The optimal evaluation of non-visible haematuria (NVH) continues to be debated, with competing interests of avoidance underdiagnosis and the harms of over-testing. Current National Institute for Health & Care Excellent (NICE) guidance recommends referral for patients ≥60 years with NVH. The American Urological Association (AUA) guideline on microhaematuria were updated in 2020 and supports a risk-stratified approach to the diagnostic work-up. The UK DETECT I trial, which developed and externally validated a haematuria risk score, detected 11.4% more cancers which would have been missed by the NICE guidelines. Apart from cancer detection, the cost implications are also important but less well recorded. A retrospective modelling analysis of nearly 4000 patients from a single institution in Texas found that use of the updated AUA guidance would have detected cancers in 0.4%, 1.0% and 6.3% of low, intermediate and high-risk groups. The cost savings were in the tune of $600,000 compared to the 2012 guidelines, or per-cancer detection costs of $61,760 (2020) compared to $100,276 (2012). The substantial cost reduction was brought about mainly by use of ultrasound instead of CT for low and intermediate risk groups. This study further underlines the need for refinement in current approaches to NVH for improved cancer detection rates and optimisation of resources at a population level.