Evaluating Hematuria: Uniform Use of CT Seen as Risky and Expensive

By Joe Elia

Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD

Strict adherence to guidelines that recommend uniform use of computed tomography (CT) to evaluate hematuria seems to cause radiation-induced cancers that erase CT's diagnostic advantage, a JAMA Internal Medicine study finds.

Researchers evaluated the benefits and harms of five guidelines. One, from the American Urological Association (AUA), recommends cystoscopy and CT urography in all cases of hematuria in patients aged 35 and up. Others, for instance Dutch and Canadian guidelines, recommend cystoscopy and ultrasonography (or no intervention) based on the patient's age and risk. Kaiser Permanente guidelines recommend CT only with gross hematuria.

In a theoretical sample of 100,000 patients with hematuria, the AUA's detection rate was highest (98%), while the Dutch rate was lowest (93%). However, radiation-induced cancers from CT amounted to 575 cases per 100,000 with the AUA approach, versus 108 with Kaiser's. In addition, the added cost of finding an additional cancer with the AUA approach relative to, say, the Kaiser approach, neared $1 million.

Commentators note that for now, "the best available evidence suggests that uniform use of CT for the initial evaluation of microscopic hematuria is ill advised."