Editorial Comment on: Isolated Red Patches Seen During Endoscopic Surveillance of Bladder Cancer: Incidence of Malignancy and When Should We Biopsy? by Nkwam et al .

Most Urologists have already had doubts regarding red patches seen during cystoscopy. This is a particularly troublesome problem in the follow-up of bladder cancer patients. Some biopsy all, others follow all, and the rest decide on a case-by-case basis depending on the characteristics of the patch and the history of the patient. I believe the first two will continue to do the same as they were doing before, but for the last, the article of Nkwam et al. adds information to decide upon. They report a 23% malignancy rate in the biopsy of red patches seen during cystoscopy in a population of patients with history of bladder cancer and 55% of the positive cases corresponded to carcinoma in situ.

Interestingly, no case of malignancy was identified in patients with low-risk bladder cancer but more than half of the malignant cases detected had a previously benign biopsy and had Bacillus Calmette-Guérin (BCG) treatments. Also, the biopsy was free from complications, even in those performed with flexible cystoscopy under local anesthesia. Their study presents several limitations recognized by the authors as the retrospective design, the low biopsy rate (provably only the more sinister looking patches were biopsied), and absence of cytology use in the follow-up of those patients. Although their results should be extrapolated to our clinical practice with caution, I will be more concerned about suspicious red patches in patients with previous negative biopsies or who had BCG treatments, and a bit less worried about doubtful red patches in patients with previous low-risk bladder cancer.

The authors should be commended for adding scientific evidence in a topic with scarce research and important implications.