Upstaging and risk migration with blue light cystoscopy for non–muscle-invasive bladder cancer: Results from a prospective multi-center registry.
Authors: Ghoreifi Alireza , Konety Badrinath R. , Pohar Kamal S. , Holzbeierlein Jeffrey , Taylor John Arthur , Kates Max , Willard Brian , Taylor Jennifer M. , Liao Joseph C. , Kaimakliotis Hristos Z. , Porten Sima P. , Steinberg Gary D. , Tyson Mark , Lotan Yair , Daneshmand Siamak 
Published: February 2025

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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.