Can routine outpatient follow-up of patients with bladder cancer be improved? A multicenter prospective observational assessment of blue light flexible cystoscopy and fulguration

Abstract

Background: The aim of this prospective cohort study was to determine the feasibility of incorporating blue light flexible cystoscopy (BLFC) and biopsy/fulguration into routine outpatient follow-up of non-muscle invasive bladder cancer patients.

Methods: The study included patients with non-muscle-invasive bladder cancer (NMIBC) who were scheduled for routine follow-up. Hexaminolevulinate was instilled in the outpatient department, and the bladder was examined under white light and then with BLFC. Biopsies were taken from all suspicious lesions. Small tumors and suspicious lesions were fulgurated on site; patients with larger lesions were referred to the operating room for resection.

Results: The study included 69 patients, with a mean age of 70 years (range 33-89 years) and a mean duration since NMIBC diagnosis of 8 years. Most patients had high-grade cancer at initial diagnosis (52/69) and were at high risk of recurrence (48/69). Two patients per hour could be assessed using outpatient BLFC. Preparation and instillation of hexaminolevulinate took less than 10 minutes per patient, and patients had an additional waiting time of 45-60 minutes following instillation, while the hexaminolevulinate solution was retained in the bladder before examination. Eleven patients had histologically confirmed tumors that were identified using both white light flexible cystoscopy and BLFC. An additional three patients had tumors that were identified by BLFC only: two with Ta tumors and one with carcinoma in situ. Of the 14 patients with confirmed tumors, 11 could be managed on site with fulguration, whereas three were referred to the operating room. No adverse events attributable to BLFC were reported.

Conclusion: Routine outpatient management of patients with NMIBC using BLFC and on-site biopsy/fulguration is feasible, despite the additional time required for hexaminolevulinate instillation, and appears to allow early detection of recurrent lesions, which can be fulgurated without the need for hospitalization.

Keywords: bladder cancer; blue light; diagnosis; flexible cystoscopy; hexaminolevulinate; outpatients.

Conflict of interest statement

Disclosure All authors have provided services as speakers in meetings funded by Photocure ASA, Oslo, Norway, and have acted as advisers for Photocure. The authors report no other conflicts of interest in this work.

Figures

Figure 1

Cystoscopic appearance of bladder tumors under white light (left) and blue light (right). Images are from a 75-year-old man with a 4-year history of bladder cancer (most serious diagnosis Ta grade 1), who was found to have carcinoma in situ on follow-up flexible cystoscopy that was clearly visible under blue light. Image credit: Reza Zare, MD, Urologist, Head of Urology Department, Bærum Hospital Vestre Viken HF, Oslo, Norway.