Jennifer M. Taylor, MD, MPH

Jennifer M. Taylor, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine in Houston, Texas, begins by citing the original American Urological Association (AUA) Microhematuria Guideline from 2012, pointing out that the guideline was created in response to a major public health problem. She outlines the benefits and drawbacks of the original guideline, including the benefit that the AUA guideline would miss the fewest number of cancers versus other guidelines. The drawbacks included not being cost-effective, having low-yield and low specificity, being too aggressive for women and for those at low risk of malignancy, and having low rates of adherence. Dr. Taylor concludes that the 2012 guideline’s adverse impacts on patients were too great, citing discomfort, infections, false positives, and radiation exposure. Dr. Taylor then turns her discussion to the Microhematuria: AUA/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) Guideline 2020, which took a risk-based, patient-centered approach, aiming to minimize harm and the waste involved in over-evaluation for low-risk patients, thereby improving specificity in those patients while maintaining specificity for those at higher risk for disease. Goals of the 2020 guideline included improving adherence with a more judicious set of guidelines and harmonizing the guidelines to achieve clarity among diverse stakeholders. The systematic review took place between January 2010 and December 2019 and included an evidence base of five systematic reviews and 91 primary literature studies. Dr. Taylor explains that the 2020 guideline maintains that microhematuria is defined as a urinalysis (UA) showing at least three red blood cells per high-powered field (≥ 3RBC/HPF). Dr. Taylor expounds upon the updated guidelines in terms of initial evaluation, diagnosis, and follow-up before confronting the gender gap in bladder cancer diagnosis. She cites a study concluding that treatment without further evaluation in the year prior to a bladder cancer diagnosis occurred 19 percent of the time in men versus 47 percent of the time in women. Further, there were three or more treatments for urinary tract infection (UTI) prior to evaluation by a urologist in 3.8 percent of men versus 15.8 percent of women. Dr. Taylor calls this significant and calls for continued advocacy for fuller symptom evaluation. Dr. Taylor then breaks down risk stratification, emphasizing that risk is highly correlated with known risk factors for urothelial cancer and doctors can tailor the intensity of the patient evaluation based on those risk factors. She presents and explains low-, medium-, and high-risk patient characteristics and evaluation recommendations. Dr. Taylor summarizes the takeaways from the 2020 guideline. For low-risk patients, practitioners should employ shared decision-making with their patients, either opting to repeat the UA or conduct a cystoscopy and renal ultrasound; for intermediate-risk patients, practitioners should conduct a cystoscopy and renal ultrasound; and for high-risk patients, the guideline recommends a cystoscopy with axial imaging. Dr. Taylor emphasizes the importance of the cystoscopy in these evaluations before displaying a summary one-page outline of the 2020 guideline and algorithm.