Pathology, Etiology, and Diagnosis of Urothelial Cancer - Experts Discuss

A multidisciplinary panel examines practical implementation of enhanced cystoscopy, the evolving management of carcinoma in situ, and the potential role of artificial intelligence in improving diagnostic precision and clinical trial interpretation. The panel focuses on real-world adoption of blue light cystoscopy and narrow band imaging in the surveillance and management of non–muscle-invasive bladder cancer. Participants describe variability in practice patterns driven by workflow constraints, cost, equipment availability, and scope platform limitations. Blue light cystoscopy requires pre-procedure intravesical instillation and scheduling adjustments, limiting spontaneous use in busy clinics. Narrow band imaging is easier to toggle during standard cystoscopy, but it is not universally available, particularly as disposable scopes become more common. Operational challenges, maintenance contracts, and discontinuation of certain flexible blue light platforms further restrict access. Despite these barriers, participants emphasize that enhanced imaging technologies improve visualization of small papillary tumors and carcinoma in situ. The debate centers on whether enhanced cystoscopy should be mandated in clinical trials to standardize detection and reduce variability in the quality of transurethral resection of bladder tumors. A major theme involves carcinoma in situ heterogeneity. Small focal lesions detected with enhanced imaging may biologically differ from extensive multifocal disease, yet both are categorized similarly in single-arm trials. The panel questions assumptions that all carcinoma in situ represents persistent disease after resection, noting that aggressive resection and fulguration may eliminate visible disease in a subset of patients. Lack of objective quantification methods complicates the assessment of response and the interpretation of therapeutic efficacy. Participants discuss limitations in histologic sampling of carcinoma in situ and challenges in molecular analysis due to minimal tissue volume. Urinary-based assays and circulating tumor DNA are suggested as potential objective tools. Artificial intelligence–based cystoscopic enhancement, image capture, and three-dimensional mapping may enable quantification of lesion surface area and improve longitudinal assessment of response. The discussion highlights the need for standardization, objective measurement, and integration of emerging technologies in both clinical practice and trial design. Don't forget to join the GRU Community: https://grandroundsinurology.com/regi... Follow us on Twitter/X: https://x.com/GRUrology And like and subscribe to us here on YouTube!