In-office blue light: Solid data, and questions

Author(s):

"Overall, the take-home message is that [blue light cystoscopy], whether in the clinic or the OR, increases the detection of tumors," writes Jeffrey M. Holzbeierlein, MD.

Jeffrey M. Holzbeierlein, MD

Dr. Holzbeierlein

Blue light cystoscopy (BLC) utilizes hexaminolevulinate HCl (Cysview), an optical imaging agent, to increase the detection of bladder tumors. It is the focus of research Daneshmand et al discussed in the October 2017 issue of Urology Times.

In the U.S., the product is utilized in the operating room to increase detection of tumors at the time of transurethral resection of a bladder tumor (TURBT). AUA guidelines on nonmuscle-invasive bladder cancer (NMIBC) advocate its use in patients with NMIBC at the time of TURBT (moderate recommendation) and in patients with a positive cytology but negative cystoscopy (expert opinion).

Multiple prospective studies have demonstrated that BLC can increase detection of tumors and in particular the detection of carcinoma in situ (CIS) (J Urol 2004; 171:135-8; J Urol 2005; 174:862-6; J Urol 2007; 178:62-7; J Urol 2007; 178:68-73). Comparisons of this technology to narrow band imaging (NBI) generally have demonstrated the superiority of blue light for detection of lesions (Urology 2017; 102:138-42). In multiple studies, BLC has also been shown to decrease recurrences and in one study reduced the rate of required cystectomy (J Urol 2010; 184:1907-13; Eur Urol 2010; 57:607-14; J Urol 2012; 188:58-62). Current studies have shown a trend, but not a significant impact, on progression (Bladder Cancer 2016; 2:273-8).

Daneshmand et al studied the use of BLC in the office setting. As expected, the study showed increased detection of tumors, with false positives similar to white light cystoscopy (WLC). In addition, more CIS was detected, which is particularly important.

There are, however, some logistical issues related to in-office BLC. The patient must have the agent instilled by a catheter 45 minutes to an hour prior to the procedure, which may be challenging to administer, for the patient to hold, and for timing of the procedure during a busy clinic.

Also, one might question whether the increased costs associated with BLC are beneficial in this setting, especially if low-grade tumors are taken out of the analysis. Since these tumors represent minimal risks to patients, not catching a small low-grade tumor on an in-office cystoscopy probably makes little difference in the disease course. In addition, how many patients with CIS that was missed on WLC in the office would have been picked up by cytology or other urinary marker? These questions deserve further study.

Overall, the take-home message is that BLC, whether in the clinic or the OR, increases the detection of tumors. In the OR, use of BLC decreases recurrences and may be shown to impact progression, but these benefits have yet to be proven in the office setting.