Available technologies today to improve TURBT and cystoscopy outcomes include the photodynamic detection (PDD), Narrow band imaging (NBI), Storz Professional Image Enhancement System (SPIES), and Optical Coherence Tomography (OCT), which is just investigational at this time.
PDD entails instillation of Hexaminolevulinate hydrochloride (HAL) 85 mg powder in 50 ml saline into the bladder, which is retained for 1 hour before TURBT. Protoporphyrin IX, which is the fluorescent substrate, accumulates in the neoplastic tissue. This substrate is introduced into the tumor cells and is detected using blue light. PDD has been FDA approved since 2010. It is important to wait at least 90 days after the last intravesical therapy to avoid false positive. A meta-analysis of prospective PDD studies has shown that PDD improves detection rate by 20% (39% in CIS only), it reduces rate of recurrence at 12 months by approximately 10% of patients, increases recurrence free survival from 12 to 24 months, and reduces the residual tumor load after TURBT with PDD. However, one of its disadvantages, is that it has been shown not to reduce recurrence rates in newly diagnosed non-muscle invasive bladder tumors (NMIBC). PDD should be reserved for high risk patients, including multifocal recurrent tumors requiring demanding resection, and in situations of occult positive urinary cytology.
NBI – filters out the red spectrum of white light. It helps detect the structural change of vessels formation and thickness of mucosa. NBI detects more tumors and abnormal lesions, including CIS. It reduces recurrence rates only in low grade tumors. It is user friendly and applicable both in lower and upper tract.
The SPIES technology is a user friendly technique and applicable to both lower and upper tract. It highlights the contrast of capillaries and vessels within the submucosa, while preserving information from deeper layers of the tissue. Unfortunately, it is a new technology with no data available regarding improvement of detection/recurrence. It is hoped that it may lead to better quality of TURBT.
Dr. Paniero concluded his elaborate presentation and stated that utilization of these techniques should become standard of care in all TURBTs.
Presented by: Dr. Luis Martinez – Pineiro
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal