# Optimizing Rigid Cystoscopy and Biopsy Requests for Red Patches After Flexible Cystoscopy: A Two‑Cycle Quality Improvement Audit

## TL;DR

This study shows that a new approach to managing red patches found during a flexible cystoscopy can reduce unnecessary procedures and safely detect cancers.

## Contribution

The study introduces a consultant-led pathway with image capture and risk stratification to optimize biopsy decisions for red patches.

## Key findings

- Biopsy rates for red patches dropped from 58.7% to 31.5% after implementing the new pathway.
- All malignancies occurred in patients over 60 years old, with three having a smoking history.
- Most red patches resolved spontaneously or after UTI treatment, and some were safely managed without biopsy.

## Abstract

Background

Flat erythematous “red patches” (RPs) identified during flexible cystoscopy are common and often benign, yet they have historically prompted rigid cystoscopy and biopsy under general anesthesia. This practice can lead to unnecessary procedures with low diagnostic yield, added morbidity, and increased healthcare burden.

Objective

To evaluate the local practice regarding rigid cystoscopy and biopsy for RPs and to assess the impact of a targeted departmental intervention.

Methods

This was a single-center, retrospective, two-cycle quality improvement audit at a UK district general hospital. Cycle 1 included all flexible cystoscopies between March and June 2024 and Cycle 2 between November 2024 and February 2025. Data collected included demographics, cystoscopy indication, smoking history, urinary tract infection (UTI) status, biopsy decisions, histology, antibiotic use, and relook outcomes. Following Cycle 1, an intervention was introduced comprising mandatory red-patch image capture, consultant review prior to biopsy listing, and structured teaching on morphology, risk stratification, and benign mimics.

Results

In Cycle 1, 63 RP cases were identified; 37 (58.7%) underwent biopsy, with three malignancies detected (8.1%). Relook cystoscopy was performed in 26 patients, with resolution in 20 (76.9%); of six persistent cases, three underwent biopsy (one malignancy) and three were observed safely. In Cycle 2, 73 cases were identified; 23 (31.5%) underwent biopsy, with one malignancy (4.3%). Relook was performed in 48 patients, with resolution in 32 (66.7%); of 16 persistent cases, eight underwent biopsy (one malignancy) and eight were managed conservatively. Across both cycles, all malignancies occurred in patients >60 years; three of four had a smoking history, and one coincided with proven UTI. Antibiotic prescribing remained frequent, including in patients without culture-proven infection.

Conclusion

In our center, a consultant-led, image-supported, risk-stratified pathway appeared to reduce unnecessary rigid cystoscopy and biopsy requests for RPs, with no observed delays in cancer detection during the audit period. Most lesions resolved spontaneously or after UTI treatment, and several persistent but low-risk patches were managed safely without biopsy. However, with only four malignant cases identified, oncological safety cannot be definitively established, and these findings should be regarded as exploratory. This study is further limited by its single-center, retrospective design and small event rate. Future work should prioritize antibiotic stewardship, standardization of relook intervals, and evaluation of urine cytology in high-risk patients.