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Prospective evaluation of blue-light flexible cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer

  • Yair Lotan,
  • Iftach Chaplin,
  • Hamed Ahmadi,
  • Xiaosong Meng,
  • Sidney Roberts,
  • Sanam Ladi‐Seyedian,
  • Aditya Bagrodia,
  • Vitaly Margulis,
  • Solomon Woldu,
  • Siamak Daneshmand

Publication: BJU International, January 2021


To evaluate the utility of blue-light flexible cystoscopy (BLFC) for surveillance of non-muscle-invasive bladder cancer (NMIBC).

Patients and methods

Prospective cohort of consecutive patients who underwent office-based BLFC for NMIBC. Clinical information was collected including cystoscopic findings and pathological data.


A total of 322 cases were performed on 190 patients. The mean age was 71 years and 83% were men. The highest stage prior to BLFC was Ta, carcinoma in situ (CIS), T1, and T2 in 45.3%, 18.4%, 30% and 2%, respectively. Prior to BLFC, 16.8%, 60.5%, and 16.8% were low grade (LG), high grade (HG), and CIS, respectively. Intravesical bacille Calmette-Guérin and intravesical chemotherapy were used in 54.2% and 18.4%, respectively. White-light cystoscopy (WLC) and BLFC were both normal in 173 (53.7%) of cases. WLC was normal and BLFC was abnormal in 26 (8%) cases. Of these, 15 had office-based biopsy and cancer was detected in 13 (87%; six CIS, four HG Ta, three LG Ta). Both WLC and BLFC were positive in 83 (25.8%) cases and 33% had additional tumours found. Cancer was found in 27 (75%) of WLC+/BLFC+ who underwent office-based biopsy including 19 LG Ta, six HG Ta, and two CIS.


Incorporation of BLFC in clinical practice has potential advantages of finding cancer in cases with normal WLC. BLFC detected additional cancers in 33% of patients with positive WLC and BLFC, which can improve surveillance and performance of office-based biopsy. Further research is needed to determine cost-effectiveness and impact on recurrence rates.

Dr. Evanguelos Xylinas

Enhanced cystoscopic techniques, such as the blue-light cystoscopy, have shown improving the detection of bladder tumours and enlarging the interval between recurrences. The use of a blue-light cystoscopy in this setting is now supported by both the American Urological Association (AUA) and the European Association of Urology (EAU) Guidelines. Since most surveillances are performed with white-light cystoscopies, the authors aimed to evaluate the benefit associated with a blue-light flexible cystoscopy over a white-light cystoscopy in the office setting for detection of recurrences.

In this prospective study, a total of 322 cystoscopies were performed in 190 patients. The results of both white-light and blue-light cystoscopies were negative in 173 (53.7%) of the cystoscopies. In 26 (8%) of the cases, the results of the white-light cystoscopy were negative, whereas the blue-light cystoscopy showed positive results. Of these cystoscopies, 15 patients had had an office biopsy, and cancer was detected in 13 (87%) of them (6 CIS, 4 HG Ta, 3 LG Ta). Both the results of white-light and blue-light cystoscopies were positive in 83 (25.8%) of the cases, of which 33% had additional tumours found in the blue light.

Incorporation of the blue-light cystoscopy in the clinical practice has potential advantages of finding cancer in cases with a normal white-light cystoscopy and of detecting more cancers in patients with an abnormal white-light cystoscopy. Further research is needed to determine the cost-effectiveness and the impact on oncological outcomes.