The use of urine cytology has been vigorously debated. Economic evaluation suggests that yield is relatively low in the presence of normal imaging and cystoscopy. Additionally, this test requires lab processing and therefore cannot be applied in the one-stop setting. Very few patients will have primary carcinoma in situ (cis) without abnormality on cystoscopy or imaging. Similarly the isolated finding of upper tract transitional cell carcinoma (TCC) in NVH with a normal ultrasound is unusual. However, photodynamic diagnosis (PDD) has highlighted a few patients who have been identified with cis on the basis of suspicious cytology with normal white light cystoscopy.

Bear in mind also, that urine cytology can be helpful in planning management of disease. For example, suspicious cytology indicates high-risk disease, which may affect strategy for endoscopic management of both lower and upper tract TCC. One approach would be to reserve cytology for those with a diagnosis of bladder tumor, or only for those with negative investigations. There are test kits available for urine markers which offer greater sensitivity compared to cytology, however, these have not proven effective enough to replace cystoscopy and specificity remains a concern.