Blue Light Cystoscopy with Cysview®: Tips and Tricks - Anne Schuckman
June 30, 2020
Anne K. Schuckman, MD, Assistant Professor, Director, LAC+USC Urologic Oncology, Keck Hospital of USC, USC Norris Cancer Hospital, Los Angeles, California
Ashish Kamat, MD, MBBS, President, International Bladder Cancer Group (IBCG), Professor of Urology & Cancer Research, MD Anderson Cancer Center, Houston, Texas
Ashish Kamat: Welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat from MD Anderson Cancer Center in Houston. And it's my great pleasure to be joined today by Anne Schuckman who's at the USC Institute of Urology and has done a lot of work with blue light cystoscopy with Cysview®, and she had a plenary session at the AUA live just recently. And today she's going to talk to us about the salient tips and tricks with blue light cystoscopy, and then share some pearls with our audience today. So, Dr. Schuckman, take it away.
Anne Schuckman: Thank you, Ashish, it's my great pleasure to be able to present today. So we'll talk a little bit about blue light cystoscopy with Cysview®, tips and tricks. As you mentioned, this is a little bit of a condensed version of the talk that I presented at the AUA plenary.
So, as we know, TURBT is the first-line treatment for bladder cancer and improvement in the quality of a TURBT can lead to a reduced risk of recurrence as well as subsequent cost savings by eliminating trips to the operating room. We also know with bladder cancer that under staging is quite common, and studies have shown that 50% of patients with high-grade TA disease had persistent disease at the time of re-resection. Fifteen percent of those high-grade patients could be upstaged to T1, and almost half of those T1 patients could be upstaged to muscle-invasive bladder cancer.
So the question really is, can we do a better TURBT? I think there's really overwhelming evidence that we can. One of the tools in our armamentarium is blue light cystoscopy with Cysview®. So, just by way of background, Cysview® is a chemical that is instilled into the bladder via a Foley catheter. It is a precursor of a photoactive porphyrin that is selectively taken up by cancerous cells within the bladder. So when you're viewing the bladder with white light, the tumor may look pink, the bladder will look pink, but under blue light, the tumor itself will actually glow to a hot pink color and the background will appear blue.
There are multiple benefits of blue light cystoscopy with Cysview®, including increased detection of TA and T1 tumors as well as carcinoma in situ, increased ability to completely resect tumors, increased time to recurrence, a potential decrease in progression, and increased satisfaction and confidence with the process on both parts of the patient as well as the provider.
So, how can we maximize these benefits and make sure that we're reaping them in our own blue light cystoscopy practice? Today, we'll talk about some tips and tricks that can help us avoid these five pitfalls. One, avoiding incomplete resection. Two missed carcinoma in situ. Three, logistics, how to make it all smooth. Four, avoiding the green view when using flexible blue light cystoscopy and five, trying to avoid false positives after BCG or some of the tangential views that you may get near the bladder neck area.
So, on this slide, we'll look at tip number one, avoiding incomplete resection. In this video, you can see that when you first look with the white light, there's an obvious papillary lesion, but that the borders of that lesion extend well beyond the papillary area. And this tumor is resected. This is obviously in the operating room using a loop, though this could be done in the office as well with the flexible scope. And even at the completion of resection, when we look back with the blue light, it becomes quite clear that there's tumor extending beyond the edges of the papillary lesion. And in this case, given that this is low-grade disease, we decided just to fulgurate this area of tumor. So because we can do a more complete resection of this lesion, this patient is unlikely to recur in the same location and will avoid being labeled as an early recurrence, as opposed to just an incomplete resection.
Tip number two is the detection of invisible carcinoma in situ. So, blue light is a great tool for detecting carcinoma in situ. We know that we can pick up at least 20% to 30% of carcinoma in situ that is completely invisible under white light. And here you can see that the lesion visualized under white light actually has fairly distinct borders. And so we can look at those borders and how the borders stay put even when we are moving the scope, which leads us to think that this is actually a true lesion that is likely to be carcinoma in situ, rather than just a false positive area that may be caused due to a tangential view. So, flipping back and forth between the blue and the white can really help in that situation.
Third tip, logistics. Everybody's always worried that adding blue light into the mix for a TURBT will take extra time and extra energy on the part of the OR or clinic staff. I like to keep it simple as far as how I use blue light to make it smooth. In the operating room, I essentially use blue light for every transurethral resection except obvious large T2 tumors where it's not really going to make a difference in terms of ultimate management for the patient. This avoids confusion in pre-op, as far as whether or not we need to insert a catheter, which consent we need and it allows us to use standard order sets. Additionally, as long as the Cysview® is in the bladder for about 30 minutes prior to rolling back to the operating room, there's plenty of time for the medication to be effective. By the time you're actually starting the case after the patient is anesthetized, it usually is between 45 minutes to an hour of dwell time.
In the flexible situation, I think that the most important thing to get the most out of blue light is optimizing patient selection. There was actually a consensus panel that came together to make recommendations as far as the use of flexible blue light cystoscopy in the clinic. So low-risk patients with just a solitary TA tumor may not be served by routine use. However, in intermediate-risk patients, particularly those patients with recurrent low-grade disease, it's recommended to use the blue light cystoscopy at the first three-month cystoscopy. I think there are also many other uses for blue light in the intermediate-risk patient as well in the longer term.
Finally, in high-risk patients, the panel recommended the use of blue light flexible cystoscopy at their first and second cystoscopies following initial diagnosis, as well as every six months for two years. By picking patients who are most likely to benefit, you can really pick and choose, so every patient in clinic is not getting blue light cystoscopy as it can be a time-consuming process for patients in their flow through clinic.
Tip and trick number four, optimizing your view with blue light cystoscopy. This is a flexible blue light picture of a mass that I was viewing at a previously resected site in a patient's bladder. Unfortunately, I forgot to evacuate the patient's bladder well prior to going into blue light mode, and then all I saw when I went into blue light mode was green urine in the bladder completely obscuring my view.
The blue light system in clinic does have suction which allows you to evacuate the urine as well as perform biopsy. So, once I evacuated the urine, I was actually able to see a much clearer view and determine if these areas were blue light positive or not. I think it also helps to have the patient void prior to initiating the cystoscopy in clinic, but really getting facile with the suction system is quite important.
Finally, I think that one of the best uses for flexible blue light cystoscopy can be in the post BCG setting. This is a patient who had had high-grade TA disease, and I was performing a post-induction flexible cystoscopy in the office. So, you can see that there are multiple areas that appear to be blue light positive, and instead of this patient really having to undergo a whole trip to the operating room, I was able to feel confident and guide my biopsies using the blue light to perform a flexible blue light biopsy in the office. And this pathology actually did come back showing high-grade TA disease. There have been several studies looking at the false-positive rates for a post BCG biopsy with white light and blue light, and the false-positive rates have been found to be quite comparable between the two.
So blue light cystoscopy certainly increases the detection of clinically significant cancers. It allows us to complete a more thorough resection and lower recurrence rates by using blue light cystoscopy. False-positive rates are similar to white light in the post BCG or intravesical therapy setting, and blue light flexible cystoscopy can allow early identification and management of disease in the ambulatory setting. Thank you.
Ashish Kamat: That was great, Anne. Thank you so much for doing that. A couple of questions that we often get from the audience and I'll ask these, not because I know the answer or have a bias, but I really want to know what you think. So, one of the things that people will often ask is, "Well, I'm going to use postoperative mitomycin, so what does it matter if I resect these little fronds that I see extending from the margin of the tumor?" How would you respond to that statement?
Anne Schuckman: Yeah, I mean, I think that the role for intravesical therapy is really thinking about preventing implantation from the small cells that are floating around after we do a resection, but I don't think that intravesical therapy will really get rid of gross disease. And so I guess you could say, "Well, is this sort of microscopic disease gross disease?" But I think it is. And I'm not sure that intravesical therapy will really eradicate a patient from existing disease.
Ashish Kamat: The other question we often get is, "Well, I have narrow-band imaging and there's not been a head-to-head comparison, but in the office, should I really invest in a whole new system? Or can I just use narrowband imaging in the office along with cytology and then blue light in the operative setting?"
Anne Schuckman: Right. So there is no head-to-head comparison as you mentioned, between the two. There are some studies that are sort of comparative retrospectively, but I don't think there's any clear data on NBI versus blue light. I've been lucky enough to have NBI in the clinic as well as flexible blue light in the clinic. And to me, I think it's night and day in terms of visualization, particularly of carcinoma in situ, with blue light cystoscopy compared to NBI.
When I use NBI, I don't find that I have those sort of "aha!" moments of, "Oh, that's a lesion I would have missed." I do think it maybe helps define a lesion that I'm already suspicious about. But with blue light, once you become facile with it, I think all of us are surprised at how many things we just would've missed.
Ashish Kamat: Right, Anne, that's my sense as well. With blue light, we pick up so many more lesions and so much more CIS that I want to know your thoughts on what do you think is going to happen with our definition that we have now with BCG unresponsive disease? Do you think that the data that came out with just BCG unresponsive disease detected with white light, the classic way of detecting it, is still going to have the same implications of someone that gets BCG and has a blue light cystoscopy, and you pick up a focus of CIS? Do you think the prognostic implication of a CIS lesion detected with blue light is going to stay the same, or is it different?
Anne Schuckman: Yeah, that's a great question. I guess time will tell, I think there probably is something to be said for the volume of carcinoma in situ and how that relates to prognosis. And so if we're picking up just small amounts, maybe that's not quite as bad as somebody whose entire bladder is filled with carcinoma in situ. I think this is something we're going to learn.
Ashish Kamat: Right, right. Another question for you is do you do bladder mapping biopsies anymore, or do you rely solely on the blue light cystoscopy to tell you where to get biopsies in someone when you're following them for a higher risk disease?
Anne Schuckman: Yeah, when we first started using blue light cystoscopy, I still did mapping biopsies because I wasn't comfortable not doing that. But over time it is clear that if it's blue light negative, the false-negative rate I think is really essentially zero. And those biopsies just consistently come back normal.
So I do not do bladder mapping anymore, like random biopsies per se. You cannot use the blue light for prostatic urethra biopsies, so obviously in that setting, we're still doing essentially random biopsies. And I think there are times in the post BCG setting where things are so inflamed that I'm not comfortable saying whether something's blue light positive as a false positive or not. And I still will just do a few biopsies that are somewhat mapping biopsies.
Ashish Kamat: And that's a good point that you bring up that even if you rely on the blue light for the bladder itself, if you're at all worried about the prostatic urethra, you need to do a biopsy because we can't use blue light in the prostatic urethra. I'm glad you brought up that point.
This has been a great conversation and, of course, we could go on for much longer, but in the interest of time, we do need to wrap up. Any closing thoughts that you want to share with the audience?
Anne Schuckman: Well, I would say that there's a little bit of a learning curve with getting used to blue light cystoscopy, but once you are familiar with it and used to it, I think that as a provider going back to just using white light almost feels like you're going in blind for a surgery. I would encourage people to try to observe some cases if they can. I think this is really a worthwhile technology that just makes us better surgeons. I think it's a fantastic tool and really one of the biggest changes that we've had available to us in the bladder cancer world and in quite a while,
Ashish Kamat: Thank you so much, Anne, for taking the time to be part of this important educational activity. I know things are crazy in California, just like they are in Texas right now. So stay safe and stay well.
Anne Schuckman: All right, thank you so much, Ashish.