Transurethral Resection of Bladder Tumor With Blue-Light Cystoscopy More Cost Effective Than White-Light Cystoscopy after Third Year

By GU Oncology Now Editors - Last Updated: January 19, 2022

Bladder cancer is among the most expensive cancers to treat on a per patient basis, due to high rates of recurrence and resulting healthcare utilization, with estimated lifetime costs of $86,000-$187,000 for each patient.1 One way in which costs can be reduced may be by utilization of blue light cystoscopy with hexaminolevulinate (BLC) rather than white light cystoscopy (WLC) for transurethral resection of bladder tumor (TURBT), the foundation of initial treatment for bladder cancer, according to a study presented by Michael L. Creswell, medical student at Georgetown University School of Medicine in Washington, DC.2

TURBT is usually performed under WLC, but BLC has been shown to improve diagnostic sensitivity and lower recurrence rate compared with WLC in patients with non-muscle invasive bladder cancer (NMIBC).3 These advantages prompted previous researchers to compare the costs of BLC versus WLC, but results were mixed, most showing cost superiority with BLC but others reporting parity and inferiority using different costing methodologies. The study by the Georgetown University researchers set out to model the American Urological Association (AUA) bladder cancer guidelines and run a Monte Carlo simulation to compare 5-year cumulative costs associated with BLC and WLC.

A Monte Carlo simulation model was created utilizing Microsoft Excel with the @RISK decision analysis simulation software add-on. The clinical decision tree was based on the 2020 AUA/SUO guideline to the diagnosis and management of NMIBC.4 The model included the key assumption that a 35% rate of high-risk NMIBC patients received radical cystectomy after failing to respond to intravesical therapy. Variant histology, re-resection TURBT, and use of trimodal bladder-preserving therapy were not included in the model. The input for NMIBC incidence and recurrence rates for WLC and BLC was based on studies by Burger et al (2013)6- and Klaassen et al 2017)6 and simulated with 60,000 iterations. Values for economic inputs were sourced from 2021 Medicare averages. The primary outcome of the study was mean year-over-year cumulative cost discounted to present value at 3% and the secondary outcome was the rate of clinical events.

Initial results of the simulation study suggested that BLC was more expensive than WLC in treatment and surveillance during years 1 and 2 ($10,493 and $14,479 vs $9,452 and $13,921, respectively). During years 3 through 5, however, cost saving with BLC became apparent, with a mean cumulative cost saving of $1527 per patient by year 5 ($27,447 vs $28,973). The researchers attributed this to a rise in cost savings with BLC of 31.4% in year 1 to 51.6% at the end of year 5. This corresponded to a lower recurrence rate in the BLC cohort compared with WLC, with 25.3% fewer recurrences (1368 WLC vs 1022 BLC per 1000 patients).

Taken as a whole, the data from this study suggest that “BLC is a dominant treatment modality compared with WLC by offering superior clinical as well as long-term economic outcomes,” Mr Creswell declared. However, he acknowledged that these conclusions were limited by the study design. Because costs were analyzed from the perspective of Medicare, capital expenditure, staffing differences, and implementation costs were not analyzed. The study also did not include hospice or patient death as a potential clinical outcome. However, as BLC does not appear to confer improved survival relative to WLC, this was unlikely to affect the relative conclusions, Mr Creswell explained.

Future studies should seek real world data to confirm the concordance between modeled and real-life practice data, the researchers suggest. “With continued analysis of economic outcomes in addition to clinical outcomes, we can better inform cost-effective care for our patients, healthcare system, and payers alike,” Mr Creswell declared.


  1. Botteman MF, Pashos CL, Redaelli A, Laskin B, Hauser R. The health economics of bladder cancer: a comprehensive review of the published literature. Pharmacoeconomics. 2003;21(18):1315-1330. DOI: 10.1007/bf03262330
  2. Creswell M, Sholklapper T, Pianka M, et al. Economic outcomes of hexaminolevulinate blue-light cystoscopy compared with white light cystoscopy for diagnosis and monitoring of non-muscle invasive bladder cancer: a 5-year Medicare-based model. Poster #28 presented at the 22nd Annual Meeting of the Society of Urologic Oncology (SUO), December 103, 2021, Orlando, LF.
  3. Lotan Y, Bivalacqua TJ, Downs T, et al. Blue light flexible cystoscopy with hexaminolevulinate in non-muscle-invasive bladder cancer: review of the clinical evidence and consensus statement on optimal use in the USA—update 2018. Nat Rev Urol. 2019;16(6):377-386. DOI: 10.1038/s41585-019-0184-4
  4. Chang SS, Boorjian SA, Chou R et al: Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. J Urol. 2016;96:1021-1029. Amended 2020. https://
  5. Accessed December 2, 2021.
  6. Burger M, Grossman HB, Droller M, et al. Photodynamic diagnosis of non-muscle- invasive bladder cancer with hexaminolevulinate cystoscopy: A meta-analysis of detection and recurrence based on raw data. Eur Urol. 2013;64:846-854. DOI: 10.1016/j. eururo.2013.03.059
  7. Klaassen Z, Li K, Kassouf W, et al. Contemporary cost-consequences analysis of blue light cystoscopy with hexaminolevulinate in non-muscle invasive bladder cancer. Can Urol Assoc J. 2017;11(6):173-181. DOI: 10.5489/cuaj.4568