Should we check urine cytology or cystoscopy in an 88-year-old male with a history of Transitional Cell Carcinoma (TCC) and Transurethral Resection of Bladder Tumor (TURBT) 11 years ago?

Surveillance Recommendations for an 88-Year-Old Male with History of TCC and TURBT 11 Years Ago

Cystoscopy is not necessary for this patient at this time, and urine cytology alone is also not recommended for routine surveillance after 11 years of disease-free follow-up.

Rationale for Recommendation

For patients with a history of low-risk non-muscle invasive bladder cancer (NMIBC) and a prolonged disease-free interval (11 years in this case), current guidelines do not support continued routine surveillance with either cystoscopy or urine cytology.

Risk Stratification and Surveillance Duration

The American Urological Association (AUA) guidelines specifically state:

• "In a patient with a history of low-risk cancer and a normal cystoscopy, a clinician should not routinely use a urinary biomarker or cytology during surveillance" (Expert Opinion) 1
• For patients with low-risk non-muscle invasive bladder cancer, follow-up cystoscopy after 5 years should only be performed based on clinical indication 1

Age Considerations

At 88 years old with 11 years since the last TURBT:

• The risk of recurrence decreases significantly over time
• The risk-benefit ratio of invasive procedures like cystoscopy shifts unfavorably in elderly patients
• The NCCN guidelines indicate that follow-up cystoscopy after 5 years should only be performed based on clinical indication 1

Evidence on Surveillance Duration

The guidelines make a clear distinction between surveillance protocols for:

• Low-risk NMIBC: Limited surveillance after 5 years if no recurrence
• Intermediate/high-risk NMIBC: More intensive and prolonged surveillance

When to Consider Surveillance Testing

Surveillance testing should be considered only if:

1. The patient develops symptoms suggestive of recurrence (hematuria, irritative voiding symptoms)
2. There are specific risk factors that would warrant continued surveillance:
   • History of high-grade disease
   • CIS (carcinoma in situ)
   • Multiple recurrences in the past
   • Variant histology

Effectiveness of Different Surveillance Methods

If symptoms develop that warrant investigation:

• Cystoscopy remains the gold standard with sensitivity of 92% and specificity of 88% 2
• Urine cytology has limited sensitivity (35-61%) but high specificity (97-100%) 3, 2
• Combined cystoscopy and cytology provides the highest sensitivity (100%) and specificity (92.3%) 3

Key Considerations for Elderly Patients

For an 88-year-old patient:

• The morbidity and discomfort associated with cystoscopy may outweigh benefits after such a long disease-free interval
• Focus should be on quality of life rather than intensive surveillance
• The negative predictive value of a normal cystoscopy with negative cytology is very high (91%) 4, suggesting that previous negative findings are reassuring

Conclusion

Based on the patient's advanced age, long disease-free interval (11 years), and guideline recommendations, neither routine cystoscopy nor urine cytology is indicated at this time unless new symptoms develop. This approach prioritizes quality of life while acknowledging the low risk of recurrence after such a prolonged disease-free interval.