Every article ever written about nonmuscle-invasive bladder cancer (NMIBC)—i.e., carcinoma in situ (CIS), T_a, and T₁—cites recurrence rates of 15% to 61% (http://www.eortc.be/tools/bladdercalculator/) within a few years and progression rates of 10% to 54%. ¹ As physicians responsible for treating this patient group, we should certainly not be satisfied with such “bad” rates.

The bases for these variable results are:

1. Nature of the disease

2. Accuracy of histopathologic classification

3. Individual visual acuity

4. Individual intraoperative responses based on the information perceived

5. Sensitivity of our instruments

The nature of NMIBC and its multifocality is explained by two nonmutually exclusive theories. ² The field cancerization effect theory ³ asserts that the urothelium in patients with NMIBC may be unstable because of genetic hits and progressive outgrowth of genetically unstable cells throughout the entire urothelium. The clonal expansion theory suggests that multifocal tumors (both synchronous and metachronous) are the result of intraluminal spread from a single transformed cell, namely seeding. ⁴ NMIBC should, therefore, not just be considered a tumor or even multiple tumors but rather a disease of the entire urothelium with varying propensity to generate malignancies.

Optimal diagnosis, treatment, and follow-up of NMIBC are highly dependent on staging and grading the tumor. Unfortunately, the reproducibility of both staging and grading is low and needs improvement for optimal treatment and follow-up. ⁵ In spite of well-defined criteria for the diagnosis of CIS, there remains significant variability among pathologists, for which agreement is achieved in only 70% to 78% of cases. ⁶ In regard to stage classification, there is also a significant interobserver variability in both the 1973 and the 2004 classifications. ⁷ Considering that the general conformity of histopathologic grading and staging is between 50% and 60% ¹ suggests that our current ability to classify, diagnose, and thereby facilitate correct management decisions is less than “optimal.”

Endoscopy is dependent on visual acuity, a subject not often addressed in urologic literature. The prevalence of visual impairment in US adults (National Health Interview Survey, 2002) is for those aged 45 to 54 years: 11.5% (confidence interval [CI ]10.5–12.5); 55 to 64: 10.4% (CI 9.3–11.4); 65 to 74: 14.5% (CI 13.0–16.0); ≥75: 21.1% (19.4–22.8). ^{8 –10} Should we not only personalize our glasses but also consider what individual adjustments can be done with current endoscopic technologies?

White light (WL) cystoscopy is still the gold standard for visualizing and establishing a diagnosis of bladder cancer. This is supported by the 100% sensitivity and 100% specificity of WL evaluation in discriminating between dysplastic/malignant and benign/reactive lesions by an experienced urologist. ¹¹ In spite of these findings, when second-look transurethral resection of the bladder (TUR-b) is performed for T₁ disease, residual tumor rates of 43% to 62% are noted, ^{12 –14} suggesting that WL sensitivity is not optimal. CIS may also be overlooked in up to 50% of lesions, leading to inadequate treatment and follow-up. ¹⁵

Individual intraoperative responses based on the information perceived is dependent on the experience and skills of the urologist performing the TUR-b. ^16,17 Complete TUR-b is essential to obtain diagnostic accuracy and to reduce recurrence as well as disease progression. Optimal TUR-b should also be augmented with prompt “single-shot” intravesical chemotherapy and in high-risk disease, immunotherapy, as indicated by guidelines (http://www.uroweb.org/gls/pdf/05%20Non-muscle%20Invasive%20BC_TaT1_LR.pdf). ¹

To address the limits of WL cystoscopy, several new technologies have been or are being developed:

• Photodynamic diagnosis (fluorescence cystoscopy) (PDD)

• Narrow-band imaging (NBI)

• STORZ professional image enhancement system (SPIES)

• Emerging technologies (optical coherence tomography, confocal laser endomicroscopy, and Raman spectroscopy)

All of the above mentioned new technologies, including new resection techniques, contribute to more complete TUR-b. ¹⁸ According to European Association of Urology (EAU) guidelines (2014), PDD is now recommended in patients who are suspected of harboring a high-grade tumor—e.g., for biopsy guidance in patients with positive cytology results or with a history of high-grade tumor. ¹ In the EAU 2014 update, it is noted that NBI-guided biopsies and resection have demonstrated improved cancer detection. In a study by Geavlete and associates, ¹⁹ it was noted that using NBI cystoscopy significantly improved diagnostic accuracy and decreased 1-year recurrence rates. Recently STORZ has developed an endoscopic image enhancement system (SPIES) that potentially will improve TUR-b results.

All of the above mentioned confounding factors contribute to the variability in reoccurrence rates and progression for NMIBC. This variability makes studying the effects of new endoscopic technologies difficult and necessitates either very restrictive patient selection or very large randomized trials to provide convincing evidence of the increased efficacy of new technologies.

A multicenter international randomized study will be conducted by the Clinical Research Office of the Endourological Society (CROES) comparing WL with SPIES. Close to 2000 patients will be included, aiming at addressing many questions on the added value of imaging enhanced endoscopy. Moreover, this technology can be used to evaluate upper tract urinary urothelial cell (UTUUC) tumors. CROES is therefore pleased that the STORZ company also supports a registry to study the indications in treatment and outcomes for UTUUC tumors. The sites that have access to ureteroscopes that are enabled with SPIES will thus also evaluate the added value of SPIES in those patients.

The oncoming SPIES projects will enable us to provide the best possible care for our patients. This is made possible through a partnership with STORZ and illustrates the importance of these collaborations. In addition, this opens the doors for every urologist involved in the management of UTUUC tumors to contribute through CROES to new insights and knowledge of this condition.