AUA 2022: Is A Restaging TURBT Necessary in High Risk NMIBC if the Initial TURBT Was Performed Using Blue Light?

( The 2022 American Urological Association (AUA) Annual Meeting included a session on the epidemiology and evaluation of bladder cancer and a presentation by Dr. Muhannad Alsyouf discussing whether a restaging TURBT is necessary for high risk Non-Muscle Invasive Bladder Cancer (NMIBC) if the initial TURBT was performed using blue light. In patients with high grade Ta and T1 urothelial carcinoma of the bladder, restaging TURBT is recommended by several guidelines (including the AUA/SUO guidelines) secondary to the high rate of residual tumors and upstaging: high grade Ta - 50% residual disease, 15% upstaged; T1 - 50-70% residual disease, 30% upstaged. Blue light cystoscopy using hexaminolevulinate (HAL/Cysview) has been shown to improve detection of NMIBC.1 Dr. Alsyouf and colleagues hypothesized that the use of blue light cystoscopy at the time of initial TURBT improves complete resection rates and reduces risk of upstaging. Consequently, patients who undergo initial TURBT with blue light cystoscopy may not require restaging TURBT thus reducing patient morbidity and resource utilization.

Using the multi-institutional Cysview registry between 2014 and 2021, all consecutive adult patients with known NMIBC (Ta and T1 disease) who underwent TURBT followed by a restaging TURBT within 8 weeks were reviewed. Patients were stratified according to their initial TURBT, blue light cystoscopy versus white light TURBT, and compared to determine rates of residual disease and upstaging to muscle invasive disease.

Overall, 123 patients had TURBT for NMIBC followed by a restaging TURBT within 8 weeks and were included in the analysis. The baseline characteristics of the patients stratified by blue light versus white light cystoscopy are as follows. 

Patients who underwent blue light cystoscopy for their initial TURBT had higher rates of benign pathology on their restaging TURBT compared to white light cystoscopy, although this was not statistically significant (47% vs 33%; p = 0.20). Among patients with residual tumors on restaging TURBT, there was no significant differences in rates of Ta (23% vs 24%; p = 1.0), T1 (23% vs 24%; p = 1.0), or CIS (3% vs 15%; p = 0.90) when the initial TURBT was done using blue light cystoscopy/HAL compared to white light cystoscopy. Rates of upstaging to muscle invasive disease were also not different when initial TURBT was performed using blue light cystoscopy/HAL compared to white light cystoscopy (Ta: 14.2% vs 8.3%, p = 0.68; T1: 3.4% versus 4.5%, p = 0.82): 

As part of his discussion, Dr. Alsyouf notes that the reason for these results may be secondary to HAL being dependent on direct contact for absorption in malignant tissue, and that residual disease and invasive layers of tumors are often microscopic. Several limitations as highlighted by Dr. Alsyouf are (i) selection bias and non-randomization, (ii) the small sample size and inability to determine the impact of other variables on outcomes (tumor size, adverse pathologic features, etc), and (iii) variations in initial TURBT quality as a potential confounding factor.

Dr. Alsyouf concluded this presentation discussing whether a restaging TURBT is necessary in high risk NMIBC if the initial TURBT was performed using blue light with the following take-home messages:

  • TURBT using blue light cystoscopy/HAL does not reduce rates of residual disease or risk of upstaging on restaging TURBT in high risk NMIBC
  • Thus, a restaging TURBT is still necessary even if initial TURBT was performed using blue light cystoscopy/HAL 

Presented by: Muhannad Alsyouf, MD, University of Southern California, Los Angeles, CA

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 2022 American Urological Association (AUA) Annual Meeting, New Orleans, LA, Fri, May 13 – Mon, May 16, 2022.


  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