SUO 2021: Economic Outcomes of Hexaminolevulinate Blue-Light Cystoscopy Compared with White Light Cystoscopy for Diagnosis and Monitoring of Non-Muscle Invasive Bladder Cancer: A 5-Year, Medicare-based Model

( The Society of Urologic Oncology (SUO) annual winter meeting included a bladder cancer session and a presentation by Dr. Michael Creswell discussing the economic outcomes of hexaminolevulinate blue-light cystoscopy compared to white light cystoscopy for the diagnosis and monitoring of non-muscle invasive bladder cancer (NMIBC). Bladder cancer is the sixth most common cancer in the United States, with NMIBC representing 70% of new bladder cancer diagnoses. Due to high recurrence rates and health system utilization, bladder cancer is among the most expensive cancers to treat on a per-patient basis. Historically, TURBT was performed with white light cystoscopy, however, blue light cystoscopy with hexaminolevulinate has gained favor over white light cystoscopy due to improved detection of clinically significant neoplastic lesions.1 Despite the higher upfront cost of blue light cystoscopy, improved diagnostic accuracy, and surveillance of NMIBC may yield long-term cost savings and decreased financial burden on healthcare systems.2 This study sought to model American Urologic Association (AUA) bladder cancer guidelines and run a Monte Carlo simulation to investigate the 5-year cost comparison of blue light cystoscopy and white light cystoscopy.

For this study, the model was created in Microsoft Excel with the @RISK simulation software. The clinical decision tree was based on the AUA bladder cancer guidelines. The model included the assumption that 35% of high-risk NMIBC patients did not respond to intravesical therapy and ultimately were managed with radical cystectomy. Variant histology, re-resection TURBT, bladder-preserving trimodality therapy, and partial cystectomy were not included in the model. Inputs for NMIBC incidence and recurrence for blue light cystoscopy and white light cystoscopy were based on Burger et al.3 and Klaassen et al.2 and simulated with 60,000 iterations. Economic inputs were sourced from 2021 national Medicare reimbursement averages. The primary outcome was mean year-over-year cumulative cost discounted to present value at 3%, and the secondary outcome was the rate of clinical events. Data were modeled for 5 years from NMIBC diagnosis and analyzed on a yearly basis.

 After 5 years, patients in the blue light cystoscopy cohort experienced 25.3% fewer recurrences than those in the white light cystoscopy cohort: 1,368 white light cystoscopy versus 1,022 blue light cystoscopy per 1,000 patients. Overall, 13.7% and 10.4% of white light cystoscopy and blue light cystoscopy patients, respectively, underwent radical cystectomy after 5 years. On a cumulative present value cost basis, blue light cystoscopy was more expensive per patient in years 1 and 2 than white light cystoscopy ($10,493 and $14,479 versus $9,452 and $13,921), however, in years 3, 4, and 5, blue light cystoscopy was economically favorable to white light cystoscopy. Year 5 blue light cystoscopy mean cumulative cost savings was $1,527 per patient ($27,447 versus $28,973). As follows is the year-over-year average cost per patient of blue-light and white-light guided TURBT:



The cumulative average cost per patient by year is as follows:


Overall, 31.4% of all patients in the blue light cystoscopy group generated cumulative cost savings compared to white light cystoscopy at year 1 compared with 51.6% at the end of year 5.

Dr. Creswell concluded his presentation with the following take-home messages:

  • In a Medicare-based economic model, blue light cystoscopy was associated with a cumulative $1,527 cost savings per patient over white light cystoscopy alone for management of NMIBC at year 5
  • Despite the higher initial annual cost, the cumulative economic advantage of blue light cystoscopy is realized by surveillance at year 3
  • A greater proportion of patients who received blue light cystoscopy achieved cost savings compared with white light cystoscopy, with no detriment in oncologic outcomes
  • As costs were assumed from the Medicare perspective, fixed costs were not included in the analysis which may limit the conclusions. However, with the emergence of alternatives to fee-for-service payment models, health system margins will be achieved through cumulative cost savings rather than volume
  • Economic simulations represent a framework through which emerging clinical innovation can be evaluated to inform cost-effective care 

Presented by: Michael L. Creswell, Georgetown University, Washington, D.C.

Co-Authors: Tamir N. Sholklapper, Mark A Pianka, James B. Mason, Christopher P. Dall, Canan Ulu, Lambros Stamatakis

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 Society of Urologic Oncology (SUO) Winter Annual Meeting, Orlando, FL, Wed, Dec 1 – Fri, Dec 3, 2021.


  1. Daneshmand S, Patel S, Lotan Y, et al. Efficacy and Safety of Blue Light Flexible Cystoscopy with Hexaminolevulinate in the Surveillance of Bladder Cancer: A Phase III, Comparative, Multicenter Study. J Urol 2018 May;199(5):1158-1165.
  2. Klaassen Z, Li K, Kassouf W, et al. Contemporary Cost-Consequences Analysis of Blue Light Cystoscopy with Hexaminolevulinate in Non-Muscle Invasive Bladder Cancer. Can Urol Assoc J 2017 Jun;11(6):173-181.
  3. Burger M, Grossman HB, Droller M, et al. Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: A meta-analysis of detection and recurrence based on raw data. Eur Urol. 2013;64:846-854.