Flexible Cystoscopy Assisted by Hexaminolevulinate Induced Fluorescence: A New Approach for Bladder Cancer Detection and Surveillance?

OBJECTIVE: The aim of this study was the assessment of flexible cystoscopy assisted by hexaminolevulinate (HAL) fluorescence. METHODS: This study was a prospective controlled, within-patient comparison of flexible HAL cystoscopy with standard flexible cystoscopy, HAL rigid and standard white light rigid cystoscopy. Eligible patients received an intravesical instillation of 50 ml hexylaminolevulinate 8 mM solution. First flexible than rigid cystoscopy was performed in each patient using a Combilight PDD system (Richard Wolf, Germany), which provided standard white light and blue light at 375 to 440 nm, with mapping of all lesions detected. All tumors and suspicious areas identified under white light and by red fluorescence with flexible or rigid cystoscopy were then resected by TUR or biopsied. The specimen was assessed by an independent blinded pathologist. RESULTS: In the 45 patients studied 41 (91%) patients had exophytic tumors, of which 39 (95.1%) were detected by HAL flexible cystoscopy and 40 (97.5%) by HAL rigid cystoscopy. 17 (37.8%) patients had concomitant or carcinoma in situ only, which was identified by HAL flexible cystoscopy in 14 (82.3%), by HAL rigid cystoscopy in 15 (88.2%), by flexible standard in 11 (64.7%) and by standard white light rigid cystoscopy in 13 (76.7%) patients. CONCLUSION: HAL fluorescence flexible cystoscopy compared to HAL rigid cystoscopy showed almost equivalent results in detecting papillary and flat lesions in bladder cancer patients. Both procedures were superior to standard white light flexible cystoscopy.     

A phase III, multicenter comparison of hexaminolevulinate fluorescence cystoscopy and white light cystoscopy for the detection of superficial papillary lesions in patients with bladder cancer

PURPOSE: We compared hexaminolevulinate fluorescence cystoscopy with white light cystoscopy for detecting Ta and T1 papillary lesions in patients with bladder cancer. MATERIALS AND METHODS: A total of 311 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM HAL for 1 hour. The bladder was inspected using white light cystoscopy, followed by blue light (fluorescence) cystoscopy. Papillary lesions were mapped and resected for histological examination. RESULTS: Noninvasive pTa tumors were found in 108 of 196 evaluable patients (55.1%). In 31 patients (29%) at least 1 more tumor was detected by HAL than by white light cystoscopy (p<0.05). Six of these patients had no lesions detected by white light, 12 had 1 lesion detected by white light and more than 1 by HAL, and 13 had multiple Ta lesions detected by the 2 methods. Conversely at least 1 more tumor was detected by white light cystoscopy than by HAL cystoscopy in 10 patients (9%, 95% CI 5-16). Tumors invading the lamina propria (T1) were found in 20 patients (10.2%). At least 1 additional T1 tumor was detected by HAL but not by white light cystoscopy in 3 of these patients (15%), while at least 1 more T1 tumor was detected by white light cystoscopy than by HAL cystoscopy in 1 patient (5%, 95% CI 0-25). Detection rates for Ta tumors were 95% for HAL cystoscopy and 83% for white light cystoscopy (p=0.0001). Detection rates were 95% and 86%, respectively, for T1 tumors (p=0.3). HAL instillation was well tolerated with few local or systemic side effects. CONCLUSIONS: HAL fluorescence cystoscopy detected at least 1 more Ta and T1 papillary tumor than white light cystoscopy in approximately a third of the patients with such tumors. Whether this would translate to improved patient outcomes has yet to be determined.     

Improved detection of urothelial carcinoma in situ with hexaminolevulinate fluorescence cystoscopy

PURPOSE: In this European multicenter study we compared hexaminolevulinate (HAL) fluorescence cystoscopy and standard white light cystoscopy for the detection of carcinoma in situ (CIS) in patients suspected of having high risk bladder cancer. MATERIALS AND METHODS: This study was a prospective controlled, within-patient comparison of standard and HAL fluorescence cystoscopy. Eligible patients received an intravesical instillation of 50 ml HAL 8 mM solution. Cystoscopy was performed using a D light system, which provided white and blue light at 375 to 440 nm. The bladder wall was inspected and mapped, first under white light, followed by blue light. All tumors and suspicious areas identified under white light and by red fluorescence were resected or biopsied. Histological findings were assessed by an independent central pathologist blinded to the identity of the biopsies. RESULTS: Of 211 evaluable patients 83 (39%) had CIS, of whom 18 (22%) were detected by HAL cystoscopy only, 62 (75%) were detected by standard and HAL cystoscopy, 2 (2%) were detected by standard cystoscopy only and 1 (1%) was detected by nonguided biopsy. Therefore, HAL cystoscopy identified 28% more patients with CIS than standard cystoscopy. The side effects of HAL instillation were negligible and no unexpected events were reported. CONCLUSIONS: HAL fluorescence cystoscopy improves the detection of bladder CIS significantly, which has consequences for clinical management and may improve the patient prognosis. The procedure is easily implemented as an adjunct to standard cystoscopy and it adds no significant risk of complications.     

Hexyl aminolevulinate fluorescence cystoscopy: new diagnostic tool for photodiagnosis of superficial bladder cancer--a multicenter study

PURPOSE: We examined the sensitivity and specificity of Hexvix (PhotoCure ASA, Oslo, Norway) hexyl aminolevulinate (HAL) fluorescence cystoscopy in patients with superficial bladder cancer. MATERIALS AND METHODS: A total of 52 patients (38 men and 14 women) with a mean age of 72 years were investigated. HAL hydrochloride (100 mg dissolved in 50 ml phosphate buffer solution) (8 mM) was instilled into the bladder 1 hour prior to the endoscopic procedure. Cystoscopy was performed with the Storz D-light (Karl Storz, Tuttlingen, Germany) system, allowing inspection of the bladder wall under white and blue light (380 to 450 nm). RESULTS: A total of 422 biopsies obtained in fluorescing (165) and nonfluorescing (257) areas, including 5 random biopsies per patient, were analyzed to provide the best reference for the calculation of sensitivity and specificity. There were a total of 143 histologically verified tumors in 45 patients, including carcinoma in situ (CIS), Ta or T1 lesions. A total of 43 patients were diagnosed by fluorescence cystoscopy compared with 33 diagnosed by white light for 96% and 73% per-patient sensitivity, respectively. HAL cystoscopy was found particularly useful for finding CIS tumors. Of 13 patients with CIS tumors all except 1 were diagnosed or confirmed by HAL cystoscopy. HAL cystoscopy was well tolerated with no definite drug related adverse events reported, including effects on standard blood parameters. CONCLUSIONS: HAL fluorescence cystoscopy is a new, sensitive, promising diagnostic procedure that showed improved detection of bladder tumors, in particular CIS. The procedure is well tolerated and can easily be implemented in current clinical practice.     

Improved detection and treatment of bladder cancer using hexaminolevulinate imaging: a prospective, phase III multicenter study

PURPOSE: We determined if improved tumor detection using hexaminolevulinate (HAL) fluorescence cystoscopy could lead to improved treatment in patients with bladder cancer. MATERIALS AND METHODS: A total of 146 patients with known or suspected bladder cancer were assessed in this open, comparative, within patient, controlled phase III study. Patients received intravesical HAL for 1 hour and were assessed with standard white light cystoscopy and blue light fluorescence cystoscopy. All lesions were mapped onto a bladder chart and biopsies were taken from suspicious areas for assessment by an independent pathologist. An independent urologist blinded to the detection method used recommended treatment plans based on biopsy results and medical history according to European Association of Urology bladder cancer guidelines. Any differences in recommended treatment plans arising from the 2 cystoscopy methods were recorded. RESULTS: HAL imaging improved overall tumor detection. Of all tumors 96% were detected with HAL imaging compared with 77% using standard cystoscopy. This difference was particularly noticeable for dysplasia (93% vs 48%), carcinoma in situ (95% vs 68%) and superficial papillary tumors (96% vs 85%). As a result of improved detection, additional postoperative procedures were recommended in 15 patients (10%) and more extensive treatment was done intraoperatively in a further 10. Overall 17% of patients received more appropriate treatment at the time of the study following blue light fluorescence cystoscopy, that is 22% or 1 of 5 if patients without tumors were excluded. CONCLUSIONS: HAL imaging is more effective than standard white light cystoscopy for detecting bladder tumors and lesions. This leads to improved treatment in a significant number of patients (p <0.0001).     

门诊患者对软性膀胱镜和硬性膀胱镜的耐受性比较

目的:为进一步阐明软性膀胱镜在门诊检查中患者耐受性方面的优势。方法:132例门诊患者随机接受软性膀胱镜检查(77例)和硬性膀胱镜检查(55例),用数字分级法对患者检查前、检查中、检查后15min和3天的疼痛指数进行评估。结果:85%的软镜组患者为检查中轻微疼痛(评分为0~3),而硬镜组仅为47%(P<0.05)。检查中疼痛评分软镜组为2.3vs硬镜组3.4(P<0.05)。软镜组检查后15min疼痛评分恢复到检查前水平(0.5vs0.2),而硬镜组(2.3vs0.3)3天后才恢复到检查前水平。结论:软性膀胱镜的耐受性明显好于硬镜,更适于门诊患者的检查。     

Virtual cystoscopy from computed tomography: a pilot study

OBJECTIVE: To assess the feasibility of virtual cystoscopy reconstructed from helical computed tomography (CT) obtained using an intravenous contrast agent, and to correlate the findings with flexible (FC) and rigid cystoscopy (RC) in patients with bladder tumours. PATIENTS AND METHODS: Eighteen patients (16 men and two women, mean age 72 years, range 59-80) with haematuria and found to have a bladder tumour on FC were included in a pilot study. Contrast-enhanced helical CT scans were taken and based on these datasets, virtual cystoscopy (VC) images were reconstructed by a radiologist unaware of the findings at cystoscopy. All patients had RC and a biopsy taken. The VC images were compared with the findings from FC and RC. RESULTS: At FC, VC and RC, 32, 34 and 36 lesions were identified, respectively; 33 (92%) of the abnormal lesions at RC were correctly identified at VC. At VC, all lesions of >4 mm were identified but only one of three <4 mm was seen. There were two false-positive finding at VC; VC correctly identified 17 (94%) of 18 abnormal bladders. Only 25% of the ureteric orifices were seen. Carcinoma in situ and urethral tumours were not visualized. CONCLUSION: CT-based VC has a high sensitivity for detecting bladder lesions and is comparable with FC; it may have a potential role as a single imaging tool for haematuria. Further larger studies are required to assess its clinical role.     

Hexylaminolaevulinate fluorescence cystoscopy in patients previously treated with intravesical bacille Calmette‐Guérin

Study Type – Diagnosis (case series) Level of Evidence 4

OBJECTIVE

To determine if hexylaminolaevulinate fluorescence cystoscopy (HAL‐FC) has the potential to improve the diagnosis of bladder cancer in patients who have been treated with bacille Calmette‐Guérin (BCG).

PATIENTS AND METHODS

Patients scheduled for rigid cystoscopy after BCG therapy were recruited prospectively between April 2005 and February 2006. Patients received HAL (Hexvix^TM, PhotoCure ASA, Oslo, Norway) and the D‐light system (Storz, Tuttlingen, Germany) was used to detect fluorescence. The bladder was mapped and biopsies taken under white light and then using HAL‐FC. The main outcome was the frequency and nature of additional pathology detected by HAL‐FC. Twenty‐seven patients (21 men and six women; median age 70 years, range 49–82) underwent 32 HAL‐FC.

RESULTS

Recurrent bladder cancer was detected in 11 of the 32 (34%) examinations. HAL‐FC detected additional pathology in five of the 27 (19%) patients. In two of these cases the additional pathology was clinically significant (one pT4G3 intraprostatic transitional cell carcinoma and one intravesical pT1G2 + carcinoma in situ), whereas in three cases the pathology was hyperplasia/dysplasia. Overall, the false‐positive biopsy rate with HAL‐FC was 63%. In the presence of positive voided urine cytology six of eight patients had recurrent bladder tumour and the false‐positive biopsy rate was only 34%. Urine cytology was positive in four of five of the patients in whom additional pathology was detected by HAL‐FC.

CONCLUSIONS

Clinically significant occult pathology can be detected using HAL‐FC after BCG therapy, but in <10% of cases. The rate of false‐positive biopsies is high but in our hands appears to be lower than with white‐light guided biopsies after BCG. Our pragmatic approach is to use HAL‐FC after BCG when clinical suspicion is high, and when the preoperative voided urine cytology is positive.     

Midazolam anesthesia during rigid and flexible cystoscopy

The objective of this study was to investigate the usefulness and safety of midazolam-induced anesthesia for cystoscopy. From September 2005 to March 2006, 80 patients scheduled for regular outpatient follow-up cystoscopy participated in this study. The patients were randomized and classified according to the cystoscope type and midazolam use as follows: group 1 (10 men and 10 women), flexible cystoscopy + midazolam; group 2 (10 men and 10 women), flexible cystoscopy + no midazolam; group 3 (10 men and 10 women), rigid cystoscopy + midazolam; and group 4 (10 men and 10 women), rigid cystoscopy + no midazolam. Immediately after the procedure, the patients were asked to rate their comfort level using a ten-point visual linear analog self-assessment pain scale. The patients assigned in the midazolam group experienced no side-effects from the midazolam. Blood pressure and pulse rate did not change significantly during the procedure. The degree of pain experienced by group 1 was lower than other groups (P < 0.05) and group 4 had a significantly greater pain score than other groups (P < 0.05). No difference was evident between group 2 and 3 regarding the pain score. Midazolam anesthesia may relieve pain during rigid and flexible cystoscopy. Our findings suggest that midazolam anesthesia during cystoscopy is useful and safe.     

Flexible cystoscopy compared with ultrasound in the detection of recurrent bladder tumours

A combination of transrectal and transabdominal ultrasound was compared with flexible cystoscopy as a means of detecting recurrent bladder tumours. The study group comprised 50 patients who had previously had rigid cystoscopy. They underwent combination ultrasound in the out-patient department 1 week before flexible cystoscopy. Combination ultrasound identified 25 patients with recurrent tumours and flexible cystoscopy identified 26. Thirty-four patients (68%) preferred ultrasound, 10 (20%) preferred flexible cystoscopy, 3 (6%) preferred general anaesthesia and rigid cystoscopy and 3 (6%) had no preference. The main objection to ultrasound was the use of the transrectal probe.     

A comparison of hexaminolevulinate fluorescence cystoscopy and white light cystoscopy for the detection of carcinoma in situ in patients with bladder cancer: a phase III, multicenter study

PURPOSE: We compared hexaminolevulinate (Hexvix) fluorescence cystoscopy with white light cystoscopy for detecting carcinoma in situ. MATERIALS AND METHODS: In this multicenter study 298 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate for 1 hour. Cystoscopy was then performed, first using standard white light and then hexaminolevulinate fluorescence cystoscopy. Lesions or suspicious areas identified under the 2 illumination conditions were mapped and biopsied for histological examination. In addition, 1 directed biopsy was obtained from an area appearing to be normal. RESULTS: Of 196 evaluable patients 29.6% (58 of 196) had carcinoma in situ, including 18 with carcinoma in situ alone, and 35 with carcinoma in situ and concomitant papillary disease, which was only detected on random biopsy in 5. Of the 18 patients with no concomitant papillary disease carcinoma in situ was detected only by hexaminolevulinate fluorescence in 4 and only by white light in 4. In the group with concomitant papillary disease carcinoma in situ was found only by hexaminolevulinate fluorescence in 5 patients and only by white light in 3. The proportion of patients in whom 1 or more carcinoma in situ lesions were found only by hexaminolevulinate cystoscopy was greater than the hypothesized 5% (p=0.0022). Overall more carcinoma in situ lesions were found by hexaminolevulinate than by white light cystoscopy in 22 of 58 patients (41.5%), while the converse occurred in 8 of 58 (15.1%). Biopsy results confirmed cystoscopy findings. Of a total of 113 carcinoma in situ lesions in 58 patients 104 (92%) were detected by hexaminolevulinate cystoscopy and 77 (68%) were detected by white light cystoscopy, while 5 were detected only on directed visually normal mucosal biopsy. Hexaminolevulinate instillation was well tolerated with no local or systemic side effects. CONCLUSIONS: In patients with bladder cancer hexaminolevulinate fluorescence cystoscopy with blue light can diagnose carcinoma in situ that may be missed with white light cystoscopy. Hexaminolevulinate fluorescence cystoscopy can be used in conjunction with white light cystoscopy to aid in the diagnosis of this form of bladder cancer.     

窄波成像电子膀胱软镜在膀胱肿瘤诊断中的应用价值

目的 研究窄波成像(NBI)电子膀胱软镜在膀胱肿瘤诊断中的应用价值.方法 临床疑似膀胱肿瘤患者31例,采用Olympus ExeraⅡ电子膀胱软镜系统,分别在NBI和普通白光(WLI)视野下检查,顺序采用随机化法,观察时间相同.分别取2种视野下膀胱内所见可疑病灶活检,比较2种检查方法膀胱肿瘤诊断准确率.结果 31例患者中,经病理检查确诊为膀胱尿路上皮癌28例(90%),其中Tis 3例、Ta 15例、T1 7例、T2 3例;低级别癌20例、高级别癌8例;多发病灶16例、单发病灶12例.WLI下共取活检73处,癌组织61处,阳性率84%,确诊膀胱癌23例;NBI下共取活检91处,癌组织80处,阳性率88%,确诊膀胱癌28例.NBI发现癌组织较WLI多19处,2组检出准确率比较,差异有统计学意义(P＜0.05). 结论 NBI诊断膀胱肿瘤的准确率明显高于WLI电子膀胱软镜.     

Computed tomographic virtual cystoscopy for the detection of urinary bladder neoplasms

OBJECTIVE: To evaluate the role of computed tomographic virtual cystoscopy (CTVC) in the detection of bladder neoplasms and to compare CTVC at conventional and reduced milliAmperes-second (mAs) settings. METHODS: Twenty-four patients with known bladder neoplasms from previous conventional cystoscopy were examined with CTVC. The urinary bladder was insufflated with room air and helical CT data were obtained. Virtual images were created using volume rendering algorithms. In eight patients we used both regular (240) and reduced (70) mAs values. The lesions were recorded on transverse tomographic slices and virtual images and compared with conventional cystoscopy, operative and pathology results. RESULTS: All bladder lesions (30) seen on conventional cystoscopy were demonstrated with CTVC. Two lesions detected on imaging studies and subsequently found at operation were not seen on conventional cystoscopy. In a third case of a neobladder, conventional cystoscopy was impossible due to neoplastic involvement of the penis. In all cases the lesions were equally conspicuous with conventional and low mAs values. CONCLUSIONS: Computed tomographic virtual cystoscopy is a minimally invasive technique that can provide comprehensive information about urinary bladder tumors. Furthermore, low mAs studies are equally effective for the examination of such patients.     

Prospective trial comparing intraoperative flexible,rigid, and no cystoscopy after ultrasound-guided transperineal permanent seed prostate brachytherapy

ObjectiveThis is a prospective trial comparing the impact of intraoperative flexible, rigid, and no cystoscopy on dysuria immediately after permanent seed prostate brachytherapy (PB). It prospectively documents the time course and characteristics of dysuria, as well as the rates of urinary retention post-PB. Furthermore, this study attempts to establish the utility of routine, post-PB cystoscopy, by documenting the incidence of finding significant pathology on cystoscopy.Materials and methodsBetween January 2003 and January 2007, 225 patients deemed by their physician to be candidates for PB alone were recruited to the study. Patients who had external beam radiation therapy and/or androgen deprivation therapy were excluded. Preimplant International Prostate Symptom Score (IPSS), urinary quality of life score, urine leakage score, Sexual Health Inventory for Men score, and Radiation Therapy Oncology Group Bowel Health Inventory Scores were obtained. Patients were assigned to one of the following three groups: intraoperative rigid cystoscopy, flexible cystoscopy, or no cystoscopy following PB. Patient self-administered questionnaires were given to the patient in the recovery room after PB. These questionnaires evaluated the intensity, type, and duration of urinary symptoms associated with the first four urinations post-PB. All patients were seen on postoperative Day 1 when the surveys were retrieved. Patients were then followed up every 3 months. Acute urinary retention (AUR) was documented in the follow ups. Frequencies of significant pathology (defined as bladder tumor, urethral stricture, or large blood clots) were documented at the time of cystoscopy. AUR rates were also evaluated by the isotope used (I¹²⁵, Pd¹⁰³, or Cs¹³¹).ResultsA total of 225 patients were enrolled into this study, but only 194 patients could be analyzed for dysuria. Thirty-one patients were excluded from analysis (6, 13, and 12 patients from the rigid, flexible, and no cystoscopy groups, respectively). These patients did not return the questionnaire, or were in retention, and thus did not have dysuria scores to report. Baseline characteristics for the 194 patients in terms of preimplant IPSS, quality of life, prostate volume, and isotope used were well balanced between all three groups. There were no significant differences in dysuria between the three cystoscopy groups at any time point following PB. The mean dysuria score across all time points was 5.5 of 10, with 0 representing “no pain” and 10 representing “the worst possible pain.” Pain was most often characterized as “burning” (78%), whereas dysuria most commonly was “only during urination” (56%). AUR rates (6.8–9.5%) and duration of catheter dependence (10.5–19 days) were not found to be significantly different between the assigned groups. When results were stratified by isotope, patients treated with I¹²⁵, Pd¹⁰³, and Cs¹³¹ seeds experienced a 6%, 14%, and 0% retention rate, respectively. The I¹²⁵ and Pd¹⁰³ patients had similar pretreatment IPSS and prostate volumes. Seven percent of patients undergoing cystoscopy had significant findings. The most common finding was “clots thought too large to void” (3%). Seeds in the bladder/urethra occurred in 1% of cases. Only 0.7% of patients were found to harbor unsuspected bladder tumors.ConclusionThere was no significant difference in dysuria in the first four urinations post-PB between patients in the rigid, flexible, and no cystoscopy groups. Larger blood clots that may have been difficult to void, seeds in the bladder and/or urethra, and other abnormalities were found in 7% of patients who had cystoscopy. This may suggest that cystoscopy may be worthwhile post-PB. The incidence of AUR was not significantly different between the three cohorts.     

Routine use of ultrasound and flexible cystoscopy in the control of benign bladder tumours

During the period 1987–1992, 99 patients with benign bladder tumours were followed regularly with transabdominal ultrasound of the bladder and out-patient flexible cystoscopy. Thirty-five patients had recurrent bladder tumours, but in only one case was there progression to invasive tumour. Seventy-six per cent of the recurrences were diagnosed by flexible cystoscopy while 22% were found by ultrasound. Compared to conventional follow-up programs with in-patient rigid cystoscopy the combination of ultrasound and flexible cystoscopy proved to be safe, highly acceptable by the patients and cost-effective. Read at the Nordic Surgical Society Centennial Meeting, Copenhagen, June 20–23, 1993.     

Fluorescence and white light cystoscopy for detection of carcinoma in situ of the urinary bladder

ObjectivesTo understand the additional benefits of HAL compared with conventional cystoscopy at the patient level and to explore relationships of urine cytology and CIS.MethodsWe reanalyzed pooled data from 3 phase III studies comparing hexaminolevulinate (HAL, Hexvix) fluorescence cystoscopy with white light (WL) cystoscopy for detecting CIS.ResultsOf 551 patients, 174 had at least one CIS lesion detected by HAL, WL, or random biopsy. The CIS detection rate of HAL was 0.87 vs. 0.75 for WL (P = 0.006). By multivariate Poisson regression, female patients had fewer CIS lesions (P < 0.0001) while older patients (≥65) had a higher number of CIS lesions detected by HAL (P = 0.04). HAL was less likely to detect CIS in patients previously treated with chemotherapy or BCG (P = 0.01 and 0.03, respectively), after adjusting for age. CIS was unifocal in 44% and multifocal in 56%. Multifocal CIS was associated with positive cytology more frequently than unifocal (65% vs. 45%; P = 0.016) whereas a negative cytology was more frequently associated with unifocal CIS. Patients with positive urine cytology had twice as many CIS lesions detected by HAL as patients with negative urine cytology (P = 0.02).ConclusionsHAL cystoscopy had a higher CIS detection rate than WL cystoscopy. The average number of CIS lesions detected was associated with baseline clinical characteristics. Cytology was positive more frequently in multifocal CIS suggesting that HAL may be particularly useful in this setting to optimize detection of the extent of CIS.     

Diagnostic efficacy of fluorescence cystoscopy for detection of urothelial neoplasms.

BACKGROUND AND PURPOSE: A major problem diagnosing bladder cancer using conventional white-light cystoscopy is that flat and tiny papillary neoplasms can be overlooked. Fluorescence cystoscopy is based on the detection of protoporphyrin IX (PpIX)-induced fluorescence in urothelial neoplasms through the topical administration of 5-aminolevulinic acid (ALA). The diagnostic efficacy of fluorescence cystoscopy in urothelial neoplasms was evaluated in this study. The focus of this investigation was to ascertain whether fluorescence cystoscopy could make a major contribution to staging and improving the choice of adjuvant therapy after transurethral resection. PATIENTS AND METHODS: A series of 62 patients with suspected bladder cancer were investigated by fluorescence cystoscopy. An intravesical instillation of ALA was conducted 2 hours prior to fluorescence. A total of 274 tissue samples were obtained from the fluorescing and nonfluorescing areas of the bladder. RESULTS: The sensitivity and negative predictive value of fluorescence cystoscopy were 98.0% and 94.7%, respectively, but the specificity was low (42.9%). Among a total of 148 lesions of urothelial neoplasm, 58 foci (dysplasia in 5, carcinoma in situ in 19, stage Ta in 15, T1 in 15, above T2 in 4) that were invisible under white-light cystoscopy were detected by fluorescence cystoscopy. The final histopathologic status was changed in 45% of patients (28/62) according to this technique. Among these patients, eight (13%) needed additional therapy, including a radical cystectomy in one patient and intravesical therapy in 10. CONCLUSIONS: The ALA-based fluorescence cystoscopy technique is a safe and simple procedure that enhances the detection of flat and papillary urothelial neoplasms. Moreover, it will be able to provide useful information that will enable proper staging and appropriate further treatment.     

Significance of fluorescence cystoscopy for diagnosis of superficial bladder cancer after intravesical instillation of delta aminolevulinic acid.

OBJECTIVES: Most lesions of superficial bladder cancer may be easily missed during conventional white light cystoscopy. The aim of this work was to evaluate the efficiency of endoscopic fluorescence diagnosis of superficial malignant bladder tumours following intravesical instillation of delta-aminoleviulenic acid. PATIENTS AND METHODS: 30 patients of suspected or previously diagnosed bladder cancer were subject of evaluation. All patients received 50 ml of a 3% delta-ALA solution intravesically, 2-3 h prior to diagnostic cystoscopy. Fluorescence excitation intraoperatively was achieved by a violet-blue light from a xenon light source. RESULTS: A clear strong red fluorescence colour was observed emitting from all malignant vesical lesions. A diagnostic sensitivity of 98% and specificity of 65% has been determined for this novel diagnostic modality. CONCLUSION: Fluorescence cystoscopy using delta-ALA is a reliable procedure that can be offered to all patients with suspected bladder cancer lesions.     

Office flexible cystoscopy

Since the development of the first purpose-built flexible cystoscope in 1984, flexible cystoscopy has become an accepted diagnostic and therapeutic modality. Indeed, it is estimated that more than 10 per cent of practicing urologists are already familiar with this technology. The flexible cystoscope has markedly extended the urologist's ability to examine the bladder, and it has become a valuable adjunct to the rigid cystoscope. Although the operation of this instrument is vastly different from that of its rigid counterpart, with practice, the technique can be learned. After experience is obtained with diagnostic flexible cystoscopy, the urologist will likely prefer this new instrument for bladder inspection, as it provides for a more thorough yet less morbid and less expensive examination. In the future, the development of improved and smaller instrumentation will further extend the therapeutic indications for flexible cystoscopy. Indeed, advances in laser technology are already providing the urologist with 300- to 600-micron (0.9 to 1.8F) flexible probes capable of incision (KTP laser), fulguration (Nd:YAG laser), and stone disintegration (tunable dye laser). Lastly, the skills obtained in using the flexible cystoscope are all readily applicable to the development of dexterity with the already available flexible nephroscope and the more recently developed flexible ureteroscope.     

Blue light cystoscopy for the diagnosis of bladder cancer: Results from the US prospective multicenter registry

Introduction

Blue light cystoscopy (BLC) using hexaminolevulinate (HAL/Cysview/Hexvix) has been previously shown to improve detection of non–muscle-invasive bladder cancer (NMIBC). Herein, we evaluated the detection of malignant lesions in a heterogenous group of patients in the real world setting and documented the change in risk category due to upstaging or upgrading.