Bladder cancer is one of the ten most commonly diagnosed cancers in the world. Of these, three quarters are diagnosed with non-muscle invasive bladder cancer (NMIBC). High-risk NMIBC following diagnosis is managed with intravesical therapy and surveillance. In an NHS Trust frequently utilising rigid cystoscopy and biopsy under general anaesthesia (GA) during maintenance BCG, we sought to investigate histological outcomes of patients to determine the safety of flexible cystoscopy as an alternative. We also assessed the burden of this pathway on elective lists and conducted a cost benefit analysis of the alternative.

This retrospective analysis covers electronic records of a representative sample of 100 patients from a cohort of 211 on the masterlist of patients who are undergoing or who previously had BCG treatments (completed or not) with the Trust. These patients had high-risk NMIBC at the time of the study and had at least 2 maintenance doses of BCG following induction and at least 2 GA rigid cystoscopy with biopsies with corresponding results. Data included patient characteristics, initial diagnosis, surveillance protocol, treatment received, indication for bladder biopsies and histology results. Targeted versus random biopsies were noted to determine whether these would yield positive or negative histological outcomes. Data was analysed thereafter utilizing summation and percentages.

The representative sample had a mean age of 71 (43-91yo) with ASA II (56%), III (42%) and IV (2%). There were 526 biopsies throughout surveillance in total. 173/526 were targeted suspicious areas and 353/526 were random. 23/173 (13.29%) of the targeted biopsies, and 2/353 (0.57%) of the random biopsies confirmed histological recurrence. 40% of cancer recurrences including the positive random biopsies were noted post BCG induction. Of the 17 patients who had recurrences, 8/17 continued maintenance BCG, 5/17 underwent reinduction BCG and 4/17 required changes in the treatment plan. The healthcare resource group (HRG) coding of each surveillance method showed £312 total price for flexible cystoscopy VS £1,024 for GA rigid cystoscopy.

Majority of patients were in their 60s-80s with ASA II-III status. Out of all 526 biopsies, there were 25 recurrences in total, only 2 of which were nontargeted. These random biopsy recurrences were noted after BCG induction, the rest were targeted. Almost all (99.43%) of the nontargeted biopsies were proven biopsy-negative. Taking into consideration HRG Coding prices, there is a 228% increase in the price from flexible cystoscopy to GA rigid cystoscopy. The random biopsies taken from the sample population would have saved a total of £249,912 (69.5%) if done under flexible cystoscopy.

This study supports the use of GA cystoscopy for patients following BCG induction, and flexible cystoscopy surveillance following maintenance BCG, reserving GA cystoscopy for suspicious lesions. This would avoid unnecessary GA on a high-risk group, reduce operational costs, manpower and the burden on elective operating lists.