Conclusions

Many different types of urine-based tests have been developed. In principle these are very exciting because if they could be developed to be as sensitive and specific as cystoscopy, then they will reduce the number of invasive procedures. The patients who will benefit include the following:

1 Patients with gross haematuria

2 Patients with microscopic haematuria

3 Patients with lower urinary tract symptoms

4 Patients undergoing follow-up cystoscopy for a diagnosis of TCC

5 Patients with invasive tumours who have been treated by bladder preserving techniques who are under regular follow-up.

As yet, none of the tests is good enough to replace cystoscopy.29 The best of the tests include BTA stat and TRAK, FDP measurement, NMP-22, Immunocyt and telomerase. On average the sensitivity is 70-80% and the specificity is about the same. For muscle-invasive or high-grade disease the sensitivity is greater - in the region of 80-90%. However, the urologist should be aware that gross haematuria can interfere with the tests. In addition conditions causing inflammation, such as stones, infection, bowel segments and stents, can cause false positive results.

In the near future, the urologist will want to see more head-to-head comparisons of the tests in large enough groups of patients to determine accurately which are the better tests.

Another variable is the ease of carrying out the tests, how reproducible they are, and whether the urologist can do them easily in the office. True cost and cost-effectiveness need to be determined. The type of healthcare system in which the urologist practises is also important in terms of how the costs of the test can be reimbursed.

In the future it would be good to see some large-scale trials of people with low-risk superficial bladder cancer.30,31 The trial could address the question of whether the frequency of cystoscopies could be reduced by the use of tests carried out by the patient or GP (or urologist).

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