Beyond morphology: Toward integrated risk assessment in urinary cytology

Urinary cytology remains the cornerstone of noninvasive detection and surveillance of urothelial carcinoma, particularly high-grade disease. Despite the advances achieved through The Paris System, diagnostic challenges persist in the detection of low-grade lesions and in the management of indeterminate cytologic findings. Two recent studies published in Cancer Cytopathology illustrate how ancillary biomarkers may address these limitations. Keratin 17 immunocytochemistry improved diagnostic performance when combined with cytology, particularly in morphologically subtle cases, whereas the methylation-based Bladder EpiCheck assay enhanced risk stratification among patients with indeterminate cytology and negative cystoscopy. Together, these studies demonstrate that biomarkers provide the greatest clinical value when integrated with cytomorphologic assessment rather than used as standalone tests. Their findings support a future model of urinary cytology that combines morphologic expertise with immunocytochemical, molecular, and epigenetic biomarkers to improve urothelial carcinoma detection and individualized risk assessment.