Comparative effectiveness of fluorescent versus white light cystoscopy for initial diagnosis or surveillance of bladder cancer on clinical outcomes: Systematic review and meta-analysis

To systematically review the comparative effectiveness of fluorescent versus white light cystoscopy on bladder cancer clinical outcomes.

Systematic literature searches of Ovid MEDLINE (January 1990 through September 2015), Cochrane databases, and reference lists were performed. Fourteen randomized trials of fluorescent cystoscopy using 5-amimolevulinic acid (5-ALA) or hexaminolevulinic acid (HAL) versus white light cystoscopy for diagnosis of initial or recurrent bladder cancer that reported bladder cancer recurrence, progression, mortality, and harms were selected for review.

Fluorescent cystoscopy was associated with decreased risk of bladder cancer recurrence versus white light cystoscopy at short-term (<3 months, ten trials, RR 0.59, 95% CI 0.40 to 0.88, I(2)=69%), intermediate-term (3 months to <1 year, six trials, RR 0.70, 95% CI 0.56 to 0.88, I(2)=19%), and long-term followup (≥1 year, 12 trials, RR 0.81, 95% CI 0.70 to 0.93, I(2)=49%). However, findings were inconsistent and potentially susceptible to performance and publication bias (strength of evidence [SOE]: low). There were no differences between cystoscopic methods in risk of mortality (3 trials, RR 1.28, 95% CI 0.55 to 2.95, I(2)=41%) (SOE: low) or progression (9 trials, RR 0.74, 95% CI 0.52 to 1.03, I(2)=0%) (SOE: moderate). Estimates for short-term recurrence (6 trials, RR 0.62, 95% CI 0.38 to 1.00), long-term recurrence (7 trials, RR 0.75, 95% CI 0.62 to 0.92) and progression (4 trials, RR 0.51, 95% CI 0.28 to 0.96) were statistically significant in the subgroup of trials that used HAL, but there were no statistically significant interactions based on the photosensitizer used. Fluorescent cystoscopy was not associated with decreased risk of long-term recurrence in three trials that utilized methods to reduce performance bias with initial cystoscopy (RR 0.96, 95% CI 0.79 to 1.18; I(2)=36%). Data on harms were sparse.

Fluorescent cystoscopy was associated with reduced risk of bladder cancer recurrence versus white light cystoscopy; however, additional trials that adequately guard against performance bias are needed to confirm these findings. Fluorescent cystoscopy with HAL may be associated with decreased risk of progression, but more studies with long-term followup are needed to better understand effects of the photosensitizer used on progression.

The Journal of urology. 2016 Oct 22 [Epub ahead of print]

Roger Chou, Shelley Selph, David I Buckley, Rongwei Fu, Jessica C Griffin, Sara Grusing, John L Gore

The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University. Electronic address: ., The Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University., The Pacific Northwest Evidence-based Practice Center, The Department of Urology, University of Washington.

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