Tips and tricks


Weak fluorescence

  • Equipment failure or
  • Blood in the bladder or
  • Inadequate time or
  • Air bubbles or
  • Concealed tumours
  • Make sure equipment is working and connected properly
  • If blood is present, remove resectoscope and flush using a bladder syringe attached to the trocar
  • Ensure that Hexvix® was instilled 1 hour prior to cystoscopy
  • Remove any air bubbles
  • Look behind any folds
tip 1

No fluorescence

  • The equipment has not been set up correctly or
  • Blue Light is not activated
  • No malignant activated lesions
  • Ensure you are using correct equipment; look for blue or violet marker
  • Make sure Hexvix® has been instilled, and check for fluorescence in bladder neck
  • Inspect light source; original light bulb?
tip 2

Green hue

  • Urine in the bladder
  • Always drain the bladder at start of the procedure
  • Remove resectoscope, set trocar valve to exit position, and allow urine to drain passively
tip 3

Entire bladder appears red under white and blue light

  • Recent Bacillus Calmette-Guerin treatment or inflammation
  • If clinically feasible, avoid BLC® with Hexvix® until 6 weeks after last BCG treatment and in patients with bladder infection
  • Either continue procedure without the benefit of Blue Light diagnosis or reschedule
tip 4

Photo bleaching

  • Prolonged use of blue light
  • Blue light too close to lesion during procedure
  • Alternate between white light and blue light. If the tumour is visible in white light, use BLC® with Hexvix® for control after resection
  • Do not use Blue Light close to the tumour for extended time periods. If photo bleaching appears, shut off the blue light and work elsewhere
  • Mark small lesions early during procedure
tip 5

Uncertainty around a large pink/red area


Direct scope 90° toward lesion. Fill bladder slightly. Stretch area with loop and see if it disappears


Has a cytology been taken? Were bacterial cultures taken? Has patient used catheter for longer periods?

Is CIS suspected?Cold cup biopsy and no fulguration

Did the patient have a positive urine cytology? Treat as carcinoma in situ

tip 6

Trouble finding orifice or suspicion that orifice might have been resected


Switch to Blue Light and wait in suspected area; you might see a green cloud emerging because urine appears fluorescent green under blue light

tip 7

Resection management in White Light

resection management

Images courtesy of Professor Malmström, Uppsala University

resection management 2

To avoid false-negative diagnoses
Ensure adequate time after instillation of Hexvix®

Pink fluorescence on bladder neck should always be seen if the instillation was administered properly

resection management 3

Images courtesy of Dr. Sia Daneshmand, Keck Hospital, USC

Bladder neck
Fluorescence is considered normal and not necessarily tumour

resection management 4