Introduction: The 2020 AUA guidelines have brought some cost and potentially morbidity-saving changes to the workup and treatment of microhematuria (MH). With these changes comes a call for validating evidence. Herein the new guidelines have been applied to 1,906 patients.
Methods: All patients diagnosed with MH (RBC =3/hpf) at a single institution between 2010 and 2019 were retrospectively analyzed. Those with a complete workup including cystoscopy and upper tract imaging within 1 year of diagnosis were included. The new 2020 risk stratification was applied and cancer detection rates by risk group were assessed. A basic cost analysis was performed using the Centers for Medicare & Medicaid Services Physician and Clinical Laboratory Fee Schedule for 2021.
Results: Of the total MH cohort (n=1906), 1010 patients were stratified as high risk according to the 2020 guidelines. 770 of the 1010 (76.3%) had cross sectional imaging as part of their workup. Overall, 28 neoplasms were diagnosed in this patient group which corresponds to a detection rate of 2.77%. Of the 28 neoplasms identified, 18 were bladder tumors, 2 were upper tract urothelial malignancies and 8 were solid renal neoplasms. Cross-sectional imaging identified a total of 10 upper tract neoplasms (urothelial and renal) which corresponds to a 1.30% (10/770) detection rate. Furthermore, of the 8 solid renal masses, only 3 were of sufficient radiologic concern to warrant upfront surgical treatment. Additionally, 3 of these 8 patients had renal US in addition to their CT, 2 out of these 3 identified the solid renal mass. Cost analysis suggests that replacement of CT urography with renal US could decrease cost of workup by 38% ($433.04 vs $703.43).
Conclusions: Cross sectional imaging in 770 patients with High-risk MH by the 2020 AUA guidelines yielded a detection rate of only 1.30% for upper tract neoplasms. Only 2 of these were urothelial malignancies that may not have been picked up via renal ultrasonography. Assuming most significant solid renal lesions could be identified by renal US, the utility of cross-sectional imaging is a positive finding in less than 1% of CT scans in this population. These data suggest that cross-sectional imaging may be unnecessary in the workup of MH, even in high-risk patients.
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