The objective of this audit is to determine the percentage of negative biopsy results following the request of bladder biopsy done after flexible cystoscopy for patients with suspicious red patches on the bladder wall. ​These patients present with hematuria, LUTS, recurrent urinary tract infections (rUTI), or are under bladder cancer surveillance. ​

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Data were retrospectively reviewed for patients undergoing flexible cystoscopy at East Surrey Hospital from March 1 to June 30, 2024. A total of 1,179 cystoscopies were performed, with 45 biopsies requested for suspicious red patches. Exclusion criteria included papillary or mass lesions, recurrent red patches, or prior TURBT. Patients presenting with hematuria, LUTS, recurrent UTIs (rUTI), or under bladder cancer surveillance were included.

Among 45 biopsies, 39 (86.7%) were negative for malignancy, showing chronic inflammation or cystitis. Positive malignancy results (13.3%) were predominantly in patients under bladder cancer surveillance (4 cases), with 2 additional cases identified in patients presenting with LUTS or visible hematuria. The biopsy requisition rate was 3.81% of all Flexible cystoscopies performed, indicating may need for refined decision-making. 

Action Plan:​
1. Senior Review for Red Patches:​ Implement a system where red patches identified during cystoscopy are reviewed by a senior clinician.​ Use the Cerner to upload and store cystoscopy images of red patches for remote review before making a biopsy decision.​
2. Identify Predisposing Factors:​ Ensure thorough patient history is taken, focusing on recurrent UTIs, chronic cystitis, long-term catheter use (LTC), and other potential causes of inflammation.​ Include routine checks such as urine dipstick tests (MSU) or cultures to rule out infection as the cause of red patches.
4. Audit and Feedback:​​ Conduct second audit to monitor the effectiveness of the new procedures and provide feedback to teams on reducing unnecessary biopsy rates.​​

The findings suggest a significant proportion of negative biopsies could be avoided with enhanced clinical judgment. Recommendations include implementing senior reviews for red patches, utilizing cystoscopy images for remote evaluation, and thorough assessments of predisposing factors like infection or chronic cystitis. A follow-up audit will measure the impact of these changes and ensure alignment with best practices to reduce unnecessary biopsies while maintaining diagnostic accuracy

The findings demonstrate that a good number of biopsy results are negative for malignancy, suggesting that some could potentially be avoided through better clinical judgment, senior review and pre-biopsy evaluation. ​

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599966/?
https://onlinelibrary.wiley.com/doi/full/10.1111/iju.13970
https://www.europeanurology.com/article/S0302-2838(03)00624-9/abstract#:~:text=In%20the%20guidelines%20on%20superficial,malignant%20lesions%20by%20doing%20so.?