What is the role of cystoscopy in the diagnosis of bladder cancer?

Updated: Feb 23, 2021
  • Author: Kara N Babaian, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Cystoscopy is one of the first tests that should be completed in a patient presenting with signs and symptoms suspicious for bladder cancer. Unfortunately, one study found that only 13% of patients with hematuria and risk factors for bladder cancer underwent cystoscopy. [65] Drawbacks of the procedure are that it is invasive and relatively expensive. [68]  In addition, flat urothelial lesions such as CIS may be difficult to distinguish from normal bladder tissue, and bleeding caused by the procedure can reduce visibility.

Use of adjunctive endoscopic techniques, such as blue light cystoscopy with hexaminolevulinic acid (HAL), may improve the accuracy of cystoscopy. HAL is instilled intravesically and remains in the bladder for one hour before cystoscopy. This allows malignant cells, which have higher intracellular accumulation of the photoactive porphyrins, to appear pink or red while the nonmalignant tissue appears blue. [64] Cytologic analysis of voided urine is frequently used as an adjunctive test to aid in identifying occult cancers.

Virtual cystoscopy can help detect many bladder tumors, but it is more expensive than cystoscopy and has lower sensitivity and specificity. Therefore, it does not play a role in surveillance at this time.

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