Introduction & objectives: The diagnostic process may be extensive in patients with positive or suspicious cytology when white-light flexible cystoscopy (WLFC) is negative. The next step would be to proceed with resection biopsies and exclusion of upper urinary tract tumour, procedures that are performed in the operating theatre (OT), being demanding on both the patient and the healthcare system.
The use of blue-light flexible cystoscopy (BLFC) might detect additional bladder tumours already at the outpatient clinic and shorten the diagnostic process. We wanted to study if BLFC could improve the diagnostic process for patients with normal WLFC and positive/suspicious urine cytology.
Materials & methods: Data was collected in a prospective multicentre registry initiated to observe clinical utility and explore possible benefits of BLFC. 40 patients from 4 different hospitals were selected, displaying positive or suspicious urinary cytology. All had been investigated with WLFC and CT urography, both regarded as negative. The Nordic BLFC registry contains variables including the subjective experience from BLFC and whether the patient preferred to have the procedure done under general anaesthesia. 
HAL was installed one hour before cystoscopy. In local gel anaesthesia the bladder was examined with WLFC followed by BLFC. Suspicious lesions where biopsied and examined by histopathology. Small tumours and localised carcinoma in situ (CIS) where fulgurated. 
Results: Bladder cancer was diagnosed in 20 out of 47 (43%) cystoscopies. 6 patients underwent BLFC more than once. In 35% (7/20) of these cystoscopies tumour(s) was only detected by BLFC. All patients with tumours detected by BLFC only (CIS:5, Ta:2) could be immediately treated completely with ablation at the outpatient clinic or with BCG.
The majority (27/29 patients) stated that they preferred to have the BLFC done at the outpatient clinic, and 2 patients preferred the alternative procedure (TURB with resection biopsies). Four patients complained about discomfort due to bladder expansion, and three due to fulguration. No serious adverse events or allergic reactions where seen.
Conclusion: BLFC at the outpatient clinic may in a simple way solve many unclear cases with malign/ suspicious urinary cytology. The procedure is well tolerated and generally preferred by patients over a procedure in the OT under general anaesthesia. 



DISCLAIMER
Anders Debes has until recently been employed by Photocure ASA

Malignant urinary cytology of unknown origin - blue light flexible cystoscopy with Hexaminolevulinate (HAL) at the outpatient clinic may be a valuable diagnostic and therapeutic tool