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Clinical Library

Clinical Library: Case Studies

Residual Tumor

Patient profile

69-year-old Caucasian female

Reason for consultation

Recent diagnosis of Ta low malignant potential urothelial cancer of the bladder status post-TURBT at an outside hospital.

Past medical history

Former flight attendant with a history of secondhand smoke exposure.

Previous adjuvant treatments

None

Indication for TURBT

Evidence of residual disease on blue light examination. 

Original Image
Modified Image

Treatment plan

TURBT pathology of blue-light-enhanced region revealed residual tumor. Plan: mitomycin C once a week for eight weeks, followed by cystoscopic reevaluation.

Ta Low-Grade

Patient profile

65-year-old Caucasian male

Reason for consultation

Hematuria evaluation led to cystoscopic diagnosis of urothelial bladder cancer (presents for TURBT).

Past medical history

Adult-onset diabetes mellitus (on metformin therapy).

Previous adjuvant treatments

None

Indication for TURBT

UCC bladder cancer on cystoscopy.

Before Blue Light
After Blue Light

Treatment plan

Blue light examination post-TURBT demonstrates absence of residual fluorescence, indicating complete resection. Histopathology reveals Ta low malignant potential tumor. Plan: cystoscopy in three months.

High-Grade T1

Patient profile

68-year-old male 

Bladder cancer history

Presented with gross hematuria.

Past histology/tumor types

High-grade Ta urothelial carcinoma.

Previous adjuvant treatments

Treated with a six-week course of BCG induction.

Indication for TURBT

On suspicion, underwent another cystoscopy with blue light.

Before Blue Light
After Blue Light

TURBT results 

(findings including histology):

Showed high-grade T1 carcinoma.

Treatment plan

Underwent radical cystectomy, given the progression of tumor following BCG therapy.

High-Grade, Papillary

Patient profile

65-year-old female 

Bladder cancer history

Presented with gross hematuria.

Past histology/tumor types

Underwent cystoscopy and was diagnosed with high-grade papillary urothelial carcinoma (TCC). Pathology stated “high-grade dysplasia and marked atypia.” She sought a second opinion.

Previous adjuvant treatments

None. The patient was observed without intravesical therapy and received a follow-up cystoscopy after three months.

Before Blue Light
After Blue Light

Indication for TURBT

On suspicion, underwent another cystoscopy with blue light.

TURBT results

(findings including histology):

Showed persistent, high-grade papillary TCC and carcinoma in situ.

Treatment plan

Receiving BCG therapy.

Case Study Videos

Large & Small Tumors Thumbnail

Large & Small Tumors

This case study video examines a large, positive tumor with some signs of necrosis, with a small tumor visible at the end of the field. The camera swipes over the fringes of the tumor, but it is visible only under blue light — it cannot be seen after switching back to white light.

Play Video
Clear Tumor Margins Thumbnail

Clear Tumor Margins

Two bladder tumors are visible from the bladder dome, which can be seen clearly under white light; however, blue light shows strong fluorescence and enhances the visualization of the tumor margins. It is particularly important to define the edges of tumors in the dome, as resection in this area is prone to complications.

Play Video
Site of Healing Process Thumbnail

Site of Healing Process

The scar from a former resection can be seen, with fibrin visible under blue light. In this case, use of blue light enables a clear view of the fringes of tissue related to the healing process, rather than malignancy.

Play Video
Small Tumors Thumbnail

Small Tumors

While viewing the dome, two small additional tumors are clearly visible under blue light — and would have very easily been overlooked under white light.

Play Video
Added Key Details Thumbnail

Added Key Details

The bladder mucosa is visible, and the presence of air bubbles is clearly evident. A fairly large tumor is easily viewed under white light; however, under blue light, it is possible to define the edges and the absence of concomitant tumor fields.

Play Video

Hints and Tips

Before using Blue Light Cystoscopy with Cysview® (BLC™ with Cysview®), watch these quick troubleshooting videos. To download a more in-depth, step-by-step troubleshooting guide, visit the Procedure page.

Problem

Lateral walls fluoresce pink, but the fluorescence is prone to “disappearing.”

Cause

Tangential view

Solution

Consider changing the angle of view and/or gently stretch the bladder wall to see if fluorescence disappears.

Problem

Green hue

Cause

Urine in the bladder

Solution

Drain the bladder at the start of the procedure and/or remove the resectoscope, set the trocar valve to the exit position, and allow the urine to drain passively.

Problem

Entire bladder appears red under white and blue light.

Cause

Recent BCG treatment and/or infection.

Solution

Hexaminolevulinate (Cysview) should not be used in patients at high risk of bladder inflammation (e.g., after 90 days of BCG therapy) or with moderate to severe leukocyturia. Widespread inflammation of the bladder should be excluded by cystoscopy before the product is administered. Inflammation may lead to increased porphyrin build up, increased risk of local toxicity upon illumination and false fluorescence. It may be possible to continue the procedure under white light alone. Either continue the procedure without the benefit of the blue light diagnosis or reschedule for a subsequent session.

Problem

Weak fluorescence

Cause

Equipment failure, blood in bladder and/or inadequate instillation time.

Solution

Conduct a quality check to include examination of the optic cables and their attachment to the plugs. If blood is present, remove the resectoscope and flush the blood away using a bladder syringe attached to the trocar. Ensure Cysview is instilled 60 minutes prior to cystoscopy.

The Benefits of
Blue Light Are Clear

Review side-by-side comparison photos of white and blue light exams, case studies (including videos) and helpful tips for using BLC with Cysview.

Case Images

Use the sliders to view the same image before and after BLC with Cysview.
(The before image appears on the left.)
Case 1
Original Image
Modified Image
Case 2
Original Image
Modified Image
Case 3
Original Image
Modified Image
Case 4
Before Blue Light
After Blue Light
Case 5
Before Blue Light
After Blue Light
Case 6
Before Blue Light
After Blue Light

Prescribing Information

Cysview is an optical imaging agent indicated for use in the cystoscopic detection of carcinoma of the bladder, including carcinoma in situ (CIS), among patients suspected or known to have lesion(s) on the basis of a prior cystoscopy, or in patients undergoing surveillance cystoscopy for carcinoma of the bladder. Cysview is used with the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) system to perform Blue Light Cystoscopy (BLCTM) as an adjunct to the white light cystoscopy.

Important Safety Information About Cysview® (hexaminolevulinate HCl)

Cysview is not a replacement for random bladder biopsies or other procedures used in the detection of bladder cancer. 

Anaphylactoid shock, hypersensitivity reactions, bladder pain, cystitis, and abnormal urinalysis have been reported after administration of Cysview. The most common adverse reactions seen in clinical trials were bladder spasm, dysuria, hematuria, and bladder pain. 

Cysview should not be used in patients with porphyria, gross hematuria, or with known hypersensitivity to hexaminolevulinate or any derivative of aminolevulinic acid. Cysview may fail to detect some malignant lesions. False-positive fluorescence may occur due to inflammation, cystoscopic trauma, scar tissue, previous bladder biopsy and recent BCG therapy or intravesical chemotherapy. No specific drug interaction studies have been performed. 

Safety and effectiveness have not been established in pediatric patients. There are no available data on Cysview use in pregnant women. Adequate reproductive and developmental toxicity studies in animals have not been performed. Systemic absorption following administration of Cysview is expected to be minimal. There are no data on the presence of hexaminolevulinate in human or animal milk, the effects on a breastfed infant, or the effects on milk production. The development and health benefits of breastfeeding should be considered along with the mother’s clinical need for Cysview and any potential adverse effects on the breastfed infant from Cysview or from the underlying maternal condition. 

Cysview is approved for use with the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) system. For system set up and general information for the safe use of the PDD system, please refer to the KARL STORZ instruction manuals for each of the components. 

Prior to Cysview administration, read the Full Prescribing Information and follow the preparation and reconstitution instructions.

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Prescribing Information

Cysview is an optical imaging agent indicated for use in the cystoscopic detection of carcinoma of the bladder, including carcinoma in situ (CIS), among patients suspected or known to have lesion(s) on the basis of a prior cystoscopy, or in patients undergoing surveillance cystoscopy for carcinoma of the bladder. Cysview is used with the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) system to perform Blue Light Cystoscopy (BLCTM) as an adjunct to the white light cystoscopy.

Important Safety Information About Cysview® (hexaminolevulinate HCl)

Cysview is not a replacement for random bladder biopsies or other procedures used in the detection of bladder cancer. 

Anaphylactoid shock, hypersensitivity reactions, bladder pain, cystitis, and abnormal urinalysis have been reported after administration of Cysview. The most common adverse reactions seen in clinical trials were bladder spasm, dysuria, hematuria, and bladder pain. 

Cysview should not be used in patients with porphyria, gross hematuria, or with known hypersensitivity to hexaminolevulinate or any derivative of aminolevulinic acid. Cysview may fail to detect some malignant lesions. False-positive fluorescence may occur due to inflammation, cystoscopic trauma, scar tissue, previous bladder biopsy and recent BCG therapy or intravesical chemotherapy. No specific drug interaction studies have been performed. 

Safety and effectiveness have not been established in pediatric patients. There are no available data on Cysview use in pregnant women. Adequate reproductive and developmental toxicity studies in animals have not been performed. Systemic absorption following administration of Cysview is expected to be minimal. There are no data on the presence of hexaminolevulinate in human or animal milk, the effects on a breastfed infant, or the effects on milk production. The development and health benefits of breastfeeding should be considered along with the mother’s clinical need for Cysview and any potential adverse effects on the breastfed infant from Cysview or from the underlying maternal condition. 

Cysview is approved for use with the KARL STORZ D-Light C Photodynamic Diagnostic (PDD) system. For system set up and general information for the safe use of the PDD system, please refer to the KARL STORZ instruction manuals for each of the components. 

Prior to Cysview administration, read the Full Prescribing Information and follow the preparation and reconstitution instructions.

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