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Photodynamic DiagnosticsPhotodynamic Diagnostics (PDD) in the treatment of non-muscle invasive Bladder CancerCancer of the urinary bladder is one of the most frequent malign tumours. Bladder Cancer mostly is restricted to the innermost layer of the bladder and does not involve the bladder muscle. Most tumours can be removed endoscopically via the urethra (TURB) and do not require radical open surgery. However following endoscopical surgery in up to 50% of cases new bladder tumours occur despite further treatment to suppress novel tumour growth such as intravesical chemotherapy. Many factors contribute to this phenomenon. However the thoroughness of removal during TURB seems to be decisive. Many tumours are small and cannot be seen without limitations by the surgeon. Thus photodynamic diagnostics (PDD), a method to improve detection of tumours, has been developed. This approach is characterised by a special fluorescent marker (Hexvix®, GE Healthcare) selectively accumulating in tumour tissue and visualised by a special light source (emitting light of 345 to 440 nanometers; Figures 1 and 2). This technique is used increasingly since 1995 in the treatment of non-muscle invasive bladder cancer. Its development and establishment was undertaken in German-speaking Europe mainly and decisively by our institution.
Figure 1: Tumor as visualised by conventional (left) and PDD (right)
Figure 2: Tumour after removal by TURB as visualised by conventional (left) and PDD (right). Using conventional light no tumour left with the initial removal is seen, while PDD reveals significant remnants. In numerous studies a reduction of remnant tumours after TURB and significantly less novel tumour occurrences over a long period of time were found. In short- and long term evaluation a significant advantage for PDD has been shown, as patients treated with PDD experience novel tumours less frequently. This was demonstrated in some studies from our institution. Thus a well founded clinical advantage for PDD has been shown and PDD has been standard procedure at our institution for many years (please refer to reference-list; Figure 3).
Figure 3: Time without novel tumour occurrence. After two years the ratio of patients without novel tumour was 88% after PDD versus 73% after conventional treatment, respectively. The difference was prominent after eight years as well, as 71% after PDD versus 45% after conventional treatment experienced novel tumours, respectively. The application of PDD is painless. Roughly one hour prior to TURB 50 ml Hexvix® solution are instilled into the bladder via a thin catheter. For the application or visualisation of the marker no adverse events are established or are commonly found. Smaller tumours and tumour rims can be seen more clearly however and can be removed more thoroughly. The application of PDD does not cause any extra costs for the patient and is standard procedure at our institution for the removal of non-muscle invasive tumours by TURB. Please contact us for further information! References: Denzinger S, Wieland WF, Otto W, Filbeck T, Knuechel R, Burger M. Does photodynamic transurethral resection of bladder tumour improve the outcome of initial T1 high-grade bladder cancer? A long-term follow-up of a randomized study. BJU Int. 2008 Mar;101(5):566-9. Epub 2007 Nov 5.
Photodynamic diagnostics of bladder tumors. Curr Urol Rep. 2008 Mar;9(2):101-5. Review.
[Diagnosis of urothelial carcinoma] Urologe A. 2008 Mar;47(3):357-67. German.
Burger M, Zaak D, Stief CG, Filbeck T, Wieland WF, Roessler W, Denzinger S. Photodynamic diagnostics and noninvasive bladder cancer: is it cost-effective in long-term application? A Germany-based cost analysis. Eur Urol. 2007 Jul;52(1):142-7. Epub 2007 Jan 22.
Denzinger S, Burger M, Walter B, Knuechel R, Roessler W, Wieland WF, Filbeck T. Clinically relevant reduction in risk of recurrence of superficial bladder cancer using 5-aminolevulinic acid-induced fluorescence diagnosis: 8-year results of prospective randomized study. Urology. 2007 Apr;69(4):675-9.
Filbeck T, Pichlmeier U, Knuechel R, Wieland WF, Rössler W. [Reducing the risk of superficial bladder cancer recurrence with 5-aminolevulinic acid-induced fluorescence diagnosis. Results of a 5-year study] Urologe A. 2003 Oct;42(10):1366-73. Epub 2003 Apr 25. German.
Filbeck T, Pichlmeier U, Knuechel R, Wieland WF, Roessler W. Do patients profit from 5-aminolevulinic acid-induced fluorescence diagnosis in transurethral resection of bladder carcinoma? Urology. 2002 Dec;60(6):1025-8.
Filbeck T, Pichlmeier U, Knuechel R, Wieland WF, Roessler W. Clinically relevant improvement of recurrence-free survival with 5-aminolevulinic acid induced fluorescence diagnosis in patients with superficial bladder tumors. J Urol. 2002 Jul;168(1):67-71.
Filbeck T, Wimmershoff MB, Pichlmeier U, Karrer S, Wieland WF, Szeimies RM, Rössler W. No generalized skin phototoxicity after intravesical application of 5-aminolevulinic acid for fluorescence diagnosis of superficial bladder cancer. Urol Int. 2000;64(3):126-8.
Filbeck T, Ullrich T, Pichlmeier U, Kiel HJ, Wieland WF, Roessler W. Correlation of persistent stress urinary incontinence with quality of life after suspension procedures: is continence the only decisive postoperative criterion of success? Urology. 1999 Aug;54(2):247-51.
Filbeck T, Roessler W, Knuechel R, Straub M, Kiel HJ, Wieland WF. Clinical results of the transurethreal resection and evaluation of superficial bladder carcinomas by means of fluorescence diagnosis after intravesical instillation of 5-aminolevulinic acid. J Endourol. 1999 Mar;13(2):117-21.
Filbeck T, Roessler W, Knuechel R, Straub M, Kiel HJ, Wieland WF. 5-aminolevulinic acid-induced fluorescence endoscopy applied at secondary transurethral resection after conventional resection of primary superficial bladder tumors. Urology. 1999 Jan;53(1):77-81.
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