Decision Curve Analysis–Based Risk‐Adaptive Strategy for Individualizing Cystoscopy Decisions in Patients With Primary Microscopic Hematuria

ABSTRACT Objectives To develop a decision curve analysis (DCA)–based risk‐adapted strategy that includes risk factors and aids clinical decision‐making to avoid unnecessary cystoscopy in patients with primary microscopic hematuria (MH). Material and Methods Data of 846 consecutive patients who underwent cystoscopy due to microscopic hematuria between September 2022 and April 2024 at a single center were prospectively collected and retrospectively analyzed. MH was defined as 3 or more erythrocytes per magnification in urine analysis. Strategies were developed according to the results of univariate and multivariate analyses. For each strategy, avoided unnecessary cystoscopy and missed bladder tumor ratios were detected. DCA was used to statistically compare the net benefits of each strategy. Results Tumors were detected in the bladder in 66 patients (7.8%). Multivariate analysis identified smoking status, pack‐years of smoking, and advanced age as risk factors for tumor detection, while concurrent lower urinary tract symptoms (LUTS) and a history of recurrent urinary tract infections (UTI)/prostatitis were associated with a decreased risk. DCA showed that the highest net benefit for detecting tumors in MH was achieved through cystoscopy in patients with > 10 pack‐years of smoking and/or no irritative LUTS. The next best strategies involved > 10 pack‐years of smoking and/or a history of macroscopic hematuria, and active smoking and/or no irritative LUTS, respectively. Conclusion DCA‐based risk‐adapted strategies aid in clinical decision‐making and reduce unnecessary interventions in patients scheduled for cystoscopy due to MH. These strategies can guide patients and clinicians regarding the advantages of avoiding cystoscopy and appropriate patient preferences.