PURPOSE OF REVIEW: The prognosis of patients with high-risk bladder cancer is generally poor. In addition to advanced stage and high-grade tumors, several histopathological subtypes of invasive bladder cancer have been identified as being more aggressive than conventional forms. However, modalities for early detection of such aggressive neoplasms are limited. This review examines the pathological features of aggressive bladder cancer and critically reviews the performance of selected methodologies that are commonly used to detect such lesions. RECENT FINDINGS: Strategies including bladder tumor antigen assay, NMP22, ImmunoCyt, and UroVysion hold promise for the early detection of aggressive urothelial carcinomas of the bladder. However, such approaches are currently limited by their sensitivity and potential for false-positive results, and are unlikely to substitute cystoscopy. SUMMARY: Molecular-based detection techniques represent potentially attractive strategies for noninvasive detection of aggressive bladder cancer using urine as the specimen source. Identification of new markers and development of novel platforms may improve detection in the future.