Comparative Effectiveness of Fluorescent Versus White Light Cystoscopy for Initial Diagnosis or Surveillance of Bladder Cancer on Clinical Outcomes

Systematic Review and Meta-Analysis

Roger Chou, Shelley Selph, David Buckley, Rongwei (Rochelle) Fu, Jessica C. Griffin, Sara Grusing, John L. Gore

Research output: Contribution to journalReview article

16 Citations (Scopus)

Abstract

Purpose We systematically reviewed the comparative effectiveness of fluorescent vs white light cystoscopy on bladder cancer clinical outcomes. Materials and Methods Systematic literature searches of Ovid MEDLINE® (January 1990 through September 2015), Cochrane databases and reference lists were performed. A total of 14 randomized trials of fluorescent cystoscopy using 5-aminolevulinic acid or hexaminolevulinic acid vs white light cystoscopy for the diagnosis of initial or recurrent bladder cancer that reported bladder cancer recurrence, progression, mortality and harms were selected for review. Results Fluorescent cystoscopy was associated with a decreased risk of bladder cancer recurrence vs white light cystoscopy at short-term (less than 3 months, 10 trials, RR 0.59, 95% CI 0.40 to 0.88, I2=69%), intermediate-term (3 months to less than 1 year, 6 trials, RR 0.70, 95% CI 0.56 to 0.88, I2=19%) and long-term followup (1 year or more, 12 trials, RR 0.81, 95% CI 0.70 to 0.93, I2=49%). However, the findings were inconsistent, and potentially susceptible to performance and publication bias (strength of evidence low). There were no differences between cystoscopic methods in risk of mortality (3 trials, RR 1.28, 95% CI 0.55 to 2.95, I2=41%) (strength of evidence low) or progression (9 trials, RR 0.74, 95% CI 0.52 to 1.03, I2=0%) (strength of evidence moderate). Estimates for short-term recurrence (6 trials, RR 0.62, 95% CI 0.38 to 1.00), long-term recurrence (7 trials, RR 0.75, 95% CI 0.62 to 0.92) and progression (4 trials, RR 0.51, 95% CI 0.28 to 0.96) were statistically significant in the subgroup of trials that used hexaminolevulinic acid, but there were no statistically significant interactions based on the photosensitizer used. Fluorescent cystoscopy was not associated with a decreased risk of long-term recurrence in 3 trials that used methods to reduce performance bias with initial cystoscopy (RR 0.96, 95% CI 0.79 to 1.18, I2=36%). Data on harms were sparse. Conclusions Fluorescent cystoscopy was associated with a reduced risk of bladder cancer recurrence vs white light cystoscopy. However, additional trials that adequately guard against performance bias are needed to confirm these findings. Fluorescent cystoscopy with hexaminolevulinic acid may be associated with a decreased risk of progression, but more studies with long-term followup are needed to better understand the effects of the photosensitizer used on progression.

Original languageEnglish (US)
Pages (from-to)548-558
Number of pages11
JournalJournal of Urology
Volume197
Issue number3
DOIs
StatePublished - Mar 1 2017

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Cystoscopy
Urinary Bladder Neoplasms
Meta-Analysis
Light
Recurrence
Photosensitizing Agents
Acids
Publication Bias
Aminolevulinic Acid
Mortality
MEDLINE
Databases

Keywords

  • aminolevulinic acid
  • cystoscopy
  • fluorescence
  • urinary bladder neoplasms

ASJC Scopus subject areas

  • Urology

Cite this

@article{fd98d5b9d26c44348c4f1b2965ff281b,
title = "Comparative Effectiveness of Fluorescent Versus White Light Cystoscopy for Initial Diagnosis or Surveillance of Bladder Cancer on Clinical Outcomes: Systematic Review and Meta-Analysis",
abstract = "Purpose We systematically reviewed the comparative effectiveness of fluorescent vs white light cystoscopy on bladder cancer clinical outcomes. Materials and Methods Systematic literature searches of Ovid MEDLINE{\circledR} (January 1990 through September 2015), Cochrane databases and reference lists were performed. A total of 14 randomized trials of fluorescent cystoscopy using 5-aminolevulinic acid or hexaminolevulinic acid vs white light cystoscopy for the diagnosis of initial or recurrent bladder cancer that reported bladder cancer recurrence, progression, mortality and harms were selected for review. Results Fluorescent cystoscopy was associated with a decreased risk of bladder cancer recurrence vs white light cystoscopy at short-term (less than 3 months, 10 trials, RR 0.59, 95{\%} CI 0.40 to 0.88, I2=69{\%}), intermediate-term (3 months to less than 1 year, 6 trials, RR 0.70, 95{\%} CI 0.56 to 0.88, I2=19{\%}) and long-term followup (1 year or more, 12 trials, RR 0.81, 95{\%} CI 0.70 to 0.93, I2=49{\%}). However, the findings were inconsistent, and potentially susceptible to performance and publication bias (strength of evidence low). There were no differences between cystoscopic methods in risk of mortality (3 trials, RR 1.28, 95{\%} CI 0.55 to 2.95, I2=41{\%}) (strength of evidence low) or progression (9 trials, RR 0.74, 95{\%} CI 0.52 to 1.03, I2=0{\%}) (strength of evidence moderate). Estimates for short-term recurrence (6 trials, RR 0.62, 95{\%} CI 0.38 to 1.00), long-term recurrence (7 trials, RR 0.75, 95{\%} CI 0.62 to 0.92) and progression (4 trials, RR 0.51, 95{\%} CI 0.28 to 0.96) were statistically significant in the subgroup of trials that used hexaminolevulinic acid, but there were no statistically significant interactions based on the photosensitizer used. Fluorescent cystoscopy was not associated with a decreased risk of long-term recurrence in 3 trials that used methods to reduce performance bias with initial cystoscopy (RR 0.96, 95{\%} CI 0.79 to 1.18, I2=36{\%}). Data on harms were sparse. Conclusions Fluorescent cystoscopy was associated with a reduced risk of bladder cancer recurrence vs white light cystoscopy. However, additional trials that adequately guard against performance bias are needed to confirm these findings. Fluorescent cystoscopy with hexaminolevulinic acid may be associated with a decreased risk of progression, but more studies with long-term followup are needed to better understand the effects of the photosensitizer used on progression.",
keywords = "aminolevulinic acid, cystoscopy, fluorescence, urinary bladder neoplasms",
author = "Roger Chou and Shelley Selph and David Buckley and Fu, {Rongwei (Rochelle)} and Griffin, {Jessica C.} and Sara Grusing and Gore, {John L.}",
year = "2017",
month = "3",
day = "1",
doi = "10.1016/j.juro.2016.10.061",
language = "English (US)",
volume = "197",
pages = "548--558",
journal = "Journal of Urology",
issn = "0022-5347",
publisher = "Elsevier Inc.",
number = "3",

}

TY - JOUR

T1 - Comparative Effectiveness of Fluorescent Versus White Light Cystoscopy for Initial Diagnosis or Surveillance of Bladder Cancer on Clinical Outcomes

T2 - Systematic Review and Meta-Analysis

AU - Chou, Roger

AU - Selph, Shelley

AU - Buckley, David

AU - Fu, Rongwei (Rochelle)

AU - Griffin, Jessica C.

AU - Grusing, Sara

AU - Gore, John L.

PY - 2017/3/1

Y1 - 2017/3/1

N2 - Purpose We systematically reviewed the comparative effectiveness of fluorescent vs white light cystoscopy on bladder cancer clinical outcomes. Materials and Methods Systematic literature searches of Ovid MEDLINE® (January 1990 through September 2015), Cochrane databases and reference lists were performed. A total of 14 randomized trials of fluorescent cystoscopy using 5-aminolevulinic acid or hexaminolevulinic acid vs white light cystoscopy for the diagnosis of initial or recurrent bladder cancer that reported bladder cancer recurrence, progression, mortality and harms were selected for review. Results Fluorescent cystoscopy was associated with a decreased risk of bladder cancer recurrence vs white light cystoscopy at short-term (less than 3 months, 10 trials, RR 0.59, 95% CI 0.40 to 0.88, I2=69%), intermediate-term (3 months to less than 1 year, 6 trials, RR 0.70, 95% CI 0.56 to 0.88, I2=19%) and long-term followup (1 year or more, 12 trials, RR 0.81, 95% CI 0.70 to 0.93, I2=49%). However, the findings were inconsistent, and potentially susceptible to performance and publication bias (strength of evidence low). There were no differences between cystoscopic methods in risk of mortality (3 trials, RR 1.28, 95% CI 0.55 to 2.95, I2=41%) (strength of evidence low) or progression (9 trials, RR 0.74, 95% CI 0.52 to 1.03, I2=0%) (strength of evidence moderate). Estimates for short-term recurrence (6 trials, RR 0.62, 95% CI 0.38 to 1.00), long-term recurrence (7 trials, RR 0.75, 95% CI 0.62 to 0.92) and progression (4 trials, RR 0.51, 95% CI 0.28 to 0.96) were statistically significant in the subgroup of trials that used hexaminolevulinic acid, but there were no statistically significant interactions based on the photosensitizer used. Fluorescent cystoscopy was not associated with a decreased risk of long-term recurrence in 3 trials that used methods to reduce performance bias with initial cystoscopy (RR 0.96, 95% CI 0.79 to 1.18, I2=36%). Data on harms were sparse. Conclusions Fluorescent cystoscopy was associated with a reduced risk of bladder cancer recurrence vs white light cystoscopy. However, additional trials that adequately guard against performance bias are needed to confirm these findings. Fluorescent cystoscopy with hexaminolevulinic acid may be associated with a decreased risk of progression, but more studies with long-term followup are needed to better understand the effects of the photosensitizer used on progression.

AB - Purpose We systematically reviewed the comparative effectiveness of fluorescent vs white light cystoscopy on bladder cancer clinical outcomes. Materials and Methods Systematic literature searches of Ovid MEDLINE® (January 1990 through September 2015), Cochrane databases and reference lists were performed. A total of 14 randomized trials of fluorescent cystoscopy using 5-aminolevulinic acid or hexaminolevulinic acid vs white light cystoscopy for the diagnosis of initial or recurrent bladder cancer that reported bladder cancer recurrence, progression, mortality and harms were selected for review. Results Fluorescent cystoscopy was associated with a decreased risk of bladder cancer recurrence vs white light cystoscopy at short-term (less than 3 months, 10 trials, RR 0.59, 95% CI 0.40 to 0.88, I2=69%), intermediate-term (3 months to less than 1 year, 6 trials, RR 0.70, 95% CI 0.56 to 0.88, I2=19%) and long-term followup (1 year or more, 12 trials, RR 0.81, 95% CI 0.70 to 0.93, I2=49%). However, the findings were inconsistent, and potentially susceptible to performance and publication bias (strength of evidence low). There were no differences between cystoscopic methods in risk of mortality (3 trials, RR 1.28, 95% CI 0.55 to 2.95, I2=41%) (strength of evidence low) or progression (9 trials, RR 0.74, 95% CI 0.52 to 1.03, I2=0%) (strength of evidence moderate). Estimates for short-term recurrence (6 trials, RR 0.62, 95% CI 0.38 to 1.00), long-term recurrence (7 trials, RR 0.75, 95% CI 0.62 to 0.92) and progression (4 trials, RR 0.51, 95% CI 0.28 to 0.96) were statistically significant in the subgroup of trials that used hexaminolevulinic acid, but there were no statistically significant interactions based on the photosensitizer used. Fluorescent cystoscopy was not associated with a decreased risk of long-term recurrence in 3 trials that used methods to reduce performance bias with initial cystoscopy (RR 0.96, 95% CI 0.79 to 1.18, I2=36%). Data on harms were sparse. Conclusions Fluorescent cystoscopy was associated with a reduced risk of bladder cancer recurrence vs white light cystoscopy. However, additional trials that adequately guard against performance bias are needed to confirm these findings. Fluorescent cystoscopy with hexaminolevulinic acid may be associated with a decreased risk of progression, but more studies with long-term followup are needed to better understand the effects of the photosensitizer used on progression.

KW - aminolevulinic acid

KW - cystoscopy

KW - fluorescence

KW - urinary bladder neoplasms

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U2 - 10.1016/j.juro.2016.10.061

DO - 10.1016/j.juro.2016.10.061

M3 - Review article

VL - 197

SP - 548

EP - 558

JO - Journal of Urology

JF - Journal of Urology

SN - 0022-5347

IS - 3

ER -