Improving the management of bladder cancer with fluorescence cystoscopy.

Endoscopic visualization (cystoscopy) and transurethral resection are effective, well-tolerated diagnostic and treatment techniques for bladder cancer. However, it is widely recognized that cystoscopy can miss biologically important lesions, such as carcinoma in situ. Attempts to improve the effectiveness of cystoscopy are not new, but initial methods were impractical and had limited efficacy. Fluorescence cystoscopy became feasible with the discovery that intravesical administration of aminolevulinic acid (ALA) made bladder cancers fluoresce when exposed to blue light. More recently, the creation of a hexyl ester of ALA (HAL) made this technique practical, because HAL significantly shortens the amount of time needed for drug exposure prior to cystoscopy. Not surprisingly, studies have shown that fluorescence cystoscopy can reveal carcinoma in situ that is visually occult under conventional (white-light) cystoscopy. An unexpected finding was that fluorescence cystoscopy also enhanced the detection of papillary tumors. Studies with ALA have shown that resection of bladder cancer with fluorescence results in improved disease-free survival compared to conventional resection under white light. This report summarizes some of the recent studies of fluorescence cystoscopy in bladder cancer.