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. 2025 Jun;131(8):1661-1669.
doi: 10.1002/jso.28148. Epub 2025 May 13.

Evaluating Cost-Effective Strategies for Asymptomatic Microhematuria Diagnosis: A Risk-Based Alternative to the American Urological Association Guidelines

Krishay Sridalla  1 , Hiten D Patel  2   3 , Dustin D French  4   5   6 , Joshua J Meeks  2   3 , Lili Zhao  7 , Yuying Xing  8 , David J Bentrem  1   3
Affiliations

Evaluating Cost-Effective Strategies for Asymptomatic Microhematuria Diagnosis: A Risk-Based Alternative to the American Urological Association Guidelines

Krishay Sridalla et al. J Surg Oncol. 2025 Jun.

Abstract

Background and objectives: The American Urological Association (AUA) guidelines recommend evaluating asymptomatic microhematuria (MH) at ≥ 3 red blood cells per high powered field (RBCs/hpf), resulting in significant costs with limited bladder cancer detections. This study evaluates alternative diagnostic strategies to improve the cost-effectiveness of asymptomatic MH evaluation.

Methods: The cost-effectiveness analysis compared three alternative strategies: Strategy 1 (cystoscopy at ≥ 26 RBCs/hpf) was compared to a 3 RBCs/hpf threshold, while Strategy 2 (cystoscopy and renal ultrasound at ≥ 3 RBCs/hpf) and Strategy 3 (cystoscopy and renal ultrasound at ≥ 26 RBCs/hpf) were compared to the AUA guidelines. Total costs, cost per patient evaluated, costs per cancer detected, and incremental cost-effectiveness ratios (ICERs) were calculated.

Results: Strategy 3 minimized costs without significantly reducing early cancer detection rates. It was cost-effective for females (ICER = $120,649) and the total sample (ICER = $50,648) but not specifically for males (ICER = $23,326). Strategies 1 and 2 yielded lower cost savings and were less efficient.

Conclusions: Strategy 3-performing cystoscopy and renal ultrasound for higher-risk patients ( ≥ 26 RBCs/hpf)-offers a more cost-effective approach than the AUA guidelines, particularly for women. Future studies should incorporate additional patient variables and diagnostic test characteristics.

Keywords: bladder cancer; cost‐effectiveness; cystoscopy; microhematuria.

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Figures

Figure 1
Figure 1
Total cancers detected initially and total diagnostic cost for T = 3 RBC/hpf and T = 26 RBC/hpf (Strategy 1). Abbreviations: F, females; M, males; RBC/hpf, red blood cells per high‐powered field.
Figure 2
Figure 2
Incremental cost per QALY gained for T = 26 RBC/hpf (Strategy 1) in comparison to T = 3 RBC/hpf. Abbreviations: F, females; M, males; QALY, quality‐adjusted life year; RBC/hpf, red blood cells per high‐powered field.
Figure 3
Figure 3
Total cancers detected initially and total diagnostic cost for AUA guidelines and Strategy 2. Abbreviations: AUA, American Urological Association; F, females; M, males.
Figure 4
Figure 4
Cancers detected per patient evaluated and diagnostic cost per cancer for AUA guidelines and Strategy 2. Abbreviations: AUA, American Urological Association; F, females; M, males.
Figure 5
Figure 5
Total cancers detected initially and total diagnostic cost for AUA guidelines and Strategy 3. Abbreviations: AUA, American Urological Association; F, females; M, males.
Figure 6
Figure 6
Cancers detected per patient evaluated and diagnostic cost per cancer for AUA guidelines and Strategy 3. Abbreviations: AUA, American Urological Association; F, females; M, males.
Figure 7
Figure 7
Incremental cost per QALY gained for Strategy 3 in comparison to AUA guidelines. Abbreviations: AUA, American Urological Association; F, females; M, males; QALY, quality‐adjusted life year.
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