Discrepant guidelines in the evaluation of hematuria

To assess discrepancies in current imaging recommendations for hematuria among North American societies: American College of Radiology (ACR), American Urological Association (AUA), and Canadian Urological Association (CUA).

The latest available ACR Appropriateness Recommendations, AUA guidelines, and CUA guidelines were reviewed. AUA and CUA guidelines imaging recommendations by variants and level of appropriateness were converted to match the style of ACR. Imaging recommendations including modality, anatomy, and requirement for contrast were recorded.

Clinical variants included microhematuria without risk factors, microhematuria with risk factors, gross hematuria, and microhematuria during pregnancy. CUA recommends ultrasound kidneys as the first-line imaging study in the first 3 variants; pregnancy is not explicitly addressed. For hematuria without risk factors, ACR does not routinely recommend imaging, while AUA recommends shared decision-making to decide repeat urinalysis versus cystoscopy with ultrasound kidneys. For hematuria with risk factors and gross hematuria, ACR recommends CT urography; MR urography can also be considered in gross hematuria. AUA further stratifies intermediate- and high-risk patients, for which ultrasound kidneys and CT urography are recommended, respectively. For pregnancy, ACR and AUA both recommend ultrasound kidneys, though AUA additionally recommends consideration of CT or MR urography after delivery.

There is no universally agreed upon algorithm for diagnostic evaluation. Discrepancies centered on the role of upper tract imaging with ultrasound versus CT. Prospective studies and/or repeat simulation studies that apply newly updated guidelines are needed to further clarify the role of imaging, particularly for patients with microhematuria with no and intermediate risk factors.