CYSVIEW® with blue-light cystoscopy (BLC) is indicated as an adjunct to standard white-light cystoscopy (WLC) in the detection and management of papillary non-muscle invasive bladder cancer (pNMIBC) in patients with known or suspicion of bladder cancer.1
CYSVIEW® is a photosensitizing agent which makes cancer cells fluoresce red under blue light illumination. In order to perform BLC only approved cystoscopic machines, equipped with necessary filters to allow both WLC and blue-light (wavelength 360–450nm) fluorescence cystoscopy, should be used; these filters can easily be switched on and off by the click of a button, giving doctors the benefit of both modes.
There are many benefits of using CYSVIEW® in addition to regular WLC:
- An improved detection of papillary non-muscle invasive bladder cancer (pNMIBC) due to the illumination of cancerous cells.1,2
- A more complete removal of tumours during resection by controlling the area with blue light after resection to see if there are any remnant tumours.4
- An improved surgical outcome as a result of an improved detection and resection which can lead to fewer recurrences.5,6,7
Improving the Patient Pathway
“Missed diagnosis leading to delayed or incomplete treatment has significant prognostic implications for patients with potentially aggressive tumours.” 8
The typical patient pathway for a pNMIBC patient is characterized by a cycle of follow-up cystoscopies and TURBTs. This is what contributes to making bladder cancer one of the most expensive cancers to manage.3,9 A longer time to recurrence, which would lead to a prolonged time without having to undergo surgery with all its risks and possible complications, will therefore give the patient an improved quality of life.2,3
CYSVIEW® with BLC significantly improves long-term time to recurrence.7
Using CYSVIEW® with BLC
The correct use of CYSVIEW® with BLC is important to provide optimal treatment. The procedure is very similar to a standard WLC with some additional preparation:10
1) Preparing and mixing CYSVIEW®.
In only a few steps the drug is prepared and ready
to be instilled into the patient.
See full descriptions on how to mix CYSVIEW®1 .
If not administered shortly after reconstitution with the solvent, the solution can be stored for up to 2 hours in a refrigerator at 2° - 8°C. If not used within 2 hours, the solution must be discarded.
2) Instill CYSVIEW®. A solution of CYSVIEW® is instilled into the bladder. After bladder instillation, CYSVIEW® enters the bladder mucosa where it is converted to the photoactive porphyrin (PAP), mainly protoporphyrin IX(PpIX), which preferentially accumulates in rapidly proliferating neoplastic cells. After a period of only one hour, sufficient PAPs have been accumulated in neoplastic bladder tissue to allow BLC to take place. Under blue light CYSVIEW® causes lesions to appear bright red and demarcated, whereas the background normal tissue appears dark blue.
See the full CYSVIEW® Bladder Instillation Procedure.1
3. Perform WLC and BLC together. The cystoscopic examination in blue light should be done within 1 - 3 hours following bladder instillation. CYSVIEW® with BLC combined with WLC is superior to a WLC alone.
Watch the blue-light cystoscopy videos, courtesy of Maximillian Burger, Germany:
The recommended cystoscopy procedure is to:1,10
- Inspect the entire bladder in white light before switching to blue light mode and repeating the inspection. Make note of any additional lesions found.
- Remove any visible tumours in white light mode.
- Examine all areas in blue light mode to ensure that there are no tumour remnants left in the bladder.
- If necessary, repeat steps 2 and 3.
During the cystoscopic examination, be aware that:
- A red fluorescence is expected at the bladder outlet and the prostatic urethra; this fluorescence occurs in normal tissue and is usually less intense and more diffuse than the bladder mucosal fluorescence associated with malignant lesions
- Tangential light may give false fluorescence. To help avoid false fluorescence, hold the endoscope perpendicular and close to the bladder wall with the bladder distended.
- False positive fluorescence may result from scope trauma from a previous cystoscopic examination and/or bladder inflammation.
- Malignant lesions may not fluoresce following CYSVIEW® administration, particularly if the lesions are coated with necrotic tissue. Blue light may fail to detect T2 tumours which have a tendency to be necrotic on the surface, and necrotic cells generally do not fluoresce.
- When performing the BLC, avoid prolonged blue light exposure. Studies have not evaluated the potential for adverse effects from blue light.
- Perform biopsy and/or resection of suspicious lesions by transurethral resection of the bladder (TURBT) only after completing white and blue light cystoscopic examinations with bladder mapping. Using standard cystoscopic practices, obtain biopsies of abnormal areas identified during either white or blue light examination and perform resections. Always check for the completeness of the resections under both white light and blue light before finalizing the TURBT procedure.
How to Perform Blue-Light Cystoscopy by Dr. J. Ryan Mark (Thomas Jefferson University, USA)
Describes the technique and practical aspects of CYSVIEW® (hexaminolevulinate) (HAL) flourescence cystoscopy, also know as “Blue-Light Cystoscopy with CYSVIEW®”
Read Blue Light-How I Do It Article
For full details on the indications and administration of CYSVIEW® as well as contraindications, warnings & precautions, adverse reactions, and drug interactions, please refer to the product monograph.
Note: CYSVIEW® (hexaminolevulinate (HAL) hydrochloride) is used with blue-light cystoscopy (BLC) as an adjunct to white-light cystoscopy (WLC) and not separately. CYSVIEW® with BLC may be referred to in a number of ways, such as CYSVIEW®, CYSVIEW® with BLC, CYSVIEW® with Photodynamic Diagnosis (PDD) System, HAL with BLC, and HAL with PDD.
- Cysview® Canadian Product Monograph. Oct 16, 2015.
- Stenzl A et al., Hexaminolevulinate Guided Fluorescence Cystoscopy Reduces Recurrence in Patients With Non-muscle Invasive Bladder Cancer; Journal of Urology 2010;184(5):1907-1913.
- Witjes J.A et al., Clinical and Cost Effectiveness of Hexaminolevulinate-guided Blue-light Cystoscopy: Evidence Review and Updated Expert Recommendation, European Urology 66 (2014) 863-871
- Hermann GG et al., Fluorescence-Guided Transurethral Resection of Bladder Tumours Reduces Bladder Tumour Recurrence Due to Less Residual Tumour Tissue in Ta/T1 Patients: a Randomized Two-Centre Study; BJU International 2011;108(8Pt2):E297-303.
- Jocham D et al., Improved Detection and Treatment of Bladder Cancer Using Hexaminolevulinate Imaging: A Prospective Phase III Multicenter Study; Journal of Urology 2005;174(3):862-866.
- Witjes JA., Is Fluorescent Cystoscopy of Cost/Benefit/Therapeutic Value for Carcinoma In Situ of the Bladder?; Journal of Urology 2013;190:19-21.
- Grossman HB et al., Long-Term Decrease in Bladder Cancer Recurrence with Hexaminolevulinate Enabled Fluorescence Cystoscopy; Journal of Urology 2012;188(1):58-62.
- Frampton JE & Plosker GL., Hexyl Aminolevulinate in the Detection of Bladder Cancer. Drugs 2006;66(4):571-578
- Sievert KD et al., Economic aspects of bladder cancer: what are the benefits and costs?; World J Urol 2009;27:295-300.
- Ryan J M et al., Blue-light cystoscopy for detection and treatment of non-muscle invasive bladder Cancer; The Canadian Journal of Urology;19 (2);April 2012 p6227-6231