for renal cell carcinoma. Sixty patients were found to have kidney stones, of which 26 had stones ≥5 mm. Incidental extraurinary findings were found in 150 (74.3%) patients, requiring further imaging costs of $17,242 or $85.35 per patient screened. Twelve patients required a total of 20 procedures for a cost of $54,655. The total cost related to extraurinary findings was $140,290 or $694.50 per initial patient screened. The incidental extraurinary findings detected on CTU can lead to expensive and invasive testing and treatment. Whereas costs associated with further workup were high, the overall outcomes in both GU and non-GU cancer diagnosis were low. Future analysis should focus on limiting the cost and invasiveness of our evaluation for this condition.

Asymptomatic microscopic hematuria in women requires separate guidelines

The guidelines recently updated by the American Urological Association for the evaluation of asymptomatic microscopic hematuria (AMH) are based on data derived predominantly from men. They cannot be reliably applied to females as the epidemiology of AMH is gender dependent. The research on women in this area has been limited. It is incumbent on the experts in the field of female pelvic medicine to advance the science and develop management algorithms for AMH in women.

Asymptomatic microscopic hematuria

To examine the 2001 American Urological Association (AUA) recommendations for the evaluation of asymptomatic microscopic hematuria (AMH) in light of the most recent studies available. AMH is a nonspecific marker of disease, but can also be found in healthy individuals. The research done seeks to better identify those patients who present with AMH and have a clinically significant disease. These investigations include epidemiological studies that describe populations at risk, define clinically significant hematuria, and provide long-term follow-up to patients with AMH. Authors have examined the validity and effectiveness of recommended and nonrecommended tests for AMH in different populations. Finally, several studies looked into what workup, if any, patients with AMH were receiving in the community. The evaluation of female patients with AMH needs to be tailored to the individual patient's presentation and risk factors. This evaluation should be timely and always include testing of both upper and lower urinary tract. After a complete negative assessment, no further follow-up is needed.

Editorial Comment

Asymptomatic microscopic hematuria (AMH) is a vexing problem for clinicians. Around 10%-15% of adults will have AMH during their lifetime and the American Urological Association Best Practice Policy recommends cystoscopy for all adults aged >40 years with microscopic hematuria and for those aged <40 years with risk factors for developing bladder cancer. 1 Grossfeld G.D. Litwin M.S. Wolf J.S. 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: 599-603 Abstract Full Text Full Text PDF PubMed Google Scholar , 2 Grossfeld G.D. Litwin M.S. Wolf Jr, J.S. 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: 604-610 Abstract Full Text Full Text PDF PubMed Google Scholar Despite these guidelines, many primary care physicians fail to refer patients with AMH for evaluation. 3 Nieder AM, Lotan Y, Nuss GR, et al. Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urol Oncol, in press. Google Scholar One of the problems is the low risk of bladder cancer (2%-5%) and even lower risk of renal cancer, and the absence of tools to risk stratify patients based on likelihood for malignancy. The guidelines dictate the same evaluation strategy for all patients despite known differences in risk based on age, gender, ethnicity, smoking history, and environmental exposures. Utility of Urine Cytology in the Workup of Asymptomatic Microscopic Hematuria in Low-risk PatientsUrologyVol. 75Issue 6PreviewTo evaluate performance and cost-effectiveness of voided cytology in patients with pure asymptomatic microscopic hematuria (AMH). Although voided cytology has been validated for use in patients with a history of urothelial carcinoma (UC), its use in low-risk patients with AMH is controversial. Full-Text PDF ReplyUrologyVol. 75Issue 6PreviewThe commentary for our aforementioned article rightfully asserts the significant dilemma with which urologists are faced when evaluating low-risk patients with asymptomatic microscopic hematuria (AMH). Investigations used can have direct impacts on the sensitivity of cancer detection, as well as the overall cost of evaluation.1 Avoiding unnecessary investigation without affecting care is paramount. Although we support the use of AUA recommendations for AMH,2 which are designed to minimize under diagnosis, our series underscores the unproven nature of cytology in this specific population. Full-Text PDF

Intravenous Urography in Evaluation of Asymptomatic Microscopic Hematuria

In 2001, the American Urologic Association Best Practice Policy Panel recommended CT or intravenous urography (IVU) over ultrasonography as the initial imaging modality in patients with asymptomatic microhematuria. We here present results of a study initiated many years ago and completed prior to 2001 that provides information pertinent to the use of IVU as the initial imaging modality for such patients. This study compared the results of IVU and ultrasonography in patients 40+ years of age who were referred to a single urology department for evaluation of microscopic hematuria between 1994 and 2000. There were 290 patients who agreed to participate by undergoing ultrasonography in addition to IVU; 247 completed both tests. There were 81 men and 166 women with a mean age of 56.4 years (range 40-86 years). Thirty patients (12%) were smokers. A renal lesion or mass suggestive of tumor was found in 8 patients (3.2%); 3 patients had this finding on the IVU examination and 5 on ultrasonography. None of the patients had such a lesion/mass on both examinations. Two patients with suspect lesions were ultimately found to have renal-cell carcinoma. Both of the patients with renal cancer had a suspect lesion on the ultrasound examination but not on the contemporaneous IVU. Intravenous urography may miss lesions/masses that lead to a diagnosis of upper-tract neoplasia.

Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—part I: definition, detection, prevalence, and etiology

Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—part I: definition, detection, prevalence, and etiology

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

P I of this report (preceding article) addressed the definition, detection, prevalence, and etiology of asymptomatic microscopic hematuria. This section of the best practice policy (Part II) is intended to serve as guidance to urologists and primary care physicians with respect to the evaluation of adult patients who may have asymptomatic microscopic hematuria. Recommendations for a nephrology evaluation and for patient follow-up are provided.

The value of cystoscopy as an initial diagnostic modality for asymptomatic microscopic hematuria.

For the patients who visit outpatient clinics due to asymptomatic microscopic hematuria, cystoscopy has been looked upon as rather invasive compared to other diagnostic methods. We tried to elucidate the actual diagnostic value of cystoscopy in the initial evaluation of asymptomatic microscopic hematuria. We reviewed the results of cystoscopic examinations in 213 patients who visited our hospital due to asymptomatic microscopic hematuria. No definite lesion that could explain the microscopic hematuria was detected by means of IVP, urine cytology, and other nephrologic evaluations for all the patients. Among the abnormal cystoscopic findings in 55 patients, the lesions suspected to be directly related to microscopic hematuria were classified as 'significant lesions' (31 patients, 17.6%) which include entities such as bladder cancer (1.31%). 27 of 31 patients with significant lesions (85.2%) were over 50 yr old, and furthermore, 3 patients who were diagnosed as bladder tumor by cystoscopy were over 60 yr. Cystoscopy should be utilized as initial diagnostic modality in older patients with asymptomatic microscopic hematuria to rule out any possibility of bladder cancer occurrence. Further studies are needed to justify implementation of cystoscopy as an initial diagnostic modality in younger patients with asymptomatic microscopic hematuria.

Limited evaluation of microscopic hematuria in pediatrics.

The purpose was to determine the value of the standard laboratory and radiologic evaluation of microscopic hematuria in children, and to determine the prevalence of idiopathic hypercalciuria in those children referred for evaluation of unexplained microscopic hematuria. This was a retrospective study of 325 children referred from 1985 to 1994 for the evaluation of asymptomatic microscopic hematuria. The diagnostic studies reviewed included serum creatinine, blood urea nitrogen, serum electrolyte studies, serum complement concentration, antinuclear antibody, urinalysis, urine calcium to creatinine ratios, urinary protein to creatinine ratio and/or 24-hour urinary protein excretion, renal ultrasounds, intravenous pyelograms, voiding cystourethrograms, and historical information. All creatinine and electrolyte values were normal for age, and none of the biochemical tests obtained in the children with hypercalciuria was abnormal. Of the 325 patients with idiopathic microscopic hematuria, only 18 had abnormal renal ultrasound examinations and 9 voiding cystourethrograms showed low-grade reflux. Hypercalciuria was found in 29 patients. The family history was positive for urolithiasis in 16% of patients without hypercalciuria compared with 14% of patients with hypercalciuria. A positive family history of hematuria was reported in 25% of patients; 62 patients did not have hypercalciuria and 4 of the patients had hypercalciuria. Microscopic hematuria in children is a benign finding in the vast majority of children. Our data demonstrate that a renal ultrasound, voiding cystourethrogram, cystoscopy, and renal biopsy are not indicated in the work-up of microscopic hematuria, and microhematuria in the otherwise healthy child is a minimal health threat, rarely indicative of serious illness.