Blue Light Surgery Cuts Bladder Cancer Recurrence by Up to 32% in High-Risk Patients

Non-muscle invasive bladder cancer (NMIBC) is notorious for high recurrence rates, placing a substantial burden on patients and healthcare systems through repeated surveillance and treatment. Standard transurethral resection under white light can miss flat or subtle tumors, particularly carcinoma in situ, leading to incomplete resection and subsequent recurrence. Blue light TURBT, which uses hexaminolevulinate to make cancer cells fluoresce red under violet-blue light, was developed specifically to overcome this limitation and achieve more thorough resections.

This updated Cochrane review searched MEDLINE, Embase, the Cochrane Library, and two clinical trial registries through March 2026. Seventeen randomized controlled trials totaling 4,890 participants were included, with one new study of 533 participants added since the 2021 version. Studies enrolled adults with suspected primary or recurrent urothelial carcinoma undergoing TURBT; surveillance-only blue light use was excluded. Risk of bias was assessed using the Cochrane RoB 1 tool, and evidence certainty was graded using GRADE. Meta-analyses used random-effects models with the Mantel-Haenszel method for dichotomous outcomes and generic inverse-variance for time-to-event data.

For the primary outcome of disease recurrence, blue light TURBT showed a hazard ratio of 0.68 (95% CI 0.56–0.82) in intermediate- and high-risk patients, translating to 102 fewer recurrences per 1,000 intermediate-risk patients and 137 fewer per 1,000 high-risk patients compared to white light. Low-risk patients showed little to no benefit. For disease progression, the hazard ratio was 0.70 (95% CI 0.55–0.90), but meaningful risk reduction was confined to high-risk patients — approximately 48 fewer progressions per 1,000 — while effects in low- and intermediate-risk groups were negligible. Evidence certainty for both recurrence and progression was rated low to moderate.

For safety outcomes, serious surgical complications showed a risk ratio of 0.84 (95% CI 0.30–2.29) across two RCTs with 951 participants — a non-significant finding with low certainty corresponding to just three fewer complications per 1,000 patients. Cancer-specific mortality (HR 0.84, 95% CI 0.42–1.68; two RCTs, 833 participants) and any-grade adverse events (RR 1.07, 95% CI 0.89–1.29; four RCTs, 1,801 participants) also showed no meaningful difference between groups, both rated low certainty. Non-serious surgical complications similarly showed no significant difference (RR 0.90, 95% CI 0.63–1.28).

The authors note that the overall body of evidence is hampered by study-level limitations including protocol deviations, differential missing data between groups, and selective outcome reporting. These issues consistently drove GRADE certainty ratings down to low, meaning future well-conducted trials could substantially alter current effect estimates. Clinicians should weigh the clear recurrence-reduction signal in intermediate- and high-risk NMIBC against the added cost and procedural complexity of blue light systems. For low-risk patients, white light TURBT appears equivalent and sufficient based on current evidence.