When should Cysview (hexaminolevulinate) be used in patients with suspected bladder cancer, particularly those with non-muscle-invasive bladder cancer and potential Impaired renal function or history of porphyria?

When to Use Cysview (Hexaminolevulinate Blue Light Cystoscopy)

Cysview should be used during transurethral resection of bladder tumor (TURBT) in patients with suspected or known non-muscle-invasive bladder cancer (NMIBC), particularly when there is a history of NMIBC with normal white light cystoscopy but positive cytology, or in patients with carcinoma in situ (CIS) or multifocal tumors. 1

Primary Indications for Cysview

Initial Diagnosis Setting

• Use Cysview at initial TURBT following suspicion of bladder cancer to improve tumor detection and reduce residual tumor rates by at least 20% 2
• Cysview detects 40.8% more CIS lesions compared to white light cystoscopy alone (P<0.001) 3
• In multifocal disease, Cysview results in AUA risk-group migration in 6% of patients and changes recommended management in 14% of cases 4

Surveillance and Follow-up Setting

• Use in patients with history of NMIBC who have normal white light cystoscopy but positive urine cytology 1
• Use for assessment of tumor recurrences in patients not previously assessed with hexaminolevulinate 2
• Use in initial follow-up of patients with CIS or multifocal tumors where detection of flat lesions is critical 2, 5
• Cysview reduces recurrence rates by 16% (47% vs 56%, p=0.026) at 9-month follow-up 6

High-Risk Scenarios

• Patients with multifocal recurrent NMIBC benefit significantly, with additional pathology detected in 57% of patients with confirmed recurrence 5
• CIS detection rate is particularly high (67% of patients with additional foci) in multifocal disease 5
• Sensitivity for tumor detection reaches 97.8% with Cysview versus 69.6% with white light alone 5

Contraindications and When NOT to Use Cysview

Absolute Contraindications

• Do NOT use in patients with porphyria (photosensitizer contraindication) 2
• Do NOT use in patients with severe renal impairment (hexaminolevulinate clearance concerns) 2

Clinical Scenarios Where Cysview is NOT Recommended

• Do NOT use for evaluation of asymptomatic microhematuria (AUA Grade C recommendation) 3
• Do NOT use in patients for whom radical cystectomy is already indicated 2
• Do NOT use in outpatient setting with flexible cystoscopy (not currently recommended) 2

Timing Restrictions to Avoid False Positives

• Avoid use within 6 weeks of prior BCG instillation due to inflammation causing false-positive fluorescence 7
• Avoid use within 6 weeks of prior bladder resection to prevent false positives from healing tissue 7
• Avoid in setting of active cystitis or significant inflammation 7

Practical Implementation Algorithm

Pre-procedure Requirements

• Instill hexaminolevulinate solution intravesically at least 1 hour before cystoscopy (optimal range 1-3 hours) 4, 5
• Ensure patient has no history of porphyria or severe renal dysfunction 2
• Confirm no recent BCG therapy or bladder resection within past 6 weeks 7

Intraoperative Technique

1. First perform complete white light cystoscopy mapping of all visible lesions 4, 6
2. Then switch to blue light inspection before and after TURBT 6
3. Resect all white light-visible lesions first, then address additional blue light-positive areas 4
4. Use techniques to minimize false positives: change cystoscopic angle for tangential views, perform multiple irrigation rounds, recognize that trigone/trabeculations may fluoresce 7

Recognizing False Positives

• Tangential views of bladder neck or side walls can create false fluorescence 7
• Trigone, trabeculations, or diverticula commonly show false-positive fluorescence 7
• Bright tiny spots and early fading lesions after irrigation are typically false positives 7
• False-positive rate is approximately 30% for blue light versus 25% for white light 4

Important Caveats

Limitations in Clinical Practice

• Cysview does NOT significantly reduce progression to muscle-invasive disease (OR 0.85, P=0.39), though trend exists (12.2% vs 17.6%, P=0.085) 3
• Requires specialized equipment and training 3
• White light cystoscopy remains the backbone of bladder cancer staging despite enhanced imaging availability 3

Safety Profile

• Hypersensitivity reactions are rare (0.2% mild dermatologic reactions) 4
• Repeat use of hexaminolevulinate is safe (up to 5 procedures documented) 4

Cost-Benefit Considerations

• Most beneficial for detecting flat lesions (CIS) that are difficult to visualize with white light 3, 5
• Additional 206 lesions detected in 25% of patients in white light-negative group 4
• Detection improvement is 12% for papillary lesions and 43% for CIS 4