Diagnostic Yield of Upper-Tract Imaging in Visible Haematuria: A Single-Centre Retrospective Clinical Audit

Introduction Visible haematuria (VH) is a common presenting symptom of urological malignancy, yet the optimal upper-tract imaging modality remains debated. Recent Getting It Right First Time (GIRFT) Greener Pathway guidance recommends ultrasound as the first-line investigation, reserving CT urogram (CTU) for high-risk patients. Our District General Hospital (DGH) currently performs CTU for all VH patients, regardless of risk factors, with adequate renal function. This audit aimed to evaluate the diagnostic yield of upper-tract imaging in our local VH pathway and to review our current local haematuria protocol. Methods A retrospective audit was conducted at a UK DGH of all consecutive patients referred to a nurse-led Haematuria Telephone Assessment Clinic with VH between 15 June and 15 September 2025. Data on demographics, clinical factors, cystoscopy findings, and upper tract imaging results were collected from electronic medical records. Descriptive statistics were used to evaluate the diagnostic outcomes of upper tract imaging. Results In this cohort study, the median age was 69 years old and patients were predominantly male (75%, n=75). Out of the 91 cystoscopies performed, four patients (4.3%) had a diagnosis of bladder cancer. All 100 patients underwent upper tract imaging with potentially malignant findings detected in 18% (n=18) of patients: three renal masses, five ureteric abnormalities, nine bladder findings, and one advanced prostate cancer in known metastatic disease. Among those with ureteric findings, four patients underwent further investigations which came back negative for malignancy. The last remaining patient was deemed too frail and was managed expectantly. Other benign pathologies included urolithiasis (16%, n=16), pyelonephritis (1%, n=1), renal cysts (7%, n=7) and pelvi-ureteric junction obstruction (1%, n=1). Conclusion While CTU effectively identifies upper tract pathology in VH, its diagnostic yield in upper tract malignancy remains low. The use of CT needs to be balanced against its diagnostic yield, patient safety and environmental impact. Local adoption of the new GIRFT guidelines in our DGH still needs to be reviewed as formulating an adequate risk-based approach for upper tract imaging requires further discussion. Further prospective, multicentre studies are required to refine evidence-based imaging pathways for VH.