Blue versus white light for transurethral resection of non-muscle invasive bladder cancer.

rationaleDisease recurrence and progression remain major challenges in the treatment of non-muscle invasive bladder cancer (NMIBC). Blue light-enhanced transurethral resection of bladder cancer (TURBT) is an approach to improve staging and achieve a complete resection of NMIBC. Since the first version of this review was published in 2021, new evidence on this topic has become available.

objectivesTo assess the effects of blue light-enhanced TURBT compared to white light-based TURBT in the treatment of non-muscle invasive bladder cancer. SEARCH

methodsWe searched several medical literature databases, including the Cochrane Library, MEDLINE, and Embase, as well as two trial registers, with no restrictions on language of publication or publication status, until March 2026. ELIGIBILITY CRITERIA: We included randomized controlled trials using blue light versus white light TURBT. Included participants (older than 18 years) had a high level of suspicion based on imaging or 'visible diagnosis' for primary urothelial carcinoma of the bladder or recurrent urothelial carcinoma of the bladder upon cytoscopy. We excluded studies in which blue light was used in a surveillance setting. OUTCOMES: Critical outcomes (primary outcomes) of this review were time to disease recurrence, time to disease progression and serious surgical complications. Important outcomes (secondary outcomes) were time to death from bladder cancer, any adverse events and non-serious surgical complications. The thresholds for clinical relevance of the outcomes were determined through consensus among all authors. RISK OF BIAS: We assessed the risk of bias using RoB 1. Two review authors independently assessed the risk of bias of each included study. Any disagreements were resolved by consensus or by consultation with a third review author. SYNTHESIS

methodsTwo review authors independently performed data extraction and risk of bias assessment. We synthesized results for each outcome using meta-analysis where possible (using a random-effects model with the Mantel-Haenszel method for dichotomous outcomes and the generic inverse-variance method for time-to-event outcomes). Where this was not possible due to the nature of the data, we synthesized results using a narrative approach. We rated the certainty of evidence using the GRADE approach. INCLUDED STUDIES: We included 17 randomized controlled trials involving a total of 4890 participants in the review (1 study with 533 eligible participants was new to this update). The studies compared blue light versus white light TURBT for treatment of NMIBC. SYNTHESIS OF

resultsCritical outcomes Blue light TURBT may have little to no effect on the risk of recurrence in people at low risk, but may reduce the risk of recurrence in those at intermediate and high risk (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56 to 0.82; low-certainty evidence). For participants with low-, intermediate-, and high-risk NMIBC, this corresponds to 45 (63 fewer to 25 fewer), 102 (145 fewer to 56 fewer), and 137 (200 fewer to 72 fewer) fewer recurrences per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT probably has little to no effect on the risk of progression in people at low risk, may have little or no effect on the risk of progression in people at intermediate risk, but may reduce the risk of progression in those at high risk (HR 0.70, 95% CI 0.55 to 0.90; low- to moderate-certainty evidence). For participants with low-, intermediate-, and high-risk NMIBC, this corresponds to 1 (1 fewer to 0 fewer), 15 (22 fewer to 5 fewer), and 48 (73 fewer to 16 fewer) fewer progressions per 1000 participants when compared to white light TURBT, respectively. Blue light TURBT may have little to no effect on serious surgical complications (risk ratio (RR) 0.84, 95% CI 0.30 to 2.29; 2 RCTS, 951 participants; low-certainty evidence). This corresponds to three fewer (13 fewer to 24 more) surgical complications per 1000 participants with blue light TURBT. Important outcomes Blue light TURBT may have little to no effect on the risk of death from bladder cancer over time (HR 0.84, 95% CI 0.42 to 1.68; 2 RCTs, 833 participants; low-certainty evidence). This corresponds to 22 deaths per 1000 participants with white light TURBT and three fewer (12 fewer to 14 more) deaths per 1000 participants with blue light TURBT. Blue light TURBT may have little to no effect on adverse events of any grade (RR 1.07, 95% CI 0.89 to 1.29; 4 RCTs, 1801 participants; low-certainty evidence). This corresponds to 22 more (35 fewer to 92 more) adverse events of any grade per 1000 participants with blue light TURBT. Blue light TURBT may have little to no effect on non-serious surgical complications (RR 0.90, 95% CI 0.63 to 1.28; 1 RCT; 426 participants; low-certainty evidence). This corresponds to 24 fewer (87 fewer to 66 more) surgical complications per 1000 participants with blue light TURBT. AUTHORS'

conclusionsBlue light-enhanced TURBT for the treatment of non-muscle invasive bladder cancer compared to white light-based TURBT may reduce the risk of disease recurrence and disease progression over time, depending on baseline risk. There may be little or no effect on serious surgical complications. Blue light TURBT may have little to no effect on the time to death from bladder cancer, adverse events or non-serious surgical complications, respectively. The certainty of evidence for our findings was mostly low, meaning that future studies are likely to change the reported estimates of effect. Frequent issues that led us to downgrade the certainty of the evidence were study limitations, inconsistency, and imprecision.

fundingThe update of this review had no dedicated funding. REGISTRATION: Protocol (2020): DOI: 10.1002/14651858.CD013776 Original review (2021): DOI: 10.1002/14651858.CD013776.pub2.