Photodynamic diagnosis – current tool in diagnosis of carcinoma in situ of the urinary bladder

Carcinoma in situ (CIS) of the urinary bladder is extremely hard to diagnose. The symptoms are highly unspecific and the small, flat CIS lesions can easily be missed, thus remaining unseen in standard white light cystoscopy. Photodynamic diagnosis (PDD) is recommended by the European Association of Urology (EAU) as a diagnostic procedure in cases of suspected CIS [1].
A 58-year-old man visited the outpatient clinic complaining of symptoms of dysuria and occasional pain during micturition. The patient had been a smoker for 20 years, with no risk of exposure to chemical substances. The medical history did not indicate any haematuria or fever. Digital rectal examination found the prostate to be of proper density, with little enlargement and no other pathological findings. The preliminary diagnosis was set as lower urinary tract syndrome secondary to prostate enlargement. The patient was sent for creatinine assay, prostate specific antigen (PSA) assay, a urine test, and ultrasound examination of the kidneys, bladder, and prostate. He received a prescription for diclofenac, tamsulosin, and ciprofloxacin.
The next appointment in the outpatient clinic was set for two months later as a follow-up. During that visit, the patient reported two episodes of painless bleeding in his urine. The serum levels of creatinine and PSA were 0.9 and 1.2 ng/ml, respectively, and no abnormalities were observed in the results of the urine test. No pathological changes were observed by ultrasonography. After the treatment, the symptoms of dysuria were diminished.
In response to the presence of bleeding in the urine, the patient was sent for urethrocystoscopy, performed with short intravenous anaesthesia, and urinary cytology, which revealed the presence of pathological cells. On the basis of this result and that of the earlier ultrasonography, which indicated no bladder tumour symptoms, the patient was qualified for PDD.
Photodynamic diagnosis was performed after intravesical instillation of a photosensitiser (Hexvix®) 60 minutes before the procedure. A Wolf PDD system was used to observe the photodynamic effect. Although the white light cystoscopy revealed only one pathological lesion, 4 mm in diameter, on the front wall of the urinary bladder, the urinary bladder mucosa seemed otherwise unaffected by any pathological changes. After switching to PDD mode, three independent points were indicated by red flashes: one on the back wall (8 mm in...


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