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Bladder wash cytology provides superior results for the detection of bladder malignancies than does voided urine analysis. Image analysis systems have been developed for quantification of cytologic fea tures. In this study, routine bladder wash cytology is compared with an automated image analysis sys tem (QUANTICYT). We studied a random set of 100 bladder wash samples from a population of 1614 patients in follow-up after bladder cancer. Four ex perienced pathologists interpreted the same 100 Pa panicolaou-stained slides. Cytologic and image analysis results were compared for prediction of a cystoscopic lesion, histologic abnormalities, and tu mor recurrence. After application of receiver oper ating characteristic curves, prediction of a cysto scopic lesion by cytology and image analysis was comparable. Both the image analysis system and the cytologic examination detected all of the high-grade lesions. Image analysis was superior to cyto logic analysis for the prediction of tumor recurrence after normal findings at cystoscopic examination