UROLOGICAL ONCOLOGY

Correlation of cystoscopy with histology of recurrent papillary tumors of the bladder
Herr HW, Donat SM, Dalbagni G
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
J Urol. 2002;168:978-80

• Purpose: We correlated individual urologist impressions of tumor stage, and grade of recurrent papillary bladder tumors at cystoscopy, with histological findings after transurethral resection to determine whether cystoscopy can reliably identify low grade, noninvasive papillary tumor for outpatient fulguration.
• Materials and Methods: A total of 144 recurrent papillary bladder tumors identified on outpatient flexible cystoscopy were classified as low grade and noninvasive (stage Ta grade 1), high grade and noninvasive (stage Ta grade 3), or invasive (stage T1). Voided urine cytology was also performed. The cystoscopic impression of each tumor was correlated with the final histological findings of tumor stage and grade after transurethral resection.
• Results: Cystoscopy classified 97 tumors as stage Ta grade 1, and 47 as stage Ta grade 3 or stage T1. Cystoscopy correctly predicted the tumor stage and grade of 93% of stage Ta grade 1, and 99% of stage Ta grade 1 lesions associated with negative urine cytology.
• Conclusions: Urologists can usually identify noninvasive, low grade recurrent papillary tumors on follow-up cystoscopy, and these may be treated safely with outpatient fulguration.
  
  
• Editorial Comment
  This paper addresses the important point of how reliable the urologist’s endoscopic evaluation is as compared to histology obtained after TUR. The authors performed flexible cystoscopy in a number of patients with non-invasive bladder cancer, and concluded that the prediction of superficial bladder tumors was reliable enough to recommend fulguration and did not require resection. Several comments, however, have to be made. The reliability of cystoscopy only comes with the help of cytology. Stage Ta grade-1 tumors were misdiagnosed in 7 of 97 cases, in that 6 tumors had grade-3 and one tumor had stage T1 in final histology. Furthermore, in cystoscopically stage Ta grade-3 tumors (37), 8 in fact were T1 tumors. In both situations, only cytology significantly improved the predictive value of cystoscopy. Thus predictive reliability will depended on a good cytologist. Finally, this paper was generated by 3 of the world’s most experienced urologists, whereas in daily outpatients practice, the individual urologist’s performance, including mine, might be significantly lower. In conclusion, it is nice to see that urologists can indeed predict superficial bladder cancer with high reliability, which to my opinion does not justify fulguration only.

Dr. Andreas Böhle
Professor and Deputy Chairman of Urology
Medical University of Luebeck
Luebeck, Germany