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Blue Light Cystoscopy in Bladder Cancer
Avery Wolfe • Nov 27, 2021 • 76 hits
After a bladder cancer diagnosis, blue light cystoscopy is useful in the OR to optimize chances of complete tumor resection. After surgery, blue light cystoscopy is also a sensitive tool to monitor for bladder cancer recurrence via surveillance office cystoscopy. Though patients may have anxiety about undergoing flexible cystoscopy in the office, office cystoscopy is generally well-tolerated and most patients experience minimal cystoscopy pain.
This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Blue light cystoscopy is useful in the OR to facilitate resection of peri-tumoral dysplasia and carcinoma in situ in addition to the bladder tumor itself.
• Blue light cystoscopy is a sensitive tool in monitoring for bladder cancer recurrence.
• Though blue light cystoscopy may identify more lesions suspicious for bladder cancer recurrence, when combined with in-office biopsy many urologists actually end up taking fewer patients to the OR.
• Patients generally tolerate flexible cystoscopy well in the office, and there are a great number of easy-to-implement techniques that minimize cystoscopy pain and patient anxiety.
Table of Contents
(1) Blue Light Cystoscopy in the OR
(2) Monitoring for Bladder Cancer Recurrence with Office-Based Blue Light Cystoscopy
(3) Helping Patients Tolerate Office Cystoscopy & Minimizing Cystoscopy Pain
Blue Light Cystoscopy in the OR
The approach to large tumors with a high suspicion for invasive bladder cancer is nuanced and difficult. Some surgeons favor a conservative approach, opting only for a tissue biopsy to establish a definitive bladder cancer diagnosis, while others favor a more aggressive technique with radical tumor resection. Blue light cystoscopy is a useful tool in the latter scenario, facilitating resection not only of the tumor itself but also surrounding peri-tumoral dysplasia or carcinoma in situ.
Okay, definitely. For larger tumors, the tumors that you go in, you're seeing it from the bladder neck, you see that it's encasing the entire bladder, what's your next step? Do you try to completely remove them and leave a possible non-functional bladder? Or do you just try to get some samples, try to get tissue samples, pathology, and then go straight for the cystectomy?
I think this is one of those things that people struggle with all the time. And once we answer this, I think it would be nice to come back and revisit using blue light enhanced cystoscopy. Based on what you're describing, my suspicion for this being a muscle-invasive bladder cancer is going to be high. And, first things first, looking at patient comorbidity, looking at the clinical picture - are they having gross hematuria with clots, etc? If it's a very large tumor, sick patient, clearly muscle invasive, hydronephrosis, extension beyond the fat, a lot of this is going to depend on the relationship with your medical oncologist as well.
If I've got a tumor like that, I would almost say that I would be fine doing an office cystoscopy, obtaining a cytology, getting a biopsy, because I don't want to run into any operative misadventures - persistent gross hematuria, bladder perforation, something that could be a catastrophe. If I know it's locally advanced, clearly T2 through T4, our medical oncologists here I think are very, very into being aggressive with multimodal therapy. In a patient like that, that’s sick, I would have a very low threshold to try to go with the less is more philosophy.
The other half of this is determining resectability. We know that patients that are ultimately pathological T0 after neoadjuvant chemotherapy and cystectomy or after cystectomy alone, do better. So if you can safely get it out - if it's in an area that's amenable to a complete resection, you don't think you're going to put the patient at a risk for a perforation or anything along those lines - I do like to completely resect, both for increasing the chance of them ultimately being pathological T0 and then also just to make sure that if they're going to be receiving chemotherapy that we don't run into issues with recurrent hematuria.
Okay. In terms of the technique, when you did a fellowship, did you have any difference from what you learned in residency in terms of the pure surgical technique?
I feel like in my residency, I was fortunate that most of our oncologists - actually all of our oncologists - were fellowship trained at reputable, prestigious centers, so I felt like we got a really nice state-of-the-art training. One of the areas that was a little bit more aggressive in terms of resection... This is kind of straightforward from the Harry Herr school of thought, would be radical resection of carcinoma in situ. That was something that in residency if your suspicion that they had diffuse carcinoma in situ, oftentimes we would just make sure we were establishing a diagnosis with multiple cold cups or several swipes, get your hemostasis and get out.
And in fellowship, there was much more emphasis on complete resection of all visible disease. That was something that's nuanced. Coming back full circle, when I came back to UT Southwestern as an attending, our institution was one of the first early adopters of blue light enhanced cystoscopy, so really making sure that we're trying to resect not only the tumor but anything that looks like peri-tumoral dysplasia or carcinoma in situ.
In a lot of ways, I think those are kind of merging, but this idea of a deep, radical resection, understanding that you may have perforations into the fat and that kind of happens part and parcel of radical TUR, was a notion that I would say was a little bit more emphasized in fellowship.
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Monitoring for Bladder Cancer Recurrence with Office-Based Blue Light Cystoscopy
Office-based blue light cystoscopy is a sensitive tool in routine surveillance for bladder cancer recurrence. This is especially useful in patients who received intravesical therapy, as differentiating bladder cancer recurrence from BCG changes is quite challenging. Combined with office-based biopsy fulguration, blue light cystoscopy can reduce the number of patients going to the OR despite recognizing a greater number of suspicious lesions.
And you had mentioned the blue light cystoscopy. Do you have blue light both in the office and in the OR, or just in the OR?
Yeah, we have it for both.
For both? Okay. And has that changed... Or let's say let's put it this way, has that made you take more patients to the OR because you see something more suspicious with the blue light? Have you been able to diagnose more patients with that technique?
It's a great question and, honestly, I would say in my clinical practice, and I think the field in general, there's been this kind of parallel emergence of flexible office blue light cystoscopy and just an increased adoption of office-based biopsy fulguration. I would say that I am diagnosing more suspicious lesions and, at the same time, biopsying those in the clinic with the idea being that many times these are going to be early dysplastic low-grade lesions or they're going to be carcinoma in situ.
And, as we know, one of the trickiest, most challenging bits of this is to sort out BCG changes from tumor recurrence. So net, I would say that I actually end up taking a lot less patients to the operating room and it's a little hard to parse out what's the contribution of blue light cystoscopy and what's the implementation of more office-based biopsy.
And for those of you that maybe don't do office-based biopsy, I must say it's really, really actually quite simple to implement. And whether you do blue light or not, putting in a catheter, a solution of a local anesthetic plus some saline, letting it dwell for 20-30 minutes and, to be perfectly frank, even if you use lidocaine gel, patients tolerate these very, very well. Uniformly it's preferred versus general anesthesia, the whole experience of coming in two hours early, general anesthesia, making sure you void, X, Y and Z. It takes it from being a half day affair with two or three days of lingering effects to literally a 15-minute procedure.
There's plenty of great information in terms of implementing an office-based biopsy program. You buy a little generator, get a flexible cold cup biopsy forceps and a Bugbee and you're home free. That's something I would say it may sound intimidating but it's actually quite, quite easy to implement.
For surveillance cystoscopies after BCG, you start doing the cold cup biopsy of that base or where there is scar tissue, you do that in the office?
No, I haven't gone that far. Office biopsies I think have a role but it's not the same. I would liken it to... It's better than trying to biopsy a lesion in the upper tract, but it's not the same as a rigid cold-cup biopsy. When you're doing a second-look resection staging biopsy etc, you really need to make sure that you have that muscle sample then. And the tools are just not quite as amenable to that with the flexible setup as they are to the rigid. I will still do my second looks in the OR, typically.
Helping Patients Tolerate Office Cystoscopy & Minimizing Cystoscopy Pain
Patients tend to tolerate flexible cystoscopy quite well in the office. Though office cystoscopy can be anxiety-provoking for patients, simple techniques like asking the patient to take a deep breath and squeezing the irrigant bag when passing through the sphincter can minimize cystoscopy pain.
And Oche, while we're on the topic of flexible cystoscopy, I think another very easy to implement set of maneuvers when you're doing these cases in the office, whether that's standard surveillance, initial diagnosis or relatively simple moves, and I may ask you from your perspective as well what you do. In our clinic... And of course they all get lidocaine jelly instilled. Then when I'm at the sphincter and about to go through the sphincter and the prostate, I'll ask the patients to take a deep breath, relax, act like they're urinating and then I'll have the assistant actually squeeze the irrigant bed to kind of passively dilate the sphincter and the prostate as well.
There's actually data that patients do better in terms of tolerating their office cystoscopies. And, again, these are going to be super simple things to implement. Really trying to keep that lumen visualized actually as you're going through the prostate and not just pass it in blindly as a catheter. Anything that you do at your end?
I do exactly that. I tell the patient to take a deep breath. It was three months ago, this patient told me that his urologist started out and always tells him to cough.
Mm-hmm (affirmative), okay.
Have you heard that? I started doing that to see. I didn't see any difference, but it was the first time that I have heard of people... because this was a patient with just surveillance cystoscopy. He had bladder cancer and his urologist retired, or I think he just moved to Florida. But that's what he told me. He told me his urologist told him to cough. I didn't know about that technique. I usually just tell the nurse to just push the bag, have the patient take a deep breath. I use the lidocaine lube. But if the patient starts complaining, I just tell them to cough to see if that helps also. But I haven't had any changes for now.
And extrapolating from prostate biopsy, if it's easily implementable, I think even playing some music. Everybody can pop in a wifi speaker, or if somebody's got their Spotify or YouTube, whatever. Just pop on something relaxing that the patient may enjoy. These are very simple things that I think we can do to just make the whole experience a little bit more tolerable.
Yeah, specifically for vasectomies. Definitely, you need to put something on for the patient to be more comfortable. Usually cystoscopy is so fast that I don't think about that. But the more comfortable the patient is, the better.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, April 16). Ep. 2 – Management of Bladder Cancer [Audio podcast]. Retrieved from https://www.backtable.com
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