Implementing Blue Light Flexible Cystoscopy in Non-Muscle Invasive Bladder Cancer Surveillance

Abstract

White light cystoscopy (WLC) has long been the standard procedure for visualisation of non-muscle-invasive bladder cancer (NMIBC), both during transurethral resection of bladder tumour (TURBT) and subsequent surveillance visits. The limitations of white light in the operating room are well recognised, and blue-light-guided diagnosis with hexaminolevulinate (HAL) is routinely used as an adjunct to white light rigid cystoscopy to allow for improved detection of malignant tumours. Emerging data for the implementation of blue light flexible cystoscopy (BLFC) in the surveillance setting demonstrate similar clinical benefits to its current use in rigid cystoscopy. In the first Phase III study comparing BLFC with HAL versus WLC for NMIBC surveillance, around 1 in 5 confirmed malignancies were detected only by BLFC (p<0.0001) and the incidence of HAL-related adverse events (AE) was very low. The introduction of BLFC for routine surveillance post-TURBT is supported by consensus among bladder cancer specialists. Patients at high risk of recurrence could benefit from BLFC at the 3 and 6-month cystoscopy, and at 3 to 6-monthly intervals thereafter for the first 2 years post-TURBT. Intermediate-risk patients may also benefit from BLFC at the initial 3-month cystoscopy. Further research is needed to confirm the optimal timing of BLFC in high and intermediate-risk patients, and to clarify the role of BLFC in surveillance of low-risk patients. The ongoing Nordic and USA blue light registries should help to answer these questions.