AUAUniversity Podcast: AUA Guidelines Amendment on Microhematuria (May 28, 2025)

Host: Jay Raman, Professor of Urology at Penn State Health and Chair of the AUA's Office of Education
Guests:

• Dr. Steve Borjian, Chair of Urology at Mayo Clinic
• Dr. Dan Baroccas, Executive Vice Chair at Vanderbilt University Medical Center

Introduction to Guideline Amendments

Dr. Jay Raman opened the episode by emphasizing the importance of keeping clinical guidelines up-to-date with evolving research. He introduced the topic of the 2025 Microhematuria Guidelines Amendment and welcomed Dr. Steve Borjian and Dr. Dan Baroccas to discuss the latest changes and their implications.

Process of Guideline Amendments

Dr. Steve Borjian outlined the structured process the American Urological Association (AUA) follows to ensure guidelines remain relevant:

• Literature Reviews: Conducted every 24 to 36 months post the previous guideline release, with potential acceleration to 12-18 months in rapidly evolving fields like oncology.

  "The AUA process is to do updated literature reviews Somewhere between 24 and 36 months after a guideline is released..."
  [01:40] – Dr. Steve Borjian

• Assessment and Decision-Making: A panel reviews new evidence to determine if updates are needed. This could range from minor text revisions to substantial amendments introducing new actionable recommendations.

Understanding Microhematuria: Scope and Importance

Dr. Dan Baroccas provided a comprehensive overview of microhematuria:

• Prevalence: Detectable in approximately 6.5% of asymptomatic populations, varying based on risk factors.

  "Microhematuria is exceedingly prevalent...around six and a half percent on average."
  [04:18] – Dr. Dan Baroccas

• Clinical Significance: It's a leading reason for urology referrals, presenting a public health challenge due to inconsistent evaluation practices—ranging from under-evaluation in high-risk individuals to over-evaluation in low-risk populations.

• Historical Guidelines: The 2012 guidelines recommended a uniform evaluation for all individuals over 35 with ≥3 red blood cells (RBCs) per high power field (HPF). However, this approach didn't account for varying malignancy risks based on individual patient factors.

Evolution to Risk-Based Stratification

Transitioning from a one-size-fits-all approach, the 2020 guidelines introduced risk stratification, categorizing patients into low, intermediate, and high-risk groups based on factors like age, gender, smoking history, and RBC count.

Dr. Jay Raman noted the initial shift towards risk-based assessment but highlighted the need for further refinement:

"...the risk groups had not perhaps been validated or at least investigated to how well are they associated with levels of malignancy..."
[08:14] – Jay Raman

Enhancements in the 2025 Guidelines Amendment

1. Low Negligible Risk Group:

• Redefinition: Previously termed "low risk," this group is now classified as "low negligible risk" due to an identified malignancy risk in the fractions of a percentage.

  "...these patients should be offered a repeat urinalysis within six months."
  [13:03] – Dr. Steve Borjian

• Evaluation Approach: Instead of immediate invasive evaluations like CT urograms or cystoscopies, patients are advised to undergo a repeat urinalysis after six months. Persistent hematuria would then elevate their risk category, guiding subsequent evaluations.

2. Intermediate Risk Group:

• Risk Estimate: Approximately 1-2% risk of malignancy.

  "I think 1 to... 2% is a good ballpark for that group."
  [26:21] – Dr. Dan Baroccas

• Guideline Changes:

  • Recommendation Language: Transitioned from "should perform" to "should recommend" for cystoscopy and renal ultrasound, promoting shared decision-making.

  • Introduction of Urine-Based Tumor Markers: Offers an alternative to cystoscopy for patients wishing to avoid the procedure, contingent on negative tumor marker results.

    "...patients that have been classified as low negligible risk should not be initially evaluated, but should be reevaluated with a urine analysis within six months..."
    [13:03] – Dr. Steve Borjian

• Safety Nets: Mandates repeat urinalysis within a year and renal ultrasound irrespective of cystoscopy decisions to ensure malignancies are not overlooked.

3. High-Risk Group:

• Risk Estimate: Approximately 3-8% risk of malignancy.

  "For the high risk, 5%. Roughly. Those are good ballpark numbers."
  [27:39] – Jay Raman

• Guideline Adjustments:

  • Gender-Specific Risk Adjustment: Women are no longer classified as high risk solely based on age (≥60 years). High-risk classification now requires additional factors like gross hematuria or significant smoking history (>30 pack-years).

    "Now that women are lower risk, but also should not be dismissed because their risk of mortality...is actually higher than men."
    [25:40] – Dr. Dan Baroccas

Imaging Modalities: Ultrasound vs. CT Urogram

Dr. Dan Baroccas discussed the rationale behind choosing renal ultrasound over CT urograms in certain risk groups:

• Renal Ultrasound: Preferred for its cost-effectiveness and lower risk profile, especially in intermediate and low-risk patients where the prevalence of upper tract urothelial carcinoma is minimal.

  "CT is superior to renal ultrasound for detection of upper tract urothelial carcinoma...not cost effective...negligible probability of increasing sensitivity for identification of a malignancy."
  [21:27] – Dr. Dan Baroccas

• CT Urogram: Reserved for high-risk individuals due to its higher sensitivity but accompanied by increased costs and radiation exposure.

Role of Urine-Based Tumor Markers and Cytology

The introduction of urine-based tumor markers in the 2025 guidelines provides a non-invasive option for risk assessment in intermediate-risk patients:

• Application: Allows patients hesitant about cystoscopy to undergo tumor marker testing, potentially reducing the need for invasive procedures if markers are negative.

  "...we may offer urine based tumor markers or cytology to help facilitate the decision regarding cystoscopy."
  [15:23] – Dr. Steve Borjian

• Limitations: Currently not recommended for routine use in high or low-risk groups. Its primary utility lies within the intermediate-risk stratification, aiding shared decision-making.

Future Directions and Considerations

Dr. Steve Borjian:

• Refinement of Risk Stratification: Anticipates continuous validation and adjustment of risk categories as more data emerges, potentially integrating new biomarkers.

  "Continual refinement of the risk stratification...as data come out from additional markers..."
  [30:57] – Dr. Steve Borjian

• Implementation Science: Emphasizes the importance of translating guidelines into clinical practice, ensuring primary care and other specialists are aligned with urological recommendations.

Dr. Dan Baroccas:

• Laboratory Variability: Highlights the need to standardize hematuria measurements across laboratories, especially with the shift to automated cell counters.

  "It's time to validate and determine what is the true risk of malignancy based on the output of these automated cell counters."
  [33:08] – Dr. Dan Baroccas

• Post-Evaluation Management: Calls for more data on managing patients post-negative evaluations, including optimal follow-up intervals and the necessity of re-evaluations.

Conclusion

The 2025 amendment to the AUA Microhematuria Guidelines represents a significant stride towards personalized medicine in urology. By refining risk stratification and incorporating patient preferences in the evaluation process, these guidelines aim to enhance diagnostic accuracy while minimizing unnecessary interventions. Future efforts will focus on further validating these risk models, integrating new diagnostic tools, and ensuring widespread adherence to optimize patient outcomes.

This summary encapsulates the key discussions and insights from the AUAUniversity podcast episode on the 2025 Microhematuria Guidelines Amendment. For more detailed information, listeners are encouraged to access the full episode through the AUAUniversity platform.