Critical Analysis of the AUA 2020/2025 Microscopic Hematuria Guidelines to Predict Urothelial but Not Renal Cortical Neoplasms and Validation of the Individual Clinical Components in Risk Stratification for Urothelial Neoplasms but Not Renal Cortical Neoplasms

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PURPOSE: To evaluate the performance of the AUA 2025 guidelines stratification process in patients with microscopic hematuria (MH) to predict urothelial and renal cortical neoplasms and to assess the specific clinical components used in this stratification. MATERIALS AND METHODS: This retrospective study analyzed 4550 patients with asymptomatic MH, evaluated from 2010 to 2023 who underwent both imaging and cystoscopy. Patients were classified into risk groups based on the AUA 2025 guidelines to predict the presence of total neoplasms, specifically urothelial and renal cortical neoplasms and to validate the specific clinical components used in the guidelines. RESULTS: Among the 4550 patients, the overall neoplasm incidence was 3.1%, with urothelial neoplasms at 1.5% and renal cortical neoplasms at 1.6% (1.3% angiomyolipomas [AML] and 0.35% non-AML renal masses). High-risk patients had a higher incidence of urothelial malignancy (3.8%) compared with intermediate-risk and low-risk patients (0.8% and 0.2%, respectively), while the incidence of renal neoplasms of any type was not significantly different across risk groups. Significant predictors of urothelial malignancies included age, male gender, smoking pack years, and urinary red blood cells count, validating the AUA 2025 guidelines. However, only male gender and smoking history but not degree of hematuria or pack years of smoking predicted non-AML renal tumors. In the recent amendment, women were not classified as high risk based on age ≥60, but this study noted that women ≥70 had an incidence of bladder cancer at 2.2%. CONCLUSIONS: The AUA 2025 guidelines effectively stratify patients with MH into risk groups for urothelial cancer but not renal cortical neoplasms of any kind. Furthermore, the variables used in the construction of this model were also validated for urothelial cancers but not renal neoplasms. In this study, women older than 70 years have an incidence of urothelial cancer of 2.2%, suggesting that women older than 70 years should be considered high risk. The lack of predictive value for renal cortical neoplasms suggests areas for guideline realignment, specifically the type and goal of renal imaging.

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