Evaluation of the 2020 American Urological Association Microscopic Hematuria Guidelines in Clinical Practice:...

Hematuria is one of the most common urologic diseases seen within clinical practice, with a prevalence range of 1.7%-31.1%. In 2020, American Urological Association (AUA) guidelines were revised and recommend that following initial evaluation, clinicians should categorize patients into three tiers (low risk, intermediate risk, and high risk) based on various factors. Recent literature has shown that the AUA guidelines have high clinical utility when compared to other international guidelines such as those outlined by the Hematuria Risk Index, Canadian Urological Association, and Kaiser Permanente; however, this guideline remains unvalidated among the population of "well adults" within the United States.

We used a retrospective study design to evaluate data abstracted from the electronic medical records of patients seen in the Emory Healthcare Executive Health Clinic from September 29, 2017, to January 29, 2021, to investigate the utility of risk stratification as a tool for clinical decision-making.

According to the AUA risk stratification system, patients were stratified into low-risk and intermediate-risk/high-risk groups based on sex, age, smoking history, history of gross hematuria, and red blood cells/high-powered field. The frequencies and percentages of different causes of hematuria across the three risk strata were reported.

Of the 882 instances of red blood cells in urine (URBC) ≥3, a total of 368 (41.72%) underwent a repeat analysis within a 6-month time span, 184 (20.86%) within a 12-month time span, and 330 (37.41%) at >12 months. Instances of a URBC <3 (N=1643) were more likely to have no urologic diagnosis-1503 (91.48%) in comparison to 633 (76.27%) for those instances with a URBC >3 (N=830). Ultimately, 23 (100%) participants in the low-risk group had no urologic diagnosis after urinalysis versus 608 (75.62%) in the intermediate-risk/high-risk group (N=804).

We found a need for a greater focus on monitoring elevated URBC counts, in accordance with clinical guidelines for managing hematuria in low-risk patients. Future research should examine the impact of risk stratification on clinical decisions and access to care, especially in underserved populations. It should also assess how the new AUA guidelines affect physician referral patterns and explore real-world implementation challenges and facilitators.