Early Photodynamic Diagnosis Cystoscopy after BCG Induction for High-Risk Non-Muscle Invasive Bladder Cancer Significantly Increased the Detection of BCG Refractory Tumors - Beyond the Abstract

Early cystoscopy after Bacillus Calmette–Guérin (BCG) induction is essential and plays an important role in ensuring to recognize BCG refractory tumors. Although Photodynamic diagnosis cystoscopy (PDD-C) is proven to be more sensitive than white light cystoscopy (WL-C) particularly for CIS,1 there is currently no recommendation to use PDD for surveillance. WL-C is the gold standard in the surveillance of patients with non-muscle-invasive bladder cancer (NMIBC)1 and the efficiency of intravesical adjuvant BCG in high-risk NMIBC relies on studies performed with WL-C.

Despite PDD improving oncological outcomes, the impact of PDD in detecting BCG refractory patients is still unknown. We hypothesize that early PDD cystoscopy may improve the detection of recurrent tumors after BCG induction. Thus, we examined a contemporary series of patients undergoing PDD cystoscopy to investigate the value of enhanced cystoscopy in the early diagnosis of BCG refractory tumors.

We performed a monocentric retrospective study of consecutive patients with high-risk NMIBC diagnosed between January 2017 and January 2021. All patients had an initial transurethral resection of bladder tumor (TURBT) with PDD, ± restaging TURBT if needed, followed by full-dose BCG induction. Within 8 weeks following BCG induction all patients had both WL-C and PDD-C under general anesthesia ± TURBT in cases of suspicious lesions. The primary endpoint was the detection of bladder cancer (BC) at post-BCG cystoscopy. A total of 136 consecutive patients met the inclusion criteria. PDD-C detected 16 additional tumors: 81.3% Ta, 18.7% T1, 75% associated CIS and 75% high grade. Systematic use of early PDD-C after BCG induction increased the detection of BCG-refractory tumors and lead to a significant modification in the treatment suggesting PDD-C should be considered in the surveillance of high-risk NMIBC.

Written by: Dr. Michele Morelli, Department of Urology and Kidney Transplantation, Conception Academic Hospital, Aix-Marseille University APHM, Marseille, France.


  1. Babjuk M, Burger M, Compérat EM, et al. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update. Eur Urol. 2019 Nov;76(5):639-657.

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