Microhematuria

ADULT UROLOGY

A NEW DIAGNOSTIC ALGORITHM FOR THE EVALUATION OF MICROSCOPIC HEMATURIA
JAMISON S. JAFFE, PHILLIP C. GINSBERG, RAJI GILL,
AND

RICHARD C. HARKAWAY

ABSTRACT Objectives. To evaluate a new diagnostic algorithm for microscopic hematuria in which intravenous urography (IVU) is performed as a secondary radiographic study when microhematuria has persisted for 3 months after theinitial workup with renal ultrasound (US) and cystoscopy was negative. Methods. We evaluated 372 consecutive patients who presented with microhematuria and negative urine cultures and cytologic findings at our institution. All patients underwent renal US scanning and cystoscopy as their initial evaluation. All patients underwent re-evaluation 3 months after the initial workup. Patients withpersistent microhematuria with no apparent etiology were then evaluated with IVU. Results. The initial evaluation was negative in 212 of 372 patients. Eighty-one of these patients had persistence of their microhematuria at the 3-month follow-up without a definitive diagnosis. Seventy-five of these patients underwent IVU. Abnormalities were found in 11 of the 75 patients. Six patients had renal stones, twohad ureteral stones, two had ureteral tumors, and one had a tumor of the renal pelvis. Forty of the 131 patients with resolution of their microhematuria underwent IVU at their request. All those studies were normal. Conclusions. The combination of cystoscopy and renal US along with urinalysis, urine culture, and cytology is a good initial evaluation in patients with microhematuria. Those patientswith persistent microhematuria after 3 months without definite etiology of the bleeding may still benefit from IVU. UROLOGY 57: 889–894, 2001. © 2001, Elsevier Science Inc.

symptomatic microhematuria is a common clinical problem that has a 1% to 13% prevalence in adults.1 Multiple etiologies exist for microhematuria, ranging from insignificant lesions to potentially life-threatening neoplasticlesions.2 Clinical evaluation is mandatory to exclude an underlying genitourinary malignancy.3 The established urologic evaluation has undergone little change during the years and consists of urinalysis with culture, cytology, cystoscopy, and an upper tract radiologic study such as intravenous urography (IVU).3 With the advent of ultrasound (US) and axial computed tomography, questions have been raisedregarding the role of these radiologic modalities in the evaluation of microhematuria. IVU has historically been the initial radiologic study for the evaluation of the upper tracts in paFrom the Division of Urology, Department of Surgery, Albert Einstein Medical Center, Philadelphia, Pennsylvania Reprint requests: Richard C. Harkaway, M.D., Albert Einstein Medical Center, Klein Professional OfficeBuilding, Suite 500, 5401 Old York Road, Philadelphia, PA 19141 Submitted: June 14, 2000, accepted (with revisions): December 8, 2000 © 2001, ELSEVIER SCIENCE INC.
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tients with hematuria. However, the value of IVU in the evaluation of the upper urinary tract has been questioned.4 –7 US has proved to be sensitive in detecting masses, cysts, and hydronephrosis in thekidney.8 –10 Because US is more sensitive in detecting the more common renal cell carcinoma (RCC) than in detecting the elusive urothelial transitional cell carcinoma (TCC) compared with IVU, we designed a prospective preliminary study to determine whether US can replace IVU in the initial evaluation of patients who present with asymptomatic microhematuria.11 MATERIAL AND METHODS
We evaluated 400consecutive patients who presented with asymptomatic microhematuria between January 1997 and January 2000. The study was approved by the Human Subject Review Board, and all subjects who participated in the study completed an informed consent form that had been explained to them by an attending urologist. Microhematuria was defined as greater than 2 red blood cells per high power field (HPF)....