Metastases most frequently occur in lymph nodes, liver, lung, bone, and adrenal glands. CT or MRI of the abdomen and pelvis is used to assess for nodal, liver, and adrenal metastases. Chest radiographs are typically performed to screen for lung metastases, given the high rate of false positives on CT scan. Radionuclide bone scans may be used to determine the presence of skeletal metastases in patients with suggestive symptoms or elevated serum alkaline phosphatase concentrations.

Urine cytology detects malignant urothelial cells in voided urine specimens or bladder washings. Current techniques are highly specific but only moderately sensitive, with the highest likelihood of a positive result in a patient with an advanced tumor.

Cystoscopy provides direct visual examination of the bladder mucosa, and it is the gold standard for diagnosis. Many grossly visible tumors can be resected during this initial evaluation (see Plate 10-39). Any abnormal-appearing or erythematous areas of mucosa should undergo directed biopsy for histopathologic examination. Random biopsies of normal-appearing areas may also be indicated, especially if urine cytology is positive but no tumor is grossly visible. Additional biopsy sites may include areas adjacent to a tumor, from the opposite bladder wall, dome, trigone, and prostatic urethra. It is essential to obtain deep tissue samples with adequate representation of the bladder wall to perform accurate staging.