Fluorescence-guided transurethral resection of bladder cancer using hexaminolevulinate: analysis of health economic impact in Sweden

Objective. A decision analytic model was established to estimate the budget impact on the Swedish health service of using hexaminolevulinate (HAL) in conjunction with white light cystoscopy (WLC) in the management of bladder cancer for 1 year following initial diagnosis. Material and methods. Flowcharts were developed to represent the diagnostic and treatment pathways for each of four risk groups for non-muscle-invasive bladder cancer (NMIBC), as defined by risk of tumour recurrence and progression. Flowcharts were based on European Association of Urology Guidelines and adjusted to current Swedish clinical practice. The model covers the use of HAL cystoscopy in the operating room to guide transurethral resection of the bladder (TURB) in all patients. HAL cystoscopy as an adjunct to WLC allows for more accurate and complete resection of tumours compared with WLC alone, and the model assumed a consequent reduction in recurrence of 40%. Results. The model projects that compared with WLC alone, use of HAL cystoscopy in the first TURB of all patients and for all TURBs due to recurrence in the first year after diagnosis, leads to a reduction of 23 cystectomies and 180 TURBs in a population of 2032 newly diagnosed bladder cancer patients. Avoidance of these procedures would result in a saving of SEK1 321 716 to the Swedish health service. Conclusion. HAL cystoscopy, used as an adjunct to white light in guiding TURB in NMIBC patients, may result in reduction of invasive, time-intensive and high-cost procedures such as cystectomy and TURB, compared with WLC alone.