A cystoscopy is the primary method used to detect bladder cancer and is the gold standard diagnostic tool for this disease. Bladder cancer begins when cells in the inner lining of the bladder, known as the urothelium, start to grow abnormally and uncontrollably. The cystoscopy procedure involves a visual examination of the bladder lining using a specialized instrument that allows a doctor to look directly for these abnormal growths. This technique is effective because most bladder tumors originate on the inner surface, making them visible to the scope. The procedure is often the first step in confirming or ruling out a malignancy, especially when symptoms like blood in the urine are present, though definitive diagnosis requires microscopic analysis of tissue.
Understanding the Cystoscopy Procedure
The cystoscopy procedure uses a slender, lighted tube called a cystoscope, which is inserted through the urethra into the bladder. The patient experience varies depending on whether a flexible or rigid instrument is used.
A flexible cystoscopy utilizes a bendable scope and is typically performed in a urologist’s office under local anesthetic, often a lubricating gel applied to the urethra. Patients remain awake and can usually return to normal activities shortly afterward, as the procedure takes only a few minutes. This flexible scope is reserved for routine diagnostic examinations and surveillance.
Rigid cystoscopy uses a straight, non-flexible instrument and is usually conducted in an operating room setting. Because this type allows for simultaneous procedures like tissue removal, it requires the patient to be under sedation or general anesthesia. Patients undergoing a rigid procedure may be asked to fast beforehand, unlike the flexible procedure.
How Cystoscopy Confirms Bladder Cancer
The immediate goal of the cystoscopy is the visual inspection of the bladder wall under white light to identify any abnormal growths or lesions. Tumors often appear as distinct, raised masses projecting from the bladder lining, but early-stage or flat lesions can be difficult to see with standard white light. Detecting these subtle changes is important because they can represent an aggressive form of the disease called carcinoma in situ (CIS).
Blue Light Cystoscopy (BLC)
To overcome the limitations of standard visualization, doctors may employ enhanced imaging techniques, such as Blue Light Cystoscopy (BLC). This technique involves instilling a special liquid into the bladder about an hour before the procedure. Cancer cells absorb this compound more readily than healthy cells, causing them to fluoresce a bright pink or red color when viewed under a specific blue light wavelength. This fluorescence makes previously invisible or hard-to-distinguish cancerous areas stand out, improving the detection rate for non-muscle invasive tumors.
While visual identification is highly suggestive, the finding alone does not confirm a cancer diagnosis. To definitively confirm malignancy, the doctor must obtain a tissue sample, or biopsy, from the suspicious area. Specialized instruments are passed through the cystoscope to collect the tissue, which is then sent to a pathologist for microscopic examination. Only the pathology report can determine the presence of cancer cells, providing the specific cell type and grade of the tumor.
Next Steps After a Positive Finding
If the cystoscopy reveals a suspicious mass, the next step often involves Transurethral Resection of Bladder Tumor (TURBT). This procedure is used both to remove the visible tumor and to gather tissue for definitive staging. TURBT is performed under general or spinal anesthesia using a rigid cystoscope equipped with cutting tools to excise the tumor from the bladder wall.
The primary purpose of the TURBT is to provide the pathologist with a sample including the tumor tissue and a piece of the underlying muscle layer. This sample determines the depth of invasion, the most important factor in staging the cancer. Cancer that has not grown into the muscle layer is classified as non-muscle invasive bladder cancer (NMIBC), while cancer that has penetrated the muscle is known as muscle-invasive bladder cancer (MIBC).
For high-grade tumors or those that have invaded the tissue layer just beneath the lining (T1 tumors), a second procedure, a “restage TURBT,” is often recommended within a few weeks. This second resection ensures the entire tumor was removed and confirms the staging, as initial resections can sometimes miss residual disease. The final pathology report from the TURBT dictates the subsequent treatment plan, which may involve additional therapies or more aggressive surgical intervention, depending on the determined stage and grade of the disease.