What are the next steps for a 65-year-old male smoker with microscopic hematuria and negative cystoscopy and computed tomography (CT) urogram?

Next Steps for a 65-Year-Old Male Smoker with Microscopic Hematuria and Negative Cystoscopy and CT Urogram

For a 65-year-old male smoker with microscopic hematuria and negative initial cystoscopy and CT urogram, the recommended next step is to implement a surveillance protocol with repeat urinalysis at 6,12,24, and 36 months, along with voided urine cytology at these intervals. 1

Rationale for Continued Surveillance

• The patient's risk factors (age >60 years, male sex, and smoking history) place him at high risk for urologic malignancy despite the negative initial evaluation 2
• Hematuria can precede the diagnosis of bladder cancer by many years, making continued monitoring necessary, especially in high-risk groups 1
• Although the risk of life-threatening lesions is low after a negative initial evaluation, some form of follow-up is indicated due to the potential for developing significant urologic disease 3, 1

Recommended Surveillance Protocol

• Repeat urinalysis at 6,12,24, and 36 months 1
• Include voided urine cytology at each follow-up interval 1
• Monitor blood pressure at each follow-up visit 1
• If hematuria persists for 3 years without any concerning developments, the patient does not require further urologic monitoring 1

Indications for Immediate Re-evaluation

• Immediate urologic re-evaluation with consideration of repeat cystoscopy, cytology, or imaging is warranted if any of the following occur:
  • Development of gross hematuria 1, 2
  • Abnormal urinary cytology 1
  • Development of irritative voiding symptoms in the absence of infection 1
  • Significant increase in the degree of microscopic hematuria 2

Additional Considerations

• Consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 4, 1
• Emphasize smoking cessation to reduce the risk of developing urologic malignancies 1, 2
• Educate the patient about the importance of completing the full surveillance protocol, even if symptoms resolve 1

Important Caveats

• The combination of age >60 years, male sex, and smoking history places this patient in a higher risk category, necessitating vigilant follow-up despite negative initial evaluation 2
• The risk of malignancy in patients with microscopic hematuria can be up to 5%, even with a negative initial evaluation 2
• Early detection of urologic malignancy significantly impacts mortality and morbidity, which is why continued surveillance is crucial 2
• Recent studies show a low but present risk of newly diagnosed malignancies (1.2-1.3%) among patients with persistent/recurrent asymptomatic microhematuria who had a prior negative workup 5