The diagnostic challenge of suspicious or positive malignant urine cytology findings when cystoscopy findings are normal: an outpatient blue-light flexible cystoscopy may solve the problem

Abstract

Purpose

To investigate whether outpatient blue-light flexible cystoscopy could solve the diagnostic challenge of positive or suspicious urine cytology findings despite normal white-light flexible cystoscopy results and normal findings on computerized tomography urography, in patients investigated for urothelial cancer.

Material and methods

In a multicentre study, a total of 70 examinations were performed with the use of blue-light flexible cystoscopy (photodynamic diagnosis) after intravesical instillation of the fluorescence agent hexaminolevulinate. The examination started with a conventional white-light flexible cystoscopy and then the settings were switched to use blue light. Suspicious lesions were biopsied. Afterwards, the patients were interviewed regarding their experience of the examinations.

Results

Bladder cancer was diagnosed in 29 out of 70 (41%) cases, among them 14/29 (48%) had malignant lesions seen only in blue light. The majority had carcinoma in situ (21/29). Normal findings were seen in 41 cases that underwent BLFC. During the further course, malignancy of the bladder was detected in six cases (9%) and malignancy of the upper urinary tract was detected in one case (1%). The majority of patients (93%) preferred the blue-light flexible cystoscopy performed at the outpatient clinic instead of the transurethral resection under general anaesthesia.

Conclusion

Blue-light flexible cystoscopy at the outpatient clinic may be a useful tool to solve unclear cases of a malignant or suspicious urinary cytology suggestive of bladder cancer. The procedure was well tolerated by the patients.

Keywords:

• Bladder cancer
• diagnosis
• flexible cystoscopy
• PDD
• outpatient clinic

Ethical approval

The study was approved by the Ethics Committee in Uppsala, Sweden (Reg. No. 2016/036) and by the Danish Data Protection Agency (Reg. No. 16/5384). The study was performed in accordance with good clinical practice and the Declaration of Helsinki.

Acknowledgements

The authors thank Jonas Richthoff, MD, PhD, Department of Urology, Ljungby Hospital, Sweden and Christoffer Björk, MD, Department of Urology, Varberg Hospital, Sweden, for their contributions to the study through recruiting patients and managing the data in the online register.

Disclosure statement

Mats Bläckberg, Per-Uno Malmström and Karsten Zeiger have received refunds for travel expenses and remuneration for talks from Photocure ASA, Oslo, Norway.

Additional information

Funding

This research was supported by grants from Stig and Ragna Gorthon’s Foundation. The Nordic BLFC registry receives financial support from Photocure ASA.