Bladder region-specific analysis of the diagnostic performance of oral 5-aminolevulinic acid fluorescence cystoscopy in non-muscle-invasive bladder cancer

Background Fluorescence cystoscopy (FL) using 5-aminolevulinic acid (ALA) enhances the detection of urothelial carcinoma compared to white-light endoscopy (WL). The location of bladder tumors may affect the diagnostic performance of FL; however, this issue has been underexplored. We analyzed the diagnostic performance of FL compared with that of WL across different bladder regions. Methods Between 2018 and 2021, 181 patients with non-muscle-invasive bladder cancer who underwent FL-guided transurethral resection of bladder tumors (TURBT) using oral ALA were identified. During TURBT, WL and FL findings were recorded separately, and samples were collected. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detecting urothelial carcinoma in each method were analyzed. Results The median patient age was 72 years, and 122 patients (85%) were male. Among the 526 collected tissues, 66, 106, and 35 were diagnosed as pTis, pTa, and pT1 urothelial carcinomas, respectively, and 319 lesions were benign. The sensitivity, specificity, PPV, and NPV of FL and WL were 91.8%, 58.3%, 58.8%, and 91.6% and 76.3%, 69.3%, 61.7%, and 81.9%, respectively. In the sensitivity analysis across different regions, the sensitivities of FL/WL in the posterior and lateral walls were 100/76.6% and 92.6/79.0%, respectively, and FL was superior (P < .001 and P = .003, respectively), whereas no advantages of FL were observed in the other regions. Conclusions FL presented a higher sensitivity than WL at the posterior and lateral walls but failed to show superiority in the other regions.