AUA 2020: Malignant Urinary Cytology of Unknown Origin: Blue Light Flexible Cystoscopy at the Outpatient Clinic May Be a Valuable Diagnostic Tool

( The diagnostic process may be extensive in patients with non-muscle invasive bladder cancer (NMIBC) who have positive or suspicious urinary cytology when white-light flexible cystoscopy is negative. The next step in management is typically to proceed with resection biopsies and exclusion of upper urinary tract tumors, procedures that are performed in the operating room, which is demanding on both the patient and the healthcare system. Blue light with rigid cystoscopy at the time of transurethral resection of bladder tumors is routinely used as an adjunct to white light rigid cystoscopy, allowing improved detection of malignancy and is recommended by the AUA guidelines.1 At the American Urological Association (AUA) 2020 Virtual Meeting, Marie Andersson, MD, presented results of their study assessing if blue light flexible cystoscopy can detect more bladder tumors at the outpatient clinic and how blue light flexible cystoscopy can improve the diagnostic process in patients with normal white light flexible cystoscopy and positive or suspicious cytology. 

For this study, data was collected from a Nordic prospective multicenter registry of blue light flexible cystoscopy. This registry contains variables including the subjective experience from blue light flexible cystoscopy and whether the patient preferred to have the procedure done under general anesthesia.

A total of 40 patients displaying positive or suspicious urinary cytology were selected. All patients had been investigated with white light flexible cystoscopy and CT urography, both of which were negative. For the blue light flexible cystoscopy procedures, hexaminolevulinate was installed one hour before cystoscopy, and local gel anesthesia was used prior to the bladder being examined with white light flexible cystoscopy followed by blue light flexible cystoscopy. Suspicious lesions were biopsied and examined by histopathology, whereas small tumors and localized carcinoma in situ (CIS) where fulgurated. In six patients, blue light flexible cystoscopy was performed more than once. 

Bladder cancer was diagnosed in 20 out of 47 (43%) cystoscopies. In 35% (7/20) of these cystoscopies, tumors were only detected by blue light flexible cystoscopy. All patients with tumors detected by blue light flexible cystoscopy only (n=5, CIS; n=2, Ta) were immediately treated completely with ablation in the outpatient clinic or subsequently treated with Bacillus Calmette-Guérin (BCG). The majority of patients (27/29) stated that they preferred to have blue light flexible cystoscopy at the outpatient clinic, whereas two patients preferred the alternative procedure (transurethral resection with biopsies) in the operating room under general anesthesia. No serious adverse events or allergic reactions were seen. 

Dr. Andersson concluded that blue light flexible cystoscopy in the outpatient clinic may be a simple way to solve many unclear cases with malignant or suspicious urinary cytology. Importantly, the procedure was well-tolerated and generally preferred by patients rather than the inconvenience of undergoing general anesthesia in the operation room.

Presented by: Marie Andersson, MD, Department of Urology, Helsingborg Hospital, Helsingborg, Sweden

Co-Authors: Anders Debes, Mats Bläckberg

Written by: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, Georgia, Twitter: @zklaassen_md at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020


  1. Chang, Sam S., Stephen A. Boorjian, Roger Chou, Peter E. Clark, Siamak Daneshmand, Badrinath R. Konety, Raj Pruthi et al. "Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline." The Journal of urology 196, no. 4 (2016): 1021-1029.
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