Photodynamic diagnosis of bladder cancer compared with white light cystoscopy: Systematic review and meta-analysis

Objectives: The aim of this study was to assess the test performance and clinical effectiveness of photodynamic diagnosis (PDD) compared with white light cystoscopy (WLC) in people suspected of new or recurrent bladder cancer. Methods: A systematic review was conducted of randomized controlled trials (RCTs), nonrandomized comparative studies, or diagnostic cross-sectional studies comparing PDD with WLC. Fifteen electronic databases and Web sites were searched (last searches April 2008). For clinical effectiveness, only RCTs were considered. Results: Twenty-seven studies (2,949 participants) assessed test performance. PDD had higher sensitivity than WLC (92 percent, 95 percent confidence interval [Cl], 80-100 percent versus 71 percent, 95 percent Cl, 49-93 percent) but lower specificity (57 percent, 95 percent Cl, 36-79 percent versus 72 percent, 95 percent Cl, 47-96 percent). For detecting higher risk tumors, median range sensitivity of PDD (89 percent [6-100 percent]) was higher than WLC (56 percent [0-100 percent]) whereas for lower risk tumors it was broadly similar (92 percent [20-95 percent] versus 95 percent [8-100 percent]). Four RCTs (709 participants) using 5-aminolaevulinic acid (5-ALA) as the photosensitising agent reported clinical effectiveness. Using PDD at transurethral resection of bladder tumor (TURBT) resulted in fewer residual tumors at check cystoscopy (relative risk [RR], 0.37, 95 percent Cl, 0.20-0.69) and longer recurrence-free survival (RR, 1.37, 95 percent Cl, 1.18-1.59), compared with WLC. Conclusions: PDD detects more bladder tumors than WLC, including more high-risk tumors. Based on four RCTs reporting clinical effectiveness, 5-aminolaevulinic acid mediated PDD at TURBT facilitates a more complete resection and prolongs recurrence-free survival.