While the AUA guidelines literature review panel will likely take a new paper about microhematuria into consideration, the AUA guideline process is the best we have and remains our gold standard.
As an AUA member and participant in the AUA guidelines process at multiple levels, I consider guidelines a very substantial member benefit. The 16 current guidelines provide guidance to the practicing urologist and represent a rigorous, evidence-based review of the literature, resulting in a peer-reviewed document that we should all be proud of.
I read with interest the article, “Microhematuria a poor predictor of urinary tract Ca” (page 8) discussing a recently published paper. The authors reviewed a cohort of 4,414 patients referred to urology for asymptomatic microscopic hematuria (AMH).
They then reviewed numerous risk factors to see if they were predictive for a diagnosis of urinary tract cancer. The overall cancer detection rate was 2.1% (88 malignancies), with gross painless hematuria in the last 6 months and age over 50 as the best predictors. The authors argue that by using these primary risk factors, about one-third of patients may avoid potential radiation hazards associated with the guideline-recommended workup for AMH.
While the authors provide food for thought, this study is essentially a chart review utilizing an EMR system. Several other limitations are worth noting. First, very few patients found in the authors’ EMR with two positive urinalyses were referred for evaluation (2.1%), leaving uncertainties about the true amount of pathology that may have been found. Second, approximately 50% of the patients underwent cystoscopy and were therefore incompletely evaluated. Finally, we don’t have long-term follow up, especially in high-risk individuals, or data on whether they developed future malignancies.
The authors state that none of the 19 statements in the recently updated AUA guidelines for the workup of AMH cite evidence strength above grade C. However, the guideline is only as good as the data available for review. AUA guideline experts reviewed evidence-based literature adequate for abstraction from an exhaustive review of 192 articles with peer review from another 30 reviewers. Further, 88 is not an inconsequential number of cancers, and although radiation exposure can lead to unwanted consequences, urothelial carcinoma can be lethal. Although I am sure the guidelines literature review panel will take this paper into consideration, our AUA guideline process is the best we have and remains our gold standard.
Dr. Thrasher, a Urology Times editorial consultant, is professor and chair of urology, University of Kansas Medical Center, Kansas City.
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