The occult urothelial cancerTransitional cell carcinoma (TCC) is the tumor that most frequently affects the urinary tract. The most common location is at the level of the bladder; the diagnosis is based, as per the follow-up, on urine cytology, endoscopic, and radiological examinations. Urine cytologic study is an important noninvasive tool used in the diagnosis and follow-up of patients with TCC. A positive urine cytologic study result is highly predictive of the presence of TCC, even in the presence of normal cystoscopy results because malignant cells may appear in the urine long before any cystoscopically visible lesion becomes apparent. A positive urinary cytology, in the absence of clinical or endoscopic evidence of a TCC, can identify an occult urothelial cancer, located in any site of the urinary tract (upper urinary tract, bladder, prostatic urethra). Actually, in literature there is no consensus on the identification and evaluation of occult urothelial cancer, whose diagnosis is still based on urine cytology. In order to improve the accuracy of urinary cytology, numerous molecular markers have been identified; however, the real clinical application remains unclear. Photodynamic diagnosis and narrow band imaging (NBI) technology increase the diagnostic accuracy of cystoscopy in the presence of lesions not easily detectable. The aim of this review is to analyze the current diagnostic standards and the new diagnostic tools in the presence of suspect occult urothelial cancer.