What is the next step in a patient with a history of Carcinoma of the Urinary Bladder (CA UB) who has undergone Transurethral Resection of Bladder Tumor (TURBT) and now has normal imaging and cystoscopy results but atypical cytology findings?

Management of Atypical Cytology in Post-TURBT Bladder Cancer Patient with Normal Cystoscopy and Imaging

For a patient with a history of bladder cancer who has undergone TURBT and now has normal cystoscopy and imaging but atypical cytology, the next step should be directed or selected mapping biopsies of the bladder along with evaluation of the upper urinary tract.

Evaluation of Atypical Cytology with Normal Cystoscopy

• In patients with positive cytology but negative cystoscopy and imaging results, a transurethral resection (TUR) must be performed with directed or selected mapping biopsies, including TUR biopsies of the prostate in male patients 1
• Positive urinary cytology may indicate urothelial tumor anywhere in the urinary tract, not just the bladder, requiring comprehensive evaluation 1
• When cystoscopy is normal but cytology is positive, the upper tracts and prostate (in men) must be evaluated, and ureteroscopy may be considered 1

Recommended Diagnostic Approach

1. Directed bladder biopsies:

   • Perform TUR with directed or selected mapping biopsies of the bladder 1
   • Include random biopsies of normal-appearing mucosa to detect carcinoma in situ (CIS) that may not be visible on standard cystoscopy 1

2. Upper tract evaluation:

   • Cytology of the upper tract must be evaluated 1
   • Consider ureteroscopy for direct visualization of the upper urinary tract 1
   • CT urography (CTU) is a comprehensive examination that can identify metachronous upper tract urothelial carcinoma 1

3. Prostate evaluation in male patients:

   • Include TUR biopsies of the prostatic urethra to rule out urothelial involvement 1

Management Based on Biopsy Results

• If bladder mapping biopsies are positive:

  • Administer intravesical BCG treatment followed by maintenance BCG (optional) if complete response is seen 1
  • For tumors that fail to respond to BCG or show incomplete response, consider cystectomy, changing the intravesical agent, or clinical trial participation 1

• If prostate biopsies are positive:

  • Treat according to guidelines for urothelial carcinomas of the prostate 1

• If upper tract evaluation is positive:

  • Treat according to guidelines for upper genitourinary tract tumors 1

• If all biopsies are negative:

  • Follow-up at 3-month intervals is recommended 1
  • Maintenance therapy with BCG is optional 1

Important Considerations

• Standard biopsy of normal-appearing bladder mucosa has a low yield (only 2.5% positive for CIS in one study) but is still necessary to rule out occult disease 2
• Extended TURBT provides detailed information about horizontal and vertical extent of bladder tumors and improves local tumor control 3
• Enhanced cystoscopy techniques such as blue light cystoscopy (BLC) or narrow band imaging (NBI) may improve detection of occult lesions not visible with standard white light cystoscopy 4, 5

Follow-up Recommendations

• For high-risk non-muscle invasive bladder cancer, follow-up should include urinary cytology and cystoscopy at 3- to 6-month intervals for the first 2 years, and at longer intervals thereafter 1
• Imaging of the upper tract should be considered every 1 to 2 years for high-risk tumors 1
• Urine molecular tests for urothelial tumor markers may be considered during surveillance, though their clinical utility remains unclear (category 2B recommendation) 1

Remember that positive cytology with normal cystoscopy represents a diagnostic challenge but requires thorough evaluation as these patients have a high risk of recurrence 2.