AUA 2019: Flexible Blue Light Cystoscopy with Hexaminolevulinate Provides Opportunity to Finalize Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer in the Outpatient Clinic: Results from a Nordic Registry

Chicago, IL ( More than 81,000 individuals are diagnosed with bladder cancer in the United States every year, of whom 75% have non-muscle invasive disease. Unfortunately, half these cases recur despite transurethral resection of bladder tumor (TURBT), and from 5% to 25% of repeated recurrences progress to muscle-invasive disease. Reliable visualization of bladder tumors is crucial to the success of TURBT, but carcinoma in situ (CIS) and other low-grade flat lesions are difficult to detect under standard white light cystoscopy (WLC). Tools to augment WLC and help increase capture of bladder cancer are critical to improving our management of patients with NMIBC.

Blue light cystoscopy (BLC) is used in conjunction with a photoactive porphyrin, either 5-aminolevulinic acid (ALA) or hexaminolevulinate hydrochloride (HAL), which accrues preferentially in neoplastic tissue and fluoresces when exposed to blue light between 375 and 440 nm in wavelength. Multiple randomized prospective studies have demonstrated that BLC increases bladder cancer yield (detection of Ta, T1 and CIS) at the time of TURBT and reduces bladder recurrences. Several studies have also indicate that the improved detection of bladder tumors with blue light cystoscopy leads to important improvements in management, including the use of intravesical therapy, earlier cystectomy, and closer surveillance.

Initially, BLC was done in conjunction with WLC at the time of rigid cystoscopy. However, there is now increased interest in utilizing it at the time of flexible cystoscopy for diagnostic purposes (and occasionally therapeutic purposes). In this study, the authors have initiated a Nordic registry study to observe the clinical value and explore possible benefits of flexible BLC in the outpatient setting.

The Nordic Blue Light Flexible Cystoscopy registry (BLFC) is an observational study including patients undergoing blue light cystoscopy with HAL in the outpatient clinic for suspicion of, or in routine follow-up for NMIBC. They captured data on patient demographics, bladder cancer history, findings under WLC and BLC, treatment performed, patient preference, physician experience and further management.

To date, the registry includes 208 patients from five hospitals with a total of 370 outpatient visits. Demographics of the cohort are as follows: average age 75, 20% female. No other demographics were provided.

Amongst patients with at least one suspicious lesion, a total of 344 lesions were identified, of which 223 (65%) were biopsied and 56 lesions were treated (fulgurated) within the same procedure, preventing referral for a transurethral resection (TURBT).

Importantly, of these 344 lesions, 99 lesions (29%) were identifiable only by BLC. 64 (65%) of these lesions were biopsied and for lesions with confirmed malignancy, 30% were CIS and 4% T1.

Based on physician responses, BLC provided added value in 75% of the patients, with a stronger confidence in confirming/refuting a suspicious lesion as the main advantage (27%).

Naturally, as can be expected, 95% of the patients preferred the outpatient procedure over a TURBT in the OR.
Based on the population to date, the authors conclude that flexible BLC as an adjunct to WLC in the outpatient clinic improves detection rate of malignant lesions (over WLC alone) and provides the possibility to finalize the diagnosis and treatment of the patients in the outpatient clinic, reducing the need for TURBT. Patients tolerate the treatment well and prefer this procedure over TURBT in the OR.

Presented by: Gorm von Gohren Edwin, Oslo Area, Norway

Co-authors: Anders Debes, Per-Uno Malmstrom

Written by: Thenappan Chandrasekar, MD, Clinical Instructor, Thomas Jefferson University, Twitter: @tchandra_uromd, @JEFFUrology at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois