The role of urine markers, white light cystoscopy and fluorescence cystoscopy in recurrence, progression and follow-up of non-muscle invasive bladder cancer

Non-muscle invasive bladder cancer (NMIBC) accounts for approximately 70 % of all bladder cancer cases and represents a heterogeneous pathological entity, characterized by a variable natural history and oncological outcome. The combination of cystoscopy and urine cytology is considered the gold standard in the initial diagnosis of bladder cancer, despite the limited sensitivity. The first step in NMIBC management is transurethral resection of the bladder tumour (TURBT). This procedure is marked by a significant risk of leaving residual disease. The primary landmark in NMIBC is the high recurrence rate. Fluorescence cystoscopy improves the bladder cancer detection rate, especially for flat lesions, and improves the recurrence-free survival by decreasing residual tumour. Progression to muscle invasive tumours constitutes the second important landmark in NMIBC evolution. Stage, grade, associated CIS and female gender are the major prognostic factors in this regard. The evolution to MIBC has a major negative impact upon the survival rate and quality of life of these patients. Fluorescence cystoscopy improves the detection rate of bladder cancer but does not improve the progression-free survival. Urine markers such as ImmunoCyt and Uro Vysion (FISH) have also limited additional value in diagnosis and prognosis of NMIBC patients. Major drawbacks are the requirement of a specialized laboratory and the additional costs. In this review, the risks of recurrence and progression are analysed and discussed. The impact of white light cystoscopy, fluorescence cystoscopy and urine markers is reviewed. Finally, the means and recommendations regarding follow-up are discussed.