Holzbeierlein, Jeffrey M.

686 Background: Blue-light cystoscopy (BLC) is an established procedure for use in the diagnosis and surveillance of patients with non-muscle-invasive bladder cancer (NMIBC). It is associated with improved detection rates compared to white light cystoscopy (WLC); however, limited data is available regarding its role in upstaging and/or upgrading when used alongside WLC. The aim of this study is to assess the incidence and features of patients undergoing upstaging and/or risk-group migration with the implementation of BLC. Methods: Using data from the prospective multi-institutional Cysview Registry (2014-2024), patients with NMIBC who underwent transurethral resection or biopsy of bladder tumors were identified. The patients in whom malignant lesions were exclusively detected by BLC, as well as those experiencing an upward change in risk category (as defined by the American Urological Association [AUA] classification) based on BLC findings, were documented. The clinical features of these patients were subsequently reviewed. Results: In this study, 2,854 patients were enrolled, who collectively underwent 4,158 resections and provided 6,432 separate pathology samples. A total of 201 (7%) patients had at least one malignant lesion detected exclusively by BLC while having negative WLC. These lesions (total 335) included carcinoma in-situ (CIS) in 145 (43%), low-grade Ta in 53 (16%), high-grade Ta in 95 (28%), high-grade T1 in 37 (11%), and high-grade T2 in 5 (1%). In patients with multifocal disease, BLC resulted in AUA risk-group upward migration in 66 (2.3%) patients.Theclinical features of these two groups are presented in the table. Taken together, the total rate of upgrading or upstaging using BLC was 9.3%, including migration to low-risk in 1.2%, intermediate-risk in 2.1%, and high-risk in 6%. Conclusions: Using BLC during transurethral resection or biopsy of bladder tumors results in risk group migration in over 9% of patients with NMIBC. This impacts patient management, including the administration of intravesical therapy when it was not initially planned, an extension in the duration of therapy, or the decision to proceed with radical cystectomy. Clinical features of patients with malignant lesions detected by BLC only (A) and those with risk group migration (B). Clinical features A B Age, median (IQR), year 71 (63-76) 71 (61-77) Gender, n (%) Male Female 140 (74)49 (26) 54 (82)12 (18) History of smoking, n (%) 117 (62) 40 (61) Primary occurrence, n (%) 65 (34) 14 (21) History on intravesical therapy, n (%) 92 (49) 40 (61) Urine cytology * , n (%) Positive Suspicious Atypical Negative/NA 33 (17)21 (10)41 (20)106 (53) 13 (20)7 (11)10 (15)36 (54) IQR: interquartile range; NA: not available. *Detected by either voided urine or bladder wash.

Background: Regional analgesia is a critical component of enhanced recovery after surgery pathways for cystectomy, but there is little research comparing different modalities. Transversus abdominis plane block is a well-established procedure used for postoperative regional analgesia, whereas erector spinae plane block is a recently described technique that some contend improves pain control. Objective: We sought to compare these modalities in patients undergoing cystectomy, with primary end points of pain scores and total narcotic utilization measured in morphine milliequivalents. Methods: We retrospectively reviewed 77 consecutive patients who underwent open radical cystectomy. Patients who did not undergo erector spinae plane block or transversus abdominis plane block or who used chronic narcotics were excluded. Pain intensity scores were measured immediately postoperatively and in 24-hour intervals until 72 hours postoperatively. Cumulative narcotic utilization at 72 hours, return to bowel function, and length of stay were measured. Results: Fifty-one patients met inclusion criteria. Seventeen patients underwent erector spinae plane block and 34 transversus abdominis plane block. Erector spinae plane block patients reported lower pain scores immediately postoperatively (P = .046), at 48 hours (P = .019), and 72 hours (P = .019). Erector spinae plane block patients used less narcotics after 72 hours than transversus abdominis plane block patients (median: 62.50 morphine milliequivalents vs 146.25 morphine milliequivalents, P = .008). Conclusions: Compared with transversus abdominis plane block, erector spinae plane block reduced total narcotic utilization by 234% while also reducing subjective patient pain scores. Increased adoption of erector spinae plane block could have major impacts on both clinical outcomes and patient satisfaction in patients undergoing radical cystectomy.

The use of blue light cystoscopy (BLC) has been shown to improve bladder tumor detection. However, data demonstrating the efficacy of BLC across different races are limited. Herein, we aim to evaluate heterogeneity in the characteristics of BLC for the detection of malignant lesions among various races. Clinicopathologic information was collected from patients enrolled in the multi-institutional Cysview® registry (2014–2021) who underwent transurethral resection or biopsy of bladder tumors. Outcome variables included sensitivity and negative and positive predictive values of BLC and white light cystoscopy (WLC) for the detection of malignant lesions among various races. Overall, 2379 separate lesions/tumors were identified from 1292 patients, of whom 1095 (85%) were Caucasian, 96 (7%) were African American, 51 (4%) were Asian, and 50 (4%) were Hispanic. The sensitivity of BLC was higher than that of WLC in the total cohort, as well as in the Caucasian and Asian subgroups. The addition of BLC to WLC increased the detection rate by 10% for any malignant lesion in the total cohort, with the greatest increase in Asian patients (18%). Additionally, the positive predictive value of BLC was highest in Asian patients (94%), while Hispanic patients had the highest negative predictive value (86%). Our study showed that regardless of race, BLC increases the detection of bladder cancer when combined with WLC.

Objectives To evaluate the role of blue‐light cystoscopy (BLC) in detecting invasive tumours that were not visible on white‐light cystoscopy (WLC). Patients and Methods Using the multi‐institutional Cysview registry database, patients who had at least one white‐light negative (WL–)/blue‐light positive (BL+) lesion with invasive pathology (≥T1) as highest stage tumour were identified. All WL–/BL+ lesions and all invasive tumours in the database were used as denominators. Relevant baseline and outcome data were collected. Results Of the 3514 lesions (1257 unique patients), 818 (23.2%) lesions were WL−/BL+, of those, 55 (7%) lesions were invasive (48 T1, seven T2; 47 unique patients) including 28/55 (51%) de novo invasive lesions (26 unique patients). In all, 21/47 (45%) patients had WL−/BL+ concommitant carcinoma in situ and/or another T1 lesions. Of 22 patients with a WL−/BL+ lesion who underwent radical cystectomy (RC), high‐risk pathological features leading to RC was only visible on BLC in 18 (82%) patients. At time of RC, 11/22 (50%) patients had pathological upstaging including four (18%) with node‐positive disease. Conclusions A considerable proportion of invasive lesions are only detectable by BLC and the rate of pathological upstaging is significant. Our present findings suggest an additional benefit of BLC in the detection of invasive bladder tumours that has implications for treatment approach.