Impact of enhanced optical techniques at time of TURBT with or without single immediate intravesical chemotherapy on recurrence rate of NMIBC, a systematic review and network meta-analysis of randomized trials.

INTRODUCTION The novel optical techniques such as blue light cystoscopy (BLC) during transurethral resection of bladder tumor (TURBT) has been shown to improve the tumor detection rate and recurrence rate. Whether a single immediate intravesical chemotherapy (SIIC) still has an additive therapeutic effect in the setting of these novel optical techniques (e.g., photodynamic diagnosis (PDD) and narrow band imaging (NBI)) remains unclear. The main aim of this systematic review and network meta-analysis was to assess whether SIIC still adds value to bladder tumor management in combination with optical techniques- enhanced TURBT. METHODS A systematic search was performed using PubMed and Web of Science databases in September 2020 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) extension statement for network meta-analysis. Studies that compared recurrence rates between intervention groups (TURBT by PDD ± SIIC, NBI ± SIIC, or WLC + SIIC) and control group (TURBT by WLC alone) were included. We used the Bayesian approach in the network meta-analysis. RESULTS Twenty-two studies (n= 4,519) met our eligibility criteria. Out of six different interventions including three different optical techniques, compared to WLC alone, BLC plus SIIC (odds ratio (OR): 0.349, 95% credible interval (CrI):0.196-0.601) and BLC alone (OR: 0.668, 95% CrI:0.459-0.931) were associated with a significantly lower likelihood of 12-month recurrence rate. In the sensitivity analysis, out of eight different interventions compared to WLC alone, PDD by 5-aminolevulinic plus SIIC (OR: 0.327, 95% CrI:0.159-0.646) and by hexaminolevulinic acid plus SIIC (OR: 0.376, 95% CrI:0.172-0.783) were both associated with a significantly lower likelihood of 12-month recurrence rate. NBI with and without SIIC were not associated with a significantly lower likelihood of 12-month recurrence rate (OR: 0.385, 95% CrI:0.105-1.29 and OR: 0.653, 95% CrI:0.343-1.15). CONCLUSION BLC during TURBT with concomitant SIIC seems to yieled superior recurrence outcomes in patients with non-muscle invasive bladder cancer. The Use of PDD was able to reduce the 12-month recurrence rate; moreover, a concomitant SIIC increased this risk benefit by 32% additional reduction of odds ratio. Although using PDD could reduce the recurrence rate, SIIC remains necessary. Moreover, the ranking analysis showed that both PDD and NBI, plus SIIC were better than these techniques alone.