Comment on “Association Between Preoperative 5‐Aminolevulinic Acid Administration Timing and Perioperative Hypotension”

We read with great interest the article by Hori et al., entitled “Association Between Preoperative 5-Aminolevulinic Acid Administration Timing and Perioperative Hypotension,” published in the International Journal of Urology [1]. This study is commendable for addressing an important clinical issue related to photodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD–TURBT) from a practical and clinical perspective. PDD–TURBT offers well-established oncological benefits, such as improved tumor visualization and reduction in residual tumor and postoperative recurrence rates. Thus, this technique is recommended by international guidelines and has been increasingly adopted in routine clinical practice. However, perioperative hypotension following oral 5-aminolevulinic acid (5-ALA) administration remains a significant safety concern and is a challenge to smooth and widespread PDD–TURBT use. In this regard, the findings reported by Hori et al. are clinically valuable. They demonstrated that maintaining at least a 4-h interval between oral 5-ALA administration and anesthesia induction significantly decreased the risk of moderate to severe perioperative hypotension [1]. In particular, this strategy can be implemented without compromising diagnostic accuracy or therapeutic effectiveness and does not require additional costs or specialized equipment. This makes it a highly feasible approach for routine clinical use. Previous studies suggest that 5-ALA-induced hypotension is not caused by a single mechanism but is rather a heterogeneous condition influenced by multiple factors [2, 3]. Fukuhara et al. reported that ALA-induced hypotension may present in several distinct clinical patterns, including severe and prolonged hypotension that requires extended vasopressor support [2]. These findings highlight the multifactorial pathophysiology of ALA-induced hypotension and the potential need for individualized perioperative management. Recent research in anesthetic management has also identified modifiable factors contributing to hemodynamic instability during PDD–TURBT. Katsumata et al. demonstrated that both anesthetic technique and agent selection influence the risk of sustained intraoperative hypotension, with certain agents associated with a lower risk [3]. These insights suggest that anesthetic management plays an important role in reducing 5-ALA–induced adverse events. Collectively, the study by Hori et al. offers important insights into perioperative management strategies for PDD–TURBT. Under certain conditions, 5-ALA-induced hypotension may be considered not as an inevitable adverse effect but as a complication that may be mitigated through appropriate interventions. In particular, for patients at higher risk of hemodynamic instability, optimizing 5-ALA administration time, carefully selecting the anesthetic techniques and agents, and fostering close collaboration between urologists and anesthesiologists are essential. We believe the study by Hori et al. presents a practical, evidence-based approach that improves safety in PDD–TURBT. Their findings provide valuable guidance for refining perioperative protocols and may help enhance patient safety while preserving the oncological benefits of this technique. Shinkuro Yamamoto: conceptualization and writing – original draft. Satoshi Fukata: writing – review and editing. Keiji Inoue: supervision. The authors would like to thank Enago (www.enago.jp) for the English language review. Keiji Inoue has received research funding and honoraria from SBI Pharmaceuticals Co. Ltd. He is also a member of the Editorial Board of the International Journal of Urology and a coauthor of this article; however, he was not involved in the editorial handling or decision-making process for this manuscript. All other authors declare no conflicts of interest. This article is linked to Yamamoto et al. To view these papers, visit https://doi/10.1111/iju.70226.