Bladder & urothelial tract


Cytology-general, normal findings & biomarker testing

Last author update: 1 December 2014
Last staff update: 13 March 2023

Copyright: 2003-2024,, Inc.

PubMed Search: Bladder [title] normal cytology

Rugvedita Parakh, M.D.
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Cite this page: Parakh R. Cytology-general, normal findings & biomarker testing. website. Accessed May 19th, 2024.
Definition / general
  • Cytology is useful to detect carcinoma in situ or marked chronic inflammation (i.e. when there is no specific lesion to biopsy), carcinoma hidden in diverticula, or for detecting residual tumor from urine specimens
  • Cystoscopic biopsy of visible lesions is more sensitive than cytology in most cases
  • Bladder irrigation is superior to collecting voided urine
  • Most sensitive and highly specific for high grade tumors (diagnosis or follow-up) whether flat (carcinoma in situ), papillary or mixed
  • Low sensitivity (difficult to diagnose) for papilloma and low malignant potential lesions because they have normal histology (Mod Pathol 1995;8:394)
  • Follow up examination of urine with FISH may improve sensitivity and specificity of cytology (Am J Clin Pathol 2001;116:79)
Types of specimens
Voided urine:
  • Non invasive, easiest to obtain
  • Obtaining three second “morning voided” midstream urine samples collected over three consecutive days appears to optimize the detection of urothelial malignancies

Instrumented urine:
  • Catheterization of the bladder or irrigation of bladder

Ileal conduit urine:
  • Ileal conduit and neobladder are the most common urine diversion techniques used in patients who have undergone cystectomy
  • A portion of the ileum is anastomosed with the ureters to the skin or to the urethra
Processing / preservation of specimen
  • Immediate processing is recommended or refrigerate if immediate processing cannot be done
  • If fixation if needed, use equal volumes of 50% ethanol or a methanol based fixative (Cytolyt® or similar)
Cytology description
Voided urine
  • Paucicellular
  • Urothelial cells, squamous cells, inflammatory cells and possibly red blood cells
  • The umbrella cells have one nucleus, abundant delicate cytoplasm, low N/C ratio, smooth nuclear contours with fine chromatin pattern and a small chromocenter
  • The basal and intermediate layers are smaller and have a columnar or cuboidal appearance; the nuclei are round with smooth nuclear contours with a fine chromatin pattern
  • Nucleoli are either absent or single and minute
  • Reactive conditions (e.g. urolithiasis, post instrumentation) demonstrate clusters of basal and intermediate urothelial cells

Instrumentation related urine
  • More cellular
  • Presence of clusters of urothelial cells forming cell balls and pseudopapillary clusters
  • The urothelial cells have a low N/C ratio, round nuclei, fine chromatin pattern and smooth nuclear contours
  • Instrumentation effect: crowded cluster formations, hyperchromasia and distinct nucleoli; may lead to a false positive diagnosis

Ileal conduit urine
  • Cellular
  • Many degenerated single cells (oval with pyknotic nuclei) and few glandular cells (vacuolated cytoplasm, hyperchromatic nuclei but preserved N/C ratio of normal cells)
  • Dirty background
  • Non-specific eosinophilic cytoplasmic inclusions
  • A potential pitfall due to hyperchromasia
Cytology images

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Urine cytology

Biomarker testing
Bladder Tumor Antigen (BTA) test
  • BTA Stat: done at physician's office or home
  • BTA Trak: done by reference laboratory; a quantitative sandwich assay
  • Based on the detection of the human complement factor H-related protein
  • Only indicated in patients with prior history of urothelial carcinoma
  • Sensitivity up to 50% for low grade urothelial carcinomas, which is higher than cytology (Can Urol Assoc J 2008;2:212)
  • Sensitivity of 69% for BTA Trak test
  • The main problem with BTA is relatively high false positive rate

Nuclear Matrix Protein 22
  • Part of the structural framework of the nucleus
  • Involved in DNA replication, ribonucleic acid transcription and regulation of gene expression
  • Nuclear mitotic apparatus proteins (NMP22) have a concentration in urothelial carcinomas of 25x normal urothelial cells
  • Either an office based test or a reference laboratory test (BladderChek®, Matritech)
  • Used to detect new cancers and to follow-up patients with a prior history of urothelial carcinoma
  • Reported sensitivity of 34.6%–100% for NMP22 Bladder Cancer Test and 49.5%–65.0% for BladderChek assays

Bladder Cancer Immunofluorescence Assay (former Immunocyt®)
  • An immunofluorescence assay
  • A cocktail of 3 monoclonal antibodies; M344, LDQ10 and 19A211
  • M344 and LDQ10 detect a mucin-like antigen
  • 19A211 recognizes a high molecular weight glycosylated form of carcinoembryonic antigen in exfoliated tumor cells
  • The test requires the correlation of the immumunofluorescence results with cytology
  • The overall sensitivity of the combined Bladder Cancer Immunofluorescence Assay and cytology assay is approximately 84%

  • Fluorescent in situ hybridization (FISH) probe set
  • A mixture of 4 fluorescent labeled DNA probes; a locus specific probe to the 9p21 band on chromosome 9 and to the centromere of chromosomes 3, 7 and 17
  • The individual sensitivity of the centromeric probes is 73.7% for chromosome 3, 76.2% for chromosome 7, 61.9% for chromosome 17
  • The sensitivity of homozygous 9p21 deletion for urothelial carcinoma is 28.6%
  • The UroVysion® test: 72% sensitivity and 83% specificity
  • According to stage of the disease, for pTa tumors sensitivity ranges from 65 to 73% and for pT1-T4 urothelial carcinomas 95-100%
  • UroVysion® and cytology have similar specificity but superior specificity to BTA
  • Patients with a positive UroVysion® test result, equivocal (atypical or suspicious) cytology diagnosis and negative cystoscopy have a higher incidence of urothelial carcinoma on subsequent follow-up
  • The UroVysion® test seems to have limited value due to a higher incidence of false positives and false negatives
  • The positive predictive value of UroVysion® for bladder carcinoma is 65% in patients with a 40+ pack year history of smoking, but only 20% in nonsmokers
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