Kathryn Chatterton

Hexylaminolaevulinate fluorescence cystoscopy in patients previously treated with intravesical bacille Calmette‐Guérin

Study Type – Diagnosis (case series) Level of Evidence 4

Hexylaminolaevulinate ‘blue light’ fluorescence cystoscopy in the investigation of clinically unconfirmed positive urine cytology

To investigate the value of photodynamic diagnosis (PDD) using hexylaminolaevulinate (Hexvix®, PhotoCure, Oslo, Norway) in the investigation of patients with positive urine cytology who have no evidence of disease after standard initial investigations.

Hexylaminolevulinate Photodynamic Diagnosis for Multifocal Recurrent Nonmuscle Invasive Bladder Cancer

OBJECTIVE To determine the potential for hexylaminolevulinate (HAL) photodynamic diagnosis (PDD) to improve the management of multifocal recurrent nonmuscle-invasive bladder cancer (NMIBC). PATIENTS AND METHODS Patients with a history of NMIBC and with at least two suspected papillary recurrences were enrolled in this prospective study between April 2005 and October 2006. The photosensitizer was hexylaminolevulinate (HAL) (PhotoCure, Norway), and the Storz D-light system was used to detect fluorescence. The bladder was mapped initially under white light and then using HAL-photodynamic diagnosis (PDD). The number and types of additional lesions detected by HAL-PDD over white light cystoscopy were measured. RESULTS Eighteen patients (11 men), median age 74 years (range 35-84 yrs), underwent HAL-PDD. The median HAL instillation time was 109 minutes (range 60-250 min). Recurrent bladder cancer was confirmed histologically in 14/18 (78%) patients. Additional pathology was detected in 8/14 (57%) patients with confirmed recurrence and confirmed histologically in 6 of these. Additional pathology was papillary in 5/6 (83%) patients, and flat pathology was found in all six patients with additional foci. Carcinoma in situ (CIS) was detected in 4/6 (67%) patients with additional foci, three of whom were subsequently treated with intravesical bacille Calmette-Guérin (BCG). The sensitivity of HAL-PDD for the detection of tumor was 97.8%, compared with 69.6% for white light cystoscopy. The false-positive fluorescence-guided biopsy rate was 18/63 (29%). CONCLUSION HAL-PDD allows more complete management of bladder tumor in patients with multifocal recurrence. The high frequency of additional lesions detected and the rate of detection of CIS suggest that HAL-PDD should be the standard of care.

Demonstration of erectile management techniques to men scheduled for radical prostatectomy reduces long‐term regret: a comparative cohort study

Study Type – Outcomes (case series)

MP22-08 LONG TERM FOLLOW UP OF A PROSPECTIVE RANDOMISED TRIAL OF HEXYLAMINOLEVULINATE (HEXVIX®) PHOTODYNAMIC DIAGNOSIS (PDD) ASSISTED VERSUS CONVENTIONAL WHITE-LIGHT TRANSURETHRAL RESECTION (TURBT) IN NEWLY PRESENTING NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC)

INTRODUCTION AND OBJECTIVES: Despite Hexvix PDD improving the detection of bladder tumours, in a prospective randomized trial in newly presenting bladder tumours we were unable to demonstrate reduced recurrence in the first year post resection. We now report longer-term follow-up with 3-year recurrence and progression rates from the trial. METHODS: 249 patients with newly presenting suspected NMIBC were enrolled at our institution between March 2005 and April 2010, and randomized to receive either Hexvix PDD assisted TURBT plus single shot Mitomycin C or white-light (W/L) TURBT plus single shot Mitomycin C. Patients with muscle invasive bladder cancer, or a previous history of bladder cancer were excluded. All operations were performed by 3 specialized bladder cancer teams. Subsequent management was standardized for all patients. All data was prospectively collected. RESULTS: 129 patients received Hexvix PDD assisted TURBT and 120 patients received W/L TURBT. 185 of 249 patients were found to have NMIBC (Hexvix e 97, W/L e 88). Final TNM classification was low grade/G1pTa 1⁄4 98 (Hexvix e 50, W/L 48); high grade/G3pTa 1⁄4 28 (Hexvix e 13, W/L 15); high grade/G3pT1 1⁄4 57 (Hexvix e 35, W/L 22). Primary CIS was seen in one patient and secondary CIS in 37 (Hexvix e 25, W/L 12). Of the patients who completed 3-month follow up, 17/86 (20%) in the Hexvix group and 14/82 (17%) in the W/L group had a recurrence (p 1⁄4 0.70). Of the patients who were recurrence free at 3 months and completed 1 year follow up, 10/63 (16%) in the Hexvix group and 15/67 (22%) in the W/L group had a recurrence (p1⁄40.38). Of the patients who were recurrence free at 1 year and completed 3 year follow up, 5/47 (10.6%) in the Hexvix group and 7/46 (15.2%) in the W/L group had a recurrence (p1⁄40.51). 3/97 (3.1%) in the Hexvix group and 4/88 (4.5%) in the W/L group had progressed to muscle invasive disease at 3 years (p1⁄40.61). (Table 1) CONCLUSIONS: Despite improving the accuracy of bladder cancer diagnosis, Hexvix PDD has not been shown in this trial to reduce the recurrence rate or progression rate of NMIBC at 3 years’ follow-up.

PD19-06 HIGH-RISK NON-MUSCLE INVASIVE BLADDER CANCER (HR-NMIBC) TREATED WITH SEQUENTIAL BCG / ELECTROMOTIVE DRUG ADMINISTRATION MITOMYCIN-C (EMDA-MMC): 2% DISEASE-SPECIFIC MORTALITY AT 4 YEARS' FOLLOW-UP

INTRODUCTION AND OBJECTIVES: Sequential BCG/EMDAMMC was previously reported to be superior to BCG alone, and since 2009, has been the standard induction regimen in our institution for the treatment of HR-NMIBC. We now present medium-term outcomes from this study. METHODS: From June 2009 to June 2013, all patients undergoing bladder conservation for HR-NMIBC were offered sequential BCG/EMDA-MMC. BCG (Immucyst until June 2012, Oncotice since Sept 2012) was given in weeks 1 and 2, and EMDA-MMC (40mg, intravesical current 20mA for 30 mins) in week 3, and this cycle was repeated 3 times for a total of 9 weeks. Maintenance treatment was with 3 doses of BCG every 6 months, commencing 3 months after induction. Response was assessed by GA cystoscopy 8 weeks post induction, followed by 6-monthly flexible cystoscopy. RESULTS: 151 patients with HR-NMIBC were treated, of whom 44 (29%) received primary cystectomy, leaving 107 patients (71%) treated with sequential BCG/EMDA-MMC. 86/107 (80%) had high grade Ta/T1 disease, of whom 34 (32%) also had carcinoma in situ (CIS). 19/107 (18%) had primary CIS. 2 (2%) had recurrent, large volume, low grade disease. Median length of follow-up was 47 months (range 4-87 months). 1 patient was lost to follow-up immediately after induction and was excluded from analysis. Overall, 37/106 (35%) patients had disease recurrence. 7/106 (7%) had disease progression, of whom 2/106 (2%) progressed to higher stage NMIBC, 3/106 (3%) progressed to muscle invasive bladder cancer (MIBC), and 2/106 (2%) developed distant metastases. 11/106 (10%) eventually underwent cystectomy for the following reasons: progression to MIBC (3/11), disease recurrence (7/11) and severe bladder storage symptoms (1/11). 17/106 patients (16%) have died, of which 2/106 (2%) died from bladder cancer. As previously reported, 30/107 patients were unable to complete the full 9-dose induction schedule, 16/30 directly due to side effects. There was no significant difference in recurrence rates between patients who received a full (36%) versus a reduced (30%) induction schedule (X21⁄40.39, p1⁄40.53). CONCLUSIONS: Despite the challenge of a 4-year recurrence rate of 35%, a low progression rate to muscle-invasive and metastatic disease of 5% and disease-specific mortality of 2% continue to attest to the oncological efficacy of sequential BCG/EMDA-MMC.

Demonstration of erectile management techniques to men scheduled for radical prostatectomy reduces long-term regret: a comparative cohort study: POST PROSTATECTOMY REGRET

Study Type – Outcomes (case series)

Demonstration of erectile management techniques to men scheduled for radical prostatectomy reduces long-term regret

Study Type – Outcomes (case series)