Using Blue Light Cystoscopy to Treat Bladder Cancer

Did you know that bladder cancer is the fourth most common non-skin cancer in the U.S.?

Unlike prostate cancer, for which there is a standard screening, bladder cancer can frequently fall under the radar. Yet anyone between the ages of 20 and 90 may be affected by it—in particular, Caucasian males 60–70 years of age. So you should never delay a hospital visit if you’re experiencing issues.

Here at MedStar Washington Hospital Center, we use an advanced technology, blue light cystoscopy, both to detect this cancer and help minimize the risk of its return. Although this technology is in use in other regions globally, the Hospital Center is one of the few medical facilities in this region utilizing the blue light technology. We perform 5 to 10 such procedures a month—more than any other medical center in the District of Columbia.

But before we understand the benefits that blue light cystoscopy brings, let’s first understand what can cause bladder cancer and how it’s typically managed.

Risk Factors

Instances of bladder cancer may be localized and confined within the organ itself, or may potentially spread elsewhere. Multiple risk factors can encourage bladder tumors to appear and grow:

• Cigarette smoking: This is the primary offender. Carcinogens inhaled by the smoker travel through the bloodstream to the kidneys, which try to eliminate the poisons via the urine. This interaction between the bladder lining and carcinogens in the urine is thought to lead to malignancies in the bladder.
• Toxic chemicals: Chemicals such as aniline dyes (used in hair dyes or automotive paint), or those used in certain professions (some benzenes or aromatic amines), may also put exposed persons at higher risk.
• Chronic bladder infections: Recurring urinary tract infections or the chronic use of tubes within the urinary tract can lead to inflammation, which can lead to bladder cancer over time.
• Radiation: When used to treat cancers in the pelvis, radiation may spur a secondary malignancy in the bladder.
• Genetic susceptibility: Hereditary conditions, such as Lynch syndrome, when combined with some of the factors listed above, can increase a patient’s risk as well.

If a patient is diagnosed with this cancer, his or her survival rate can depend largely on the stage at which the cancer is detected, and whether it is muscle-invasive or non–muscle-invasive.

The Stages of Bladder Cancer

Tumors of the bladder are assigned very specific stages, based on these conditions:

• Stage 0: In this beginning stage, abnormal cells are discovered in the tissue that lines the interior of the bladder. Stage 0a—sometimes referred to as noninvasive papillary carcinoma—can resemble long, thin growths, while Stage 0is (carcinoma in situ) presents as a flat tumor.
• Stage I: Cancer has formed and spread to connective tissue adjacent to the bladder’s lining.
• Stage II: Cancer has spread to include layers of the bladder’s muscle tissue.
• Stage III: In Stage IIIA, cancer has spread to the fat layer surrounding the bladder and potentially to reproductive organs, but not to lymph nodes, or it has spread to a single lymph node in the pelvis not near its major arteries. In Stage IIIB, cancer has spread to multiple lymph nodes in the pelvis, or to at least one near a main artery.
• Stage IV: In Stage IVA, cancer has spread from the bladder to the abdominal or pelvic wall, or to lymph nodes above the main pelvic arteries. In Stage IVB, cancer has metastasized to parts of the body, such as the liver, lungs or bones.

How Is Bladder Cancer Diagnosed?

There is no standardized screening for this cancer. A tumor of the bladder may cause no pain or other symptoms and may even be randomly discovered during an unrelated imaging test. More commonly, a patient’s first clue that there is an issue comes when they spot blood in their urine (hematuria), prompting medical attention.

For women, although bladder cancer presents less frequently than it does in men, it tends to be caught at more advanced stages of the disease. This situation may occur because blood in a woman’s urine can be mistakenly connected with menstruation or a urinary tract infection.

Any patient who discovers blood in their urine should consult their healthcare practitioner, who may recommend a hematuria workup.

Or, if symptoms from conditions such as overactive bladder don’t improve with traditional therapies, it could also be a signal to discuss possible other causes with your practitioner.

In these situations, your doctor might refer you to a urologist, who may recommend a comprehensive workup, including a CT scan and cystoscopy.

In bladder cancer’s earliest stages, when it remains localized within the bladder, patients require close surveillance and sometimes local therapies within the bladder. But they generally do well under treatment, and their bladder can often be preserved.

Blue Light Cystoscopy

The conventional first-line treatment for the removal of bladder cancer is via transurethral removal of bladder tumor, or TURBT for short. TURBT is used for surveillance and treatment of non-invasive bladder cancer, or if there are multiple sites to check for cancer cells and growth. It’s also a critical aid for identifying recurrences early on, and potentially preventing progression of the disease.

The “incision-less” TURBT process, usually performed as an outpatient procedure, involves resection of one or more tumors—that is, cutting out the diseased tissue—performed with the patient under anesthesia. Using a specialized endoscope inserted into the bladder, we scrape the tumor off the bladder’s inner lining. This allows us to not just eliminate the diseased area but also to diagnostically examine if it is invasive or non-invasive and whether it has spread.

Blue light cystoscopy is the newest tool in our TURBT toolbox, a unique technology for pinpointing tumors of the bladder. It allows us to locate problem areas more easily than standard white light cystoscopy, which can miss very small tumors or lesions.

An hour or so before TURBT, with the patient in pre-op, we first inject an imaging dye known as Cysview® through the urethra and into the bladder, giving it time to interact with the bladder lining and accumulate within abnormal tissue, such as cancerous cells. The dye is absorbed quickly by the rapidly dividing cancer cells. A compound within this dye—hexaminolevulinic acid—is photo-luminescent; exposed to blue light, it causes abnormal cells to glow pink (“fluorescence”).

TURBT surgery generally takes about an hour. We use a thin, lighted, tube-like cystoscope to inspect the bladder. While typical cystoscopes use just white light, the blue light instruments allow the surgeon to switch between white light and blue light.

Under this blue light, cancerous cells—which have absorbed the Cysview dye—glow a fluorescent pink, drawing the attention of the surgeon to the abnormal tissue. Thanks to this fluorescence, the surgeon can more readily note the edges of the bladder tumor, and remove even tiny lesions more quickly and thoroughly.

After the Procedure

Most patients do quite well immediately following this procedure, apart from some temporary irritation, frequent urination for a short time or residual bleeding in the urine. Generally, patients may return home immediately after surgery, with their urinary health back to normal in a week or two. Sometimes, the patient will go home with a catheter in their bladder for several days to facilitate bladder healing.

Post-recovery, patients will return to the Hospital Center to discuss next steps in the management of their bladder cancer. We’ll meet with patients every three to four months to assure there has been no recurrence of the tumor. In many cases where we’d like to continue surveillance on a patient, we’re able to perform blue light cystoscopy as an outpatient service in an office setting, thanks to the flexibility, speed and ease of the procedure.

If we find no issues after a period of observation, the patient’s check-ups can be spaced out over time.

The good news: Multiple studies in the U.S. and Europe show that the recurrence rate of non-invasive bladder cancer is lower for patients who undergo resection using blue light cystoscopy, compared with patients under white light. Depending on the tumor type, performing a TURBT with blue light has been shown to prevent recurrences by 12–43%.

Reducing Your Risk

So, what measures can the average individual take to protect themselves against bladder cancer? Here are some recommendations:

• If you smoke, take measures to quit. And if you don’t smoke, don’t start.
• Blood in your urine can be a signal. Talk to your healthcare provider and ensure that you receive the appropriate tests. Together, determine a necessary treatment path.

Lastly, don’t let COVID-19 cause you to delay care. We’re available to you, ready to answer your questions and help you consider options. Even in the midst of the pandemic, cystoscopy, CT scans and other screenings can be done safely and efficiently on-site here, without exposure to other patients.