title: Clinical and cost effectiveness of hexaminolevulinate-guided blue-light cystoscopy: evidence review and updated expert recommendations.
abstract: BACKGROUND
  Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates.
  
  
  OBJECTIVE
  To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input.
  
  
  METHODS
  PubMed and conference searches, supplemented by personal experience.
  
  
  RESULTS
  Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time.
  
  
  CONCLUSIONS
  HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system.
  
  
  RESULTS
  Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.
authors.affiliation: Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. Electronic address: fred.witjes@radboudumc.nl.
authors.forename: J Alfred
authors.initials: JA
authors.lastname: Witjes
authors.affiliation: Department of Urology, Motol Hospital, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic.
authors.forename: Marek
authors.initials: M
authors.lastname: Babjuk
authors.affiliation: Department of Urology, San Giovanni Battista Hospital, University of Turin, Turin, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Gontero
authors.affiliation: Department of Urology, Strasbourg University Hospital, Strasbourg, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Jacqmin
authors.affiliation: Department of Urology, Ludwig Maximilians University, Munich, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Karl
authors.affiliation: Department of Urology, Eberhard Karls University, Tübingen, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Kruck
authors.affiliation: Department of Urology, Western General Hospital, Edinburgh, UK.
authors.forename: Paramananthan
authors.initials: P
authors.lastname: Mariappan
authors.affiliation: Urologic Oncology Unit, Department of Urology, Puigvert Foundation, Barcelona, Spain.
authors.forename: Juan
authors.initials: J
authors.lastname: Palou Redorta
authors.affiliation: Department of Urology, Eberhard Karls University, Tübingen, Germany.
authors.forename: Arnulf
authors.initials: A
authors.lastname: Stenzl
authors.affiliation: Department of Urology, Jules Bordet Institute, Brussels, Belgium.
authors.forename: Roland
authors.initials: R
authors.lastname: van Velthoven
authors.affiliation: Department of Urology, Traunstein Hospital, Traunstein, Germany.
authors.forename: Dirk
authors.initials: D
authors.lastname: Zaak
mesh_terms: D000622:Aminolevulinic Acid / Q000031:analogs & derivatives* / Q000191:economics; D003362:Cost-Benefit Analysis; D015653:Cystectomy / Q000191:economics* / Q000379:methods / Q000592:standards; D003558:Cystoscopy / Q000191:economics* / Q000379:methods / Q000592:standards; D018450:Disease Progression; D018572:Disease-Free Survival; D017048:Health Care Costs; D006801:Humans; D018803:Models, Economic; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local; D018365:Neoplasm, Residual; D011237:Predictive Value of Tests; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000191:economics* / Q000473:pathology / Q000601:surgery*
chemical_list: D000622:Aminolevulinic Acid; C419924:5-aminolevulinic acid hexyl ester
keywords: Bladder cancer; Cost effectiveness; Fluorescence cystoscopy; Hexaminolevulinate; Quality-adjusted life-years; Recurrence