Initial evaluation
Since bleeding may be intermittent, red blood cells may not be present on microscopic evaluation of the urine. Voided urine cytology is a Pap smear of cells lining the urinary tract than have fallen off into the urine. Since these cell have the capability to undergo changes in size from cubical (when the bladder is empty) to flat (when the bladder is full) they are called transitional cells. The vast majority of bladder cancers are transitional cell cancers. If the urinary cytology is positive, then transitional cell cancer of the urothelium is almost certainly present. However, cytologic examinations may be negative in up to half of patients with bladder cancer; thus, a negative study does not rule out bladder cancer.3 DNA ploidy analysis is a method of measuring the amount of DNA in the cancer cells. Because of its cost, it is not recommended for the initial evaluation of blood in the urine unless the physician is highly suspicious that a bladder cancer is present.4 Recently, several companies have started to offer dip-stick test of the urine to check for the presence of bladder cancer.5
Since transitional cells line the urinary tract starting at the kidney, down the ureter, into the bladder and includes most of the urethra, the entire urinary tract needs to be evaluated for transitional cell cancer. The lining of the kidneys (renal pelvis) and ureters are best evaluated by intravenous pyelogram (IVP) or retrograde pyelogram.6 An IVP involves an intravenous injection of constrast material which is then filtered out of the blood in into the urine by the kidney. Plain x-rays taken during this process show the uninary tract. Typically a retrograde pyelogram is reserved for patients with an intravenous contrast allergy or poor visualization on IVP. A retrograde pyelogram is performed at the time of cystoscopy (looking into the bladder with a telescopic instrument). Through the cystoscope a small plastic tube is inserted into the ureter and contrast material in injected into the kidney. Other diagnostic modalities such as ultrasound, computed tomography, or magnetic resonance imaging may miss small subtle abnormalities. Office cystoscopy is an essential part of the initial evaluation and cannot be substituted by x-ray tests. Today most office cystoscopic examinations are performed with a flexible scope. Compared to rigid cystoscopy, flexible endoscopy is more comfortable and allows the physician to see around the curves of an enlarged prostate.
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