Bladder region-specific analysis of the diagnostic performance of oral 5-aminolevulinic acid fluorescence cystoscopy in non-muscle-invasive bladder cancer.

The Importance of Transurethral Resection of Bladder Tumor in the Management of Nonmuscle Invasive Bladder Cancer: A Systematic Review of Novel Technologies

Due to the COVID19 pandemic, the EAU has recommended to, if needed, postpone second transurethral resection of bladder tumour (TURBT) after BCG induction in selected patients. We aimed to evaluate the oncological outcomes of postponed TURBT and the potential to replace second TURBT by routine cystoscopy and cytology. A single-center, retrospective analysis of patients with TaG3/high grade (HG) or T1HG urothelial bladder cancer was performed. All patients underwent a complete TURBT between 2000 and 2013 with presence of detrusor muscle, full BCG induction and routine cystoscopy and cytology, followed by a second TURBT. Results of the cystoscopy, cytology and pathology reports of the TURBT were analyzed by descriptive characteristics, sensitivity, specificity, negative and positive predictive values, as well as survival analyses. 112 patients were included. Residual tumour was present at second TURBT in 21.4%. Upstaging rate from pTaHG to pT1HG and pT1HG to pT2 was 0% and 2.7%, respectively. pT0 was confirmed in 79% of patients, but in 98% of patients with combined negative cytology and cystoscopy after BCG. With a median follow-up of 109months, the 3-year OS was 85%, RFS 74% and PFS 89%. Sensitivity, specificity, negative predictive value and positive predictive value of cystoscopy and urinary cytology for the presence of residual tumour were 92%, 97%, 98% and 85%, respectively. This study underpins the recommendation of the EAU NMIBC guideline panel that, if needed and in selected patients, second TURBT may be postponed until after BCG induction treatment in pT1HG disease. Also, routine second TURBT can be omitted in pTaHG disease. Data on replacing second TURBT after BCG treatment by routine cystoscopy and cytology appear promising but require further confirmation in prospective studies.

Early Detection of Carcinoma In Situ of the Bladder: A Comparative Study of White Light Cystoscopy, Narrow Band Imaging, 5-ALA Fluorescence Cystoscopy and 3-Dimensional Optical Coherence Tomography

A Comparison of Hexaminolevulinate Fluorescence Cystoscopy and White Light Cystoscopy for the Detection of Carcinoma In Situ in Patients With Bladder Cancer: A Phase III, Multicenter Study

Long-Term Decrease in Bladder Cancer Recurrence with Hexaminolevulinate Enabled Fluorescence Cystoscopy

Long-Term Survival in Bone-Predominant Metastatic Urothelial Carcinoma

Objectives: to investigate the accuracy of transurethral resection of bladder tumours (TURBT) in detecting histological variants (BHV) at radical cystectomy (RC) and to evaluate the impact of TURBT before cystectomy on oncological outcomes. Methods: Data of 410 consecutive RCs were assessed. Positive and negative predictive values were used to assess the accuracy of TURBT in detecting BHV. Cohen’s Kappa coefficient was used to calculate the agreement grade. Logistic regression analysis predicted features based on the presence of BHV at TURBT. Multivariable backward conditional Cox regression analysis was used to estimate oncological outcomes. Results: A total of 73 patients (17.8%) showed BHV at TURBT as compared to 108 (26.3%) at RC. A moderate agreement in histological diagnosis was found between TURBT and RC (0.58). However, sensitivity and specificity in detecting BHV were 56% and 96%, respectively. Furthermore, positive predictive value (PPV) was 84.7% and negative predictive value (NPV) was 84.6%. Presence of BHV at TURBT was an independent predictor for pathologic upstage, albeit not a predictor for positive nodes or positive surgical margins. However, at multivariable analysis adjusted for all confounders, presence of BHV at TURBT was an independent predictor for recurrence after RC, but not for survival. Conversely, the presence of BHV at RC was an independent predictor for both recurrence and survival. Conclusion: There was a moderate agreement between TURBT and RC histopathological findings. TURBT, alone, could not provide an accurate and definitive histological diagnosis. Detection of BHV in TURBT specimens is not an independent predictor of oncological outcomes; indeed, only pathological features at RC are associated with worse survival. However, BHV presence in cystectomy specimens resulted as an independent predictor of both cancer-specific and overall mortality.

To evaluate accuracy and inter-observer variability using Vesical Imaging-Reporting and Data System (VI-RADS) for discrimination between non-muscle invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC). Between September 2017 and July 2018, 78 patients referred for suspected bladder cancer underwent multiparametric MRI of the bladder (mpMRI) prior to transurethral resection of bladder tumor (TURBT). All mpMRI were reviewed by two radiologists, who scored each lesion according to VI-RADS. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each VI-RADS cutoff. Receiver operating characteristics curves were used to evaluate the performance of mpMRI. The Ƙ statistics was used to estimate inter-reader agreement. Seventy-five patients were included in the final analysis, 53 with NMIBC and 22 with MIBC. Sensitivity and specificity were 91% and 89% for reader 1 and 82% and 85% for reader 2 respectively when the cutoff VI-RADS > 2 was used to define MIBC. At the same cutoff, PPV and NPV were 77% and 96% for reader 1 and 69% and 92% for reader 2. When the cutoff VI-RADS > 3 was used, sensitivity and specificity were 82% and 94% for reader 1 and 77% and 89% for reader 2. Corresponding PPV and NPV were 86% and 93% for reader 1 and 74% and 91% for reader 2. Area under curve was 0.926 and 0.873 for reader 1 and 2 respectively. Inter-reader agreement was good for the overall score (Ƙ = 0.731). VI-RADS is accurate in differentiating MIBC from NMIBC. Inter-reader agreement is overall good. • Traditionally, the local staging of bladder cancer relies on transurethral resection of bladder tumor. • However, transurethral resection of bladder tumor carries a significant risk of understaging a cancer; therefore, more accurate, faster, and non-invasive staging techniques are needed to improve outcomes. • Multiparametric MRI has proved to be the best imaging modality for local staging; therefore, its use in suitable patients has the potential to expedite radical treatment when necessary and non-invasive diagnosis in patients with poor fitness.

To confirm the reproducibility of the effectiveness and safety in photodynamic diagnosis of non-muscle-invasive bladder cancer using 5-aminolevulinic acid in a prospective multicenter non-randomized phase III trial. A total of 61 patients with primary or recurrent non-muscle-invasive bladder cancer were prospectively enrolled from five hospitals between May 2015 and March 2016. 5-Aminolevulinic acid (20 mg/kg) was orally administered 3 h before transurethral resection of bladder tumors using white light or fluorescent light. Of 60 evaluable patients, 511 specimens were obtained from tumor-suspicious lesions and normal-looking mucosa. The primary end-point was sensitivity. The secondary end-points were specificity, positive and negative predictive values, and safety. The sensitivity of the fluorescent light source (79.6%) was significantly higher (P < 0.001) than that of the white light source (54.1%). In total, 25.4% (46/181) of tumor specimens were diagnosed as positive with only the fluorescent light source. In nine (15%) of 60 patients, the risk classification and recommended treatment after transurethral resection of bladder tumors were changed depending on the additional types of tumor diagnosed by the fluorescent light source. The specificity of the fluorescent light versus white light source was 80.6% versus 95.5%. No grade 4-5 adverse event was noted. Hypotension and urticaria were severe adverse events whose relationship to oral 5-aminolevulinic acid could not be excluded. These findings confirm the diagnostic efficacy and safety of photodynamic diagnosis with 20 mg/kg of oral 5-aminolevulinic acid, and show that transurethral resection of bladder tumors with a fluorescent light source using oral 5-aminolevulinic acid is well tolerated.

PurposeTo evaluate the performance of MRI for detection of bladder cancer following transurethral resection of bladder tumour (TURBT).MethodsThis single-centre retrospective study included forty-one consecutive patients with bladder cancer who underwent bladder MRI after TURBT. Two uroradiologists retrospectively assessed the presence of tumour using bladder MRI with and without DWI (diffusion weighted imaging) using a five-point Likert scale. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated and inter-reader agreement was assessed. Histopathology was used as the reference standard.Results24 out of 41 patients (58.5%) had no residual tumour or Tis (carcinoma in situ) after TURBT. Sensitivity, specificity, PPV and NPV for detection of tumour using T1WI (T1-weighted imaging) and T2WI (T2-weighted imaging) was 50.0%, 54.6%, 21.1%, and 81.8%, respectively and for T1WI, T2WI and DWI combined was 100%, 76.5%, 50.0% and 100%, respectively. Overestimation of tumour was more common than underestimation. MRI showed high accuracy for patients in whom there was no residual tumour (78.9%). Inter-reader agreement for tumour detection improved from fair (κ = 0.54) to moderate (κ = 0.70) when DWI was included.ConclusionNon-contrast MRI with DWI showed high sensitivity and relatively high specificity for detection of residual tumour after TURBT. Inter-reader agreement improved from fair to moderate with the addition of DWI. MRI can be useful after TURBT in order to guide further management.Graphical abstract

Background: Bladder cancer represents a major worldwide health challenge, with over 614,000 new diagnoses and approximately 220,000 fatalities reported globally in recent estimates, highlighting the urgent need for accurate early detection and staging to guide effective therapeutic interventions.Objective: To assess the predictive accuracy of cystoscopic findings during initial transurethral resection of bladder tumor (TURBT) with histopathological outcomes in newly diagnosed bladder cancer, with the aim of enhancing diagnostic precision and guiding clinical management.Methods: This prospective study enrolled 153 patients with newly diagnosed bladder tumors at a tertiary care center (January 2023-April 2025). Cystoscopic features (tumor size, number, location, morphology) were recorded using white light cystoscopy (WLC) at the time of TURBT, performed by two experienced urologic surgeons. These features were correlated with histopathological outcomes (grade, stage, subtype). Diagnostic accuracy was assessed via sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Logistic regression identified predictors of histopathological outcomes, and TURBT quality was evaluated by detrusor muscle presence.Results: Of 153 patients (male-to-female ratio: 4.88:1; mean age: 56.97 ± 15.73 years), 71.24% had non-muscle-invasive bladder cancer (NMIBC), and 28.76% had muscle-invasive bladder cancer (MIBC). Tumors sized 1-3 cm were predominant (50.33%). The prediction model achieved 81.05% accuracy, with sensitivities of 81.65% for NMIBC and 79.55% for MIBC. Low-grade Ta (LGTa) tumors had the highest prediction accuracy (83.33%). Tumor size >3 cm and sessile morphology were significant predictors of MIBC (p<0.05).Conclusion: Initial TURBT cystoscopic findings accurately predict histopathological outcomes in newly diagnosed bladder cancer, achieving an 81.05% diagnostic accuracy. Larger (>3 cm) and sessile tumors strongly indicate MIBC, while solitary, pedunculated tumors are associated with NMIBC. The high NPV (63.64%-99.17%) supports reliable exclusion of incorrect diagnoses, particularly in resource-limited settings. High-quality TURBT, with detrusor muscle sampled in 89.4% of cases, reduces understaging and guides treatment decisions. However, lower sensitivity for high-grade NMIBC suggests that repeat TURBT could enhance staging accuracy. Future multicenter studies incorporating repeat TURBT (re-TURBT) and advanced cystoscopic technologies are needed to improve predictions and personalize treatment.Cystoscopic findings during TURBT reliably predict histopathological outcomes, particularly for LGTa tumors, with high NPV across stages.

Measuring the dimension of invasive component in pT1 urothelial carcinoma in transurethral resection specimens can predict time to recurrence

Defining Progression in Nonmuscle Invasive Bladder Cancer: It is Time for a New, Standard Definition

The Effect of Restaging Transurethral Resection on Recurrence and Progression Rates in Patients with Nonmuscle Invasive Bladder Cancer Treated with Intravesical Bacillus Calmette-Guérin

Background: Bladder cancer is the most common malignancy of the urinary tract. Pre-operative tumour staging and grading play a significant role in treatment planning and prognosis estimation for bladder cancer. Aims and Objectives: This study aims to evaluate the utility of multiparametric-magnetic resonance imaging (mp-MRI) in detecting and staging bladder cancers and hence its role in final management. Materials and Methods: A total of 40 patients with documented urinary bladder mass undergoing mp-MRI before transurethral resection of bladder tumours for primary bladder cancer were identified and compared with post-operative histopathological reports. The data were collected and analysed using SPSS software. Results: The mean age in the study population was 53.68 ± 13.2 years, including 7 (17.5%) females and 33 (82.5%) males. Twenty-three (57.5%) of our patients had muscle invasion on the MRI pelvis. In muscle-invasive urothelial carcinoma, there were significantly more patients with Vesical Imaging-Reporting and Data System (VIRADS) 3, VIRADS 4 and VIRADS 5 than in non-muscle invasive urothelial carcinoma. The proportion of patients with VIRADS 1 and VIRADS 2 on MRI pelvis was significantly lower in muscle-invasive urothelial carcinoma than in non-muscle-invasive urothelial carcinoma (P = 0.0001). Histopathology and muscle invasion on the MRI pelvis agree well in the current study (κ = 0.742; P = 0.0001). There was an overall concordance rate of 87.5% and an overall discordance rate of 12.5% between histopathology and muscle invasion on the MRI pelvis. The sensitivity, specificity, area under the curve, positive predictive value, negative predictive value and diagnostic accuracy of the mp-MRI scan were 87.5%, 87.5%, 0.88, 91.3%, 82.35% and 87.50%, respectively. Conclusion: The mp-MRI and VIRADS scoring is an effective comprehensive tool with satisfactory sensitivity, specificity and diagnostic value for detecting muscle invasiveness of primary bladder cancer. We recommend VIRADS scoring for all bladder cancer patients for better pre-operative staging and overall management.