What is the next step in evaluating microscopic hematuria in a 65-year-old asymptomatic smoker with negative cystoscopy and Computed Tomography (CT) urogram results?

Management of Persistent Microscopic Hematuria After Negative Initial Workup

For a 65-year-old asymptomatic smoker with 5 RBC/hpf on urinalysis and negative cystoscopy and CT urogram, the next appropriate step is urine cytology (option A). 1

Risk Stratification and Rationale

This patient presents with several high-risk factors for urologic malignancy:

• Age >60 years (65 years old)
• Smoking history (significant risk factor)
• Persistent microscopic hematuria (5 RBC/hpf)

Despite negative initial evaluation with cystoscopy and CT urogram, follow-up is essential because:

1. The American Urological Association (AUA) guidelines emphasize that some patients with negative initial evaluations for asymptomatic microhematuria eventually develop significant urologic disease 2

2. Follow-up is particularly important in high-risk groups, including:

   • Patients older than 40 years
   • Tobacco users
   • Those with occupational exposures 2

Appropriate Next Steps

Urine Cytology (Recommended)

• Urine cytology is the appropriate next step for this high-risk patient with persistent microscopic hematuria despite negative initial workup
• Cytology can detect malignant cells that may not be visible on cystoscopy, particularly for flat urothelial lesions or carcinoma in situ
• The AUA guidelines recommend some form of follow-up for patients with negative initial evaluations 2, 1

Why Other Options Are Not Appropriate:

• FISH assay (option B): While useful in some settings, this is not recommended as the next step after negative initial evaluation according to current guidelines 1

• Urinalysis in one year (option C): Insufficient for this high-risk patient; more immediate follow-up with cytology is warranted given the risk factors 2, 1

• Cytology in one year (option D): Too delayed for a high-risk patient with persistent hematuria; cytology should be performed now rather than delayed 1

• Repeat cystoscopy and CT urogram in one year (option E): Premature to repeat these invasive and radiation-exposing studies before performing cytology; research shows low diagnostic yield (1.2% for repeat cystoscopy, 1.3% for repeat imaging) in patients with negative initial workup 3

Follow-up Recommendations

If urine cytology is negative:

• Continue surveillance with repeat urinalysis at 6,12,24, and 36 months as recommended by the AUA 1
• Immediate re-evaluation if the patient develops:
  • Recurrent gross hematuria
  • Abnormal urinary cytology
  • New irritative voiding symptoms 1

Important Considerations

• Attributing hematuria solely to smoking without thorough evaluation is inappropriate
• The risk of malignancy remains elevated in this population even after negative initial workup
• Persistent microscopic hematuria in a 65-year-old smoker should never be dismissed without appropriate follow-up