While there are several techniques by which urothelial cancer can be identified, only cystoscopy provides reliable, direct visualization and localization of a bladder tumor. Cystoscopy, which remains the gold standard for the detection of bladder cancer, provides the opportunity for initial assessments of tumor grade and stage. Studies have demonstrated that an experienced urologist can distinguish high-grade from low-grade tumors as well as superficial from grossly invasive disease (5). In general, low-grade, noninvasive tumors appear papillary, contacting the surface of the bladder on a narrow stalk. Carcinoma in situ, a noninvasive, high-grade tumor, appears as a flat velvety lesion, arising in isolated areas or involving large regions of the urothelial lining. High-grade, invasive tumors lose their papillary configuration, frequently appearing as sessile, solid, or nodular lesions. Few studies address the utility of cystoscopy alone in the local staging of bladder cancer. Satoh et al. performed 275 cystoscopies on 165 patients in order to evaluate cystoscopic features that predict muscle invasion (6). They found that size, stalk (sessile vs. pedunculated), and configuration (nonpapillary vs. papillary) were independent predictors of muscle invasion. Cina et al. (7) evaluated the ability of the trained urologist to determine grade and stage of bladder cancer by cystoscopy alone, reporting a sensitivity and specificity of predicting low-grade tumor of 91% and 46%. In contrast, the sensitivity and specificity was poor for the detection of high-grade tumors, lamina propria invasion, or muscle invasion. Others have reported a similar sensitivity for the cystoscopic detection of low-grade noninvasive tumors in a select population of patients undergoing surveillance for superficial bladder cancer (5). Several modalities are currently under investigation as adjuncts to cystoscopy for bladder cancer staging. These approaches, such as optical coherence tomography and confocal microscopy, may allow visual inspection of the extent of bladder tumor invasion (8).

The bimanual examination of the bladder, prostate, rectum, and gynecologic organs is an important part of the overall evaluation of the bladder cancer patient. The EUA can detect locally advanced disease, which may present as gross extravesical extension, invasion of adjacent organs, or pelvic sidewall extension. It is a useful adjunct to imaging in assessing tumor operability. However, the EUA is relatively insensitive for the staging of tumors confined to the bladder. The presence of grossly palpable disease or tumor fixation to adjacent structures or the pelvic side walls may predict a worse survival
in patients with bladder cancer (9,10). False positives may result from changes related to previous surgery, pelvic radiation, or inflammatory disease (11).

The role of transurethral resection (TUR) includes the provision of tissue for diagnosis and removal of tumor that may be therapeutic. The clinical stage and grade of a bladder tumor is strongly associated with its risk of both local and distant progression. Treatment varies dramatically based on the staging information provided prior to determination of definitive management. Distinguishing non-muscle-invasive bladder cancer (Ta, T1) from muscle-invasive bladder lesions (≥T2) is the most important task of clinical tumor staging. To date, no technique achieves this better than TUR of a bladder tumor.

Invasive tumors frequently extend into bladder wall as a collection of fingerlike projections rather than as a solid tumor front. To assure accurate clinical staging and the most complete resection possible, it is important that a TUR is carried deep to the tumor and into the muscularis propria, and extended widely on either side of the tumor base. Sampling the tumor base with a separate specimen by loop or cold cup can confirm complete resection. Finally, careful evaluation of the surrounding bladder for carcinoma in situ should be performed as well.

The role of repeat TUR following an initial diagnostic or therapeutic resection has been evaluated in several studies. Initial TUR understages T1 disease in up to 30% to 40% of lesions, particularly when no muscle is identified in the initial TUR specimen (12,13,14). Even in the absence of upstaging, repeat resection in this setting frequently reveals residual Ta or T1 disease that should be removed prior to intravesical therapy. Repeat resection plays an important role for patients with T1 disease for whom conservative management is considered. Dalbagni et al. showed that a second TUR performed at 6 to 8 weeks after initial TUR allows for a more complete resection and improved staging accuracy of clinical T1 tumors (15).

As a diagnostic procedure, the goal of a TUR is to provide evaluable material to the pathologist that allows for a histologic diagnosis of cell type, tumor grade, and depth of invasion, if present. Proper technique should aim to minimize cautery or crush artifact and, when appropriate, provide anatomical orientation. Cautery artifact may be minimized by performing tumor resection using a cutting current. Using a finer diameter loop cut with a more concentrated current can minimize cautery artifact as well, but provides less hemostasis than larger-diameter loops. Technologic advances in bipolar equipment may provide improved resection performance by allowing cutting at lower temperatures to enhance tissue preservation while still providing adequate hemostasis. Cold-cup biopsy can sample the urothelium without cautery artifact but provides a less controlled resection, limiting its therapeutic effectiveness.