Arguments against the Use of Fluorescence for the Diagnosis of Non–Muscle-Invasive Bladder Tumours (NMIBT)

ObjectivesArguments against hexaminolevulinate (HAL) fluorescence cystoscopy are considered by evaluating standard white light cystoscopy and its possible future improvements in tumour detection.DiscussionConventional cystoscopy has two major disadvantages: high rate of residual papillary tumours after transurethral resection (TUR); poor detection rate of dysplasia and carcinoma in situ (CIS). Improved detection rates have been reported with HAL fluorescence cystoscopy, but several unanswered questions remain:1.Can we improve standard TUR to reduce the number of overlooked/residual tumours or flat lesions? If we use a bladder diagram at the time of diagnosis, urinary cytology 21 d after TUR, and an experienced urologist to perform TUR, we can reduce the 3-mo recurrence rate (3-RR). Specialised teaching programs also reduce the 3-RR.2.What happens to patients with small undiagnosed papillary tumours? Very little: These tumours are not at risk of progression.3.Do we have effective adjuvant treatments that can reduce the risk of recurrence or progression of undiagnosed tumours? Most patients at intermediate or high risk with undiagnosed tumours in the bladder after TUR will receive adjuvant chemotherapy or immunotherapy, which can reduce this risk.4.Is HAL fluorescence cystoscopy definitively better than standard cystoscopy? There are no long-term comparative studies suggesting that early diagnosis of CIS or dysplasia with blue light cystoscopy reduces the progression rate or improves survival.ConclusionsLike all new technologies that improve diagnosis and treatment of a disease, HAL fluorescence cystoscopy needs to be critically evaluated before it is promoted as a new standard diagnostic tool.