Staging and Staging Errors in Bladder Cancer

ContextThe staging of bladder cancer (BCa) is crucial for optimal management of the disease. The staging process is known to be challenging and fraught with errors.ObjectiveOur aim was to present current BCa grading and staging systems and to review the crucial steps of the staging process. Sources of errors and pitfalls in the staging process are also discussed.Evidence acquisitionA comprehensive literature review was performed to identify relevant original articles, review articles, and clinical guidelines in the field of BCa staging.Evidence synthesisStaging error is extremely common with reported upstaging in up to 40% of patients. Sadly, little, if any, improvements have been reported during the past two decades. Quality of the transurethral resection of bladder tumor (TURBT) and pathologic evaluation of resected tissue by a specialized uropathologist is the cornerstone of BCa staging. In addition to primary resection, restaging transurethral resection is indicated in high-risk noninvasive cancers and also if incomplete resection is demonstrated or suspected. The accuracy of traditional imaging studies (computed tomography [CT], magnetic resonance imaging [MRI]) is of limited value both in the staging of the primary tumor and nodal status. Novel imaging studies, such as positron emission tomography–CT and USPIO (ultra–small-particle superparamagnetic iron oxide)–MRI are promising modalities and may improve the accuracy of imaging in the future. Nomograms provide some additional information, but novel variables, such as molecular markers, are needed to improve the accuracy of risk-stratification models.ConclusionsIncorrect clinical staging and especially understaging is a serious problem in BCa, and improvements in all steps of the staging process are needed to achieve more accuracy and improved care for BCa patients.