A review of the records of more than 1,000 patients with bladder cancer has led to the identification of 9 with superficial papillary tumors and no evidence of muscle invasion in whom distant metastases developed. The majority of these patients had multiple recurrent tumors that were difficult to control by endoscopic means and failed to respond to intravesical chemotherapy, Helmstein's therapy or radiotherapy. Of the patients 4 had superficial tumors in the prostatic ducts but no stromal invasion. In 7 patients with well or moderately differentiated tumors the histological grade was the same in the metastases. The sites of metastases were bone in 5 patients, lung in 3 and liver in 1, which suggested hematogenous spread of tumor. Histological evidence of microvascular invasion was seen in 2 of the resected bladder tumors. We conclude that failure to control bladder tumors by local means should be an indication for early cystectomy, even in patients with no evidence of muscle invasion.

Flexible carbon dioxide cystoscopy has been carried out in 65 patients using an Olympus BF type 1 TR endoscope (usually used for bronchoscopy). Good views were obtained and comparison with standard cystoscopy confirmed that no lesions were missed. The procedure was well tolerated under local anaesthesia. The flexible cystoscope was particularly useful in examining patients with diverticula, anterior bladder neck lesions or the post-radiation fibrotic pelvis.