Change in Pain and Quality of Life Among Women Enrolled in a Trial Examining the Use of Narrow Band Imaging During Laparoscopic Surgery for Suspected Endometriosis

The reporting quality and spin of randomized controlled trials of endometriosis pain: Methodological study based on CONSORT extension on abstracts

OBJECTIVE

To assess the reporting quality of published RCT abstracts regarding patients with endometriosis pelvic pain and investigate the prevalence and characteristics of spin in these abstracts.

METHODS

PubMed and Scopus were searched for RCT abstracts addressing endometriosis pelvic pain published from January 1st, 2010 to December 1st, 2023.The reporting quality of RCT abstracts was assessed using the CONSORT statement for abstracts. Additionally, spin was evaluated in the results and conclusions section of the abstracts, defined as the misleading reporting of study findings to emphasize the perceived benefits of an intervention or to confound readers from statistically non-significant results. Assessing factors affecting the reporting quality and spin existence, linear and logistic regression was used, respectively.

RESULTS

A total of 47 RCT abstracts were included. Out of 16 checklist items, only three items including objective, intervention and conclusions were sufficiently reported in the most abstracts (more than 95%), and none of the abstracts presented precise data as required by the CONSORT-A guidelines. In the reporting quality of material and method section, trial design, type of randomization, the generation of random allocation sequences, the allocation concealment and blinding were most items identified that were suboptimal. The total score for the quality varied between 5 and 15 (mean: 9.59, SD: 3.03, median: 9, IQR: 5). Word count (beta = 0.015, p-value = 0.005) and publishing in open-accessed journals (beta = 2.023, p-value = 0.023) were the significant factors that affecting the reporting quality. Evaluating spin within each included paper, we found that 18 (51.43%) papers had statistically non-significant results. From these studies, 12 (66.66%) had spin in both results and conclusion sections. Furthermore, the spin intensity increased during 2010-2023 and 38.29% of abstracts had spin in both results and conclusion sections.

CONCLUSION

Overall poor adherence to CONSORT-A was observed, with spin detected in several RCTs featuring non-significant primary endpoints in obstetrics and gynecology literature.

A systematic review to determine use of the Endometriosis Health Profiles to measure quality of life outcomes in women with endometriosis

BACKGROUND

The Endometriosis Health Profiles (EHPs), the EHP-30 and EHP-5, are patient-reported outcome measures that were developed to measure the health-related quality of life (HRQoL) of women living with endometriosis. Prior to their development, a systematic review was undertaken which identified that the HRQoL of women living with endometriosis was poorly understood, with only three medical and one surgical study identified.

OBJECTIVE AND RATIONALE

The 20-year anniversary of the EHP-30 provided a timely opportunity to assess how the tools have been used and explore what the findings tell us about the impact of endometriosis and its associated treatments upon women's QoL. Applying robust systematic review methodology, following PRISMA guidelines, we sought to answer: How many studies have used the EHP and for what purpose?; What are the demographic characteristics and international context of the studies?; What is the methodological nature and quality of the studies?; Which interventions have been assessed and what are the reported EHP outcomes?; and Can the EHP outcomes of these interventions be analysed using a meta-analysis and, if so, what do the results show?

SEARCH METHODS

The electronic databases MEDLINE, CINAHL, PsycINFO, PubMed, and Google Scholar were searched from the year the EHP was first published, in 2001 to 26 February 2020 using the search terms 'EHP30', 'EHP5', 'EHP-30', 'EHP-5', 'endometriosis health profile 30', and 'endometriosis health profile 5'. We updated the searches on 9 April 2021. All included studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT).

OUTCOMES

The review included 139 papers. In clinical intervention studies, the EHPs were deployed most frequently to measure the outcomes of medical (n = 35) and surgical (n = 21) treatment. The EHPs were also used in 13 other intervention studies, 29 non-interventional studies, 32 psychometric/cross cultural validation studies; six diagnostic studies, and in three other studies to measure outcomes in related conditions. They were mainly deployed in studies undertaken in Europe and North America. Overall, regardless of the nature of the intervention, most women reported improvements in HRQoL after treatment. Surgical interventions generally resulted in significant improvements for the longest amount of time. There was also evidence that when participants stopped taking medication their EHP scores worsened, perhaps reinforcing the temporary impact of medical treatment. Younger patients reported more negative impact upon their HRQoL. Further evidence using classical test theory to support the EHPs' robust psychometric properties, including acceptability, dimensionality, reliability, validity (including cross-cultural), and responsiveness, was demonstrated, particularly for the EHP-30. Strikingly, using anchor-based methods, EHP-30 responsiveness studies demonstrate the largest mean changes in the 'control and powerlessness' domain post-intervention, followed by 'pain'. MMAT outcomes indicated the quality of the papers was good, with the exception of five studies. A meta-analysis was not undertaken owing to the heterogeneity of the interventions and papers included in this review.

WIDER IMPLICATIONS

Women with endometriosis face a lifetime of surgical and/or medical interventions to keep the condition under control. Less invasive treatments that can lead to improved longer term physical and psycho-social outcomes are needed. The EHPs are reliable, valid, acceptable, and responsive tools, but more assessment of EHP outcomes using modern psychometric methods and in the context of women from ethnically diverse backgrounds and in routine clinical care would be beneficial. Given the brevity of the EHP-5, it may be the most appropriate version to use in routine clinical practice, whereas the longer EHP-30, which provides more granularity, is more appropriate for research.

Patient-Reported Outcome Measures Used in Randomized Controlled Trials Following Surgical Intervention for Endometriosis: A Structured Review from the AAGL Practice Guidelines Group

OBJECTIVE

No consensus currently exists regarding patient-reported outcome measure (PROM) instruments. This structured review was conducted to identify the PROMs used by randomized controlled trials (RCTs) that evaluated surgical treatment in patients with endometriosis.

DATA SOURCES

Two parallel searches were conducted by a medical librarian using Ovid MEDLINE, Ovid Embase, and Cochrane Library for RCTs published from 2000 to July 2022. One search focused on studies reporting quality of life (QoL), and the second search focused on studies reporting pain and sexual, bowel, and bladder function.

METHOD OF STUDY SELECTION

During the title and abstract screening and reference check, 600 results were identified on PROMs relating to QoL and 465 studies on PROMs relating to pain and sexual, bowel, and/or bladder function and an evaluation of 17 and 12 studies conducted, respectively. The inclusion criteria involved selecting RCTs that focused on surgical intervention and assessing QoL, pain, and sexual, bowel, and/or bladder function using PROMs.

TABULATION, INTEGRATION, AND RESULTS

Covidence software was used to organize and identify duplicate articles through screening. We developed a data extraction form to collect key information about each included study, as well as the pertinent PROMs used in the study. Assessment of the risk of bias of each study was also performed. A total of 19 studies were identified involving 2089 participants and a total of 16 PROMs used across the studies; 9 of 19 studies (47%) were rated as having a low risk of bias. There were no high-risk studies identified in this review.

CONCLUSION

This study identified a large number of RCTs in surgical treatment of endometriosis that used various PROMs to assess QoL, pain, and bladder, bowel, and sexual function. The PROMs used by high-quality RCTs for QoL include Endometriosis Health Profile-30, Endometriosis Health Profile-5, Short-Form 36, Short-Form 12, and EQ-5D; for bowel-related symptoms Knowles-Eccersley-Scott-Symptom Questionnaire, Gastrointestinal Quality of Life Index, and Cleveland Clinic Fecal Incontinence Severity Scoring System/Wexner; for bladder-related function Bristol Female Lower Urinary Tract Symptoms, International Prostate Symptom Score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and Urinary Symptom Profile; and finally for sexual function Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and Sexual Activity Questionnaire. Unlike other domains, only one tool (visual analog scale) was the dominant PROM used for the assessment of pain. In addition, the use of more than one PROM in each study to assess different aspects of patient's health and pain symptoms did not become prevalent until after 2015.

Pain-focused psychological interventions in women with endometriosis: A systematic review

AIMS

As a chronic inflammatory disease, endometriosis (EMS) is often associated with pain affecting different aspects of women's lives. Up to now, a wide variety of interventions have been implemented to alleviate pain in patients with this condition, including pharmacological, surgical, and rarely non-pharmacological ones. Against this background, this review aimed to investigate pain-focused psychological interventions among EMS women.

METHODS

A systematic review of the articles published in this field was conducted through a comprehensive search on the databases of Scopus, PubMed, MEDLINE, Web of Science, ScienceDirect, the Cochrane Library, PsycINFO, Google Scholar, and Scientific Information Database (SID). The quality of studies was then assessed by the Jadad Scale.

RESULTS

In total, 10 articles were entered into this systematic review. The findings further revealed that the pain-focused psychological interventions in patients with EMS were cognitive-behavioral therapy (CBT) (n = 2), mindfulness therapy (n = 4), yoga (n = 2), psychoeducation (n = 1), and progressive muscle relaxation (PMR) training (n = 1). Besides, the findings established that all the given interventions had improved and reduced pain in women living with this condition. Moreover, five articles were of good quality based on the Jadad Scale.

CONCLUSION

The study results demonstrated that all the listed psychological interventions had affected pain relief and improvement in women suffering from EMS. Considering the limited number of studies in this field and the fact that there were only five articles endowed with good quality, more high-quality studies could provide stronger evidence to support the implementation of the mentioned interventions influencing pain in patients.

Improving tissue characterization, differentiation and diagnosis in gynecology with the narrow-band imaging technique: A systematic review

Narrow-band imaging (NBI), an on-demand, real-time endoscopic imaging technique, was developed to enhance visualization of the mucosal vascular network and surface texture. The present article provides a systematic review of studies that assessed the use of NBI in gynecological endoscopy. The following electronic databases were searched: PubMed (1950-2020), Google Scholar (2004-2020) and Cochrane Library (2010-2020). In the initial search, 3,836 entries were identified, of which 31 were finally included in the systematic review. Of the selected studies, 10 (32%) were case reports, 19 (61.2%) were prospective studies and 2 (6.4%) were randomized controlled trials with control groups. The selected studies reported on the use of NBI in hysteroscopy, laparoscopy and colposcopy. It was revealed that NBI utilization in hysteroscopy increased the accuracy, sensitivity and specificity in detecting malignant and premalignant lesions. NBI improved the specificity and sensitivity in the detection of endometriotic lesions and cervical lesions. Conventional white light endoscopy in gynecology may be significantly improved by the use of NBI. Further studies with larger cohorts and improved design are required to achieve more reliable results. It is of special interest that utilization of this method requires apparatus which is expensive; concerns are the long training and experience of staff required and the long learning curve.

Laparoscopic surgery for endometriosis

BACKGROUND

Endometriosis is associated with pain and infertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy.

OBJECTIVES

To assess the effectiveness and safety of laparoscopic surgery in the treatment of pain and infertility associated with endometriosis.

SEARCH METHODS

This review has drawn on the search strategy developed by the Cochrane Gynaecology and Fertility Group including searching the Cochrane Gynaecology and Fertility Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, reference lists for relevant trials, and trial registries from inception to April 2020.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) that compared the effectiveness and safety of laparoscopic surgery with any other laparoscopic or robotic intervention, holistic or medical treatment, or diagnostic laparoscopy only.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed selection of studies, assessment of trial quality and extraction of relevant data with disagreements resolved by a third review author. We collected data for the core outcome set for endometriosis. Primary outcomes included overall pain and live birth. We evaluated the quality of evidence using GRADE methods.

MAIN RESULTS

We included 14 RCTs. The studies randomised 1563 women with endometriosis. Four RCTs compared laparoscopic ablation or excision with diagnostic laparoscopy only. Two RCTs compared laparoscopic excision with diagnostic laparoscopy only. One RCT compared laparoscopic ablation or excision with laparoscopic ablation or excision and uterine suspension. Two RCTs compared laparoscopic ablation and uterine nerve transection with diagnostic laparoscopy only. One RCT compared laparoscopic ablation with diagnostic laparoscopy and gonadotropin-releasing hormone (GnRH) analogues. Two RCTs compared laparoscopic ablation with laparoscopic excision. One RCT compared laparoscopic ablation or excision with helium thermal coagulator with laparoscopic ablation or excision with electrodiathermy. One RCT compared conservative laparoscopic surgery with laparoscopic colorectal resection of deep endometriosis infiltrating the rectum. Common limitations in the primary studies included lack of clearly described blinding, failure to fully describe methods of randomisation and allocation concealment, and poor reporting of outcome data. Laparoscopic treatment versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic treatment on overall pain scores compared to diagnostic laparoscopy only at six months (mean difference (MD) 0.90, 95% confidence interval (CI) 0.31 to 1.49; 1 RCT, 16 participants; very low quality evidence) and at 12 months (MD 1.65, 95% CI 1.11 to 2.19; 1 RCT, 16 participants; very low quality evidence), where a positive value means pain relief (the higher the score, the more pain relief) and a negative value reflects pain increase (the lower the score, the worse the increase in pain). No studies looked at live birth. We are uncertain of the effect of laparoscopic treatment on quality of life compared to diagnostic laparoscopy only: EuroQol-5D index summary at six months (MD 0.03, 95% CI -0.12 to 0.18; 1 RCT, 39 participants; low quality evidence), 12-item Short Form (SF-12) mental health component (MD 2.30, 95% CI -4.50 to 9.10; 1 RCT, 39 participants; low quality evidence) and SF-12 physical health component (MD 2.70, 95% CI -2.90 to 8.30; 1 RCT, 39 participants; low quality evidence). Laparoscopic treatment probably improves viable intrauterine pregnancy rate compared to diagnostic laparoscopy only (odds ratio (OR) 1.89, 95% CI 1.25 to 2.86; 3 RCTs, 528 participants; I² = 0%; moderate quality evidence). We are uncertain of the effect of laparoscopic treatment compared to diagnostic laparoscopy only on ectopic pregnancy (MD 1.18, 95% CI 0.10 to 13.48; 1 RCT, 100 participants; low quality evidence) and miscarriage (MD 0.94, 95% CI 0.35 to 2.54; 2 RCTs, 112 participants; low quality evidence). There was limited reporting of adverse events. No conversions to laparotomy were reported in both groups (1 RCT, 341 participants). Laparoscopic ablation and uterine nerve transection versus diagnostic laparoscopy We are uncertain of the effect of laparoscopic ablation and uterine nerve transection on adverse events (more specifically vascular injury) compared to diagnostic laparoscopy only (OR 0.33, 95% CI 0.01 to 8.32; 1 RCT, 141 participants; low quality evidence). No studies looked at overall pain scores (at six and 12 months), live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage. Laparoscopic ablation versus laparoscopic excision There was insufficient evidence to determine whether there was a difference in overall pain, measured at 12 months, for laparoscopic ablation compared with laparoscopic excision (MD 0.00, 95% CI -1.22 to 1.22; 1 RCT, 103 participants; very low quality evidence). No studies looked at overall pain scores at six months, live birth, quality of life, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy, miscarriage and adverse events. Helium thermal coagulator versus electrodiathermy We are uncertain whether helium thermal coagulator compared to electrodiathermy improves quality of life using the 30-item Endometriosis Health Profile (EHP-30) at nine months, when considering the components: pain (MD 6.68, 95% CI -3.07 to 16.43; 1 RCT, 119 participants; very low quality evidence), control and powerlessness (MD 4.79, 95% CI -6.92 to 16.50; 1 RCT, 119 participants; very low quality evidence), emotional well-being (MD 6.17, 95% CI -3.95 to 16.29; 1 RCT, 119 participants; very low quality evidence) and social support (MD 5.62, 95% CI -6.21 to 17.45; 1 RCT, 119 participants; very low quality evidence). Adverse events were not estimable. No studies looked at overall pain scores (at six and 12 months), live birth, viable intrauterine pregnancy confirmed by ultrasound, ectopic pregnancy and miscarriage.

AUTHORS' CONCLUSIONS

Compared to diagnostic laparoscopy only, it is uncertain whether laparoscopic surgery reduces overall pain associated with minimal to severe endometriosis. No data were reported on live birth. There is moderate quality evidence that laparoscopic surgery increases viable intrauterine pregnancy rates confirmed by ultrasound compared to diagnostic laparoscopy only. No studies were found that looked at live birth for any of the comparisons. Further research is needed considering the management of different subtypes of endometriosis and comparing laparoscopic interventions with lifestyle and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.

Surgical Outcomes in Patients With Endometriosis: A Systematic Review

OBJECTIVE

Among women treated surgically for endometriosis-associated pain, comprehensive data are lacking on the proportions of patients who experience little or no symptom relief, develop recurrent symptoms, or require further surgical treatment for endometriosis. The aim of this study was to assess the efficacy of surgical procedures used to treat endometriosis-associated pain.

METHODS

Medline and Embase were searched on October 13, 2016. Articles referring to women undergoing surgery for the treatment of endometriosis-associated pain were screened by two independent investigators. For each included treatment arm, data were extracted for the proportion of patients reporting partial or no improvement after surgery for endometriosis-associated pain, pain recurrence, or requirement for further surgery.

RESULTS

A total of 38 studies were included. Most studies did not report relevant outcomes to evaluate pain (71.1%) and recurrent surgery (68.4%). Of the women who underwent lesion excision, 11.8% reported no improvement in pain, and 22.6% underwent further surgery. Postoperative pain, recurrent pain, and adverse events were reported by 34.3%, 28.7%, and 14.8%, respectively, of patients who underwent excision or ablation of endometriosis combined with pelvic denervation and in 25.0%, 15.8%, and 8.1% of women who underwent lesion excision alone. Of the patients who were treated surgically for deep endometriosis affecting the bowel and/or bladder, 7.0% experienced recurrent symptoms, and 4.1% underwent further surgery.

CONCLUSION

This review supports the findings of previous studies and highlights the need for standardized reporting and more detailed follow-up after surgery for endometriosis-associated pain.

Systematic review of quality of life measures in patients with endometriosis

OBJECTIVES

Endometriosis and quality of life has been the subject of much research, however, there is little consensus on how best to evaluate quality of life in endometriosis, resulting in many and diverse scales being used. In our study, we aim to identify quality of life scales used in endometriosis, to review their strengths and weaknesses and to establish what would define an ideal scale in the evaluation of endometriosis-related quality of life.

MATERIALS AND METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English and French for the period from 1980 to February 2017, using the words 'endometriosis' and 'quality of life'. Publications were selected if they reported on quality of life in patients with endometriosis and specified use of a quality of life scale. A quantitative and a qualitative analysis of each scale was performed in order to establish the strengths and weaknesses for each scale (systematic registration number: PROSPERO 2014: CRD42014014210).

RESULTS

A total of 1538 articles publications were initially identified. After exclusion of duplicates and application of inclusion criteria, 201 studies were selected for analysis. The SF-36, a generic HRQoL measure, was found to be the most frequently used scale, followed by the EHP-30, a measure specific to endometriosis. Both perform well, when compared with other scales, with scale weaknesses offset by strengths. EHP-5 and EQ-5D also showed to be of good quality. All four were the only scales to report on MCID studied in endometriosis patients.

CONCLUSION

For clinical practice, routine evaluation of HRQOL in women with endometriosis is essential both for health-care providers and patients. Both SF-36 and EHP-30 perform better overall with regard to their strengths and weaknesses when compared to other scales.

Can Narrowband Imaging Improve the Laparoscopic Identification of Superficial Endometriosis? A Prospective Cohort Trial

STUDY OBJECTIVE

To assess the usefulness of narrowband imaging (NBI) to detect additional areas of endometriosis not identified by standard white light in patients undergoing laparoscopy for the investigation of pelvic pain.

DESIGN

A prospective cohort trial (Canadian Task Force classification II). Evidence obtained from a well-designed cohort study.

SETTING

A tertiary laparoscopic subspecialty unit in Melbourne, Australia.

PATIENTS

Fifty-seven patients undergoing laparoscopy for the investigation of pelvic pain were recruited. Fifty-three patients were eligible for analysis.

INTERVENTIONS

Patients underwent standard white-light laparoscopy of the pelvis followed by NBI survey to assess for any additional areas suspicious for endometriosis.

MEASUREMENTS AND MAIN RESULTS

All identified areas of possible endometriosis were resected and sent for blinded histopathological analysis. The additional predictive value of NBI was 0% if the preceding white-light survey was negative and 86% if the preceding white-light survey was positive.

CONCLUSION

The use of NBI at laparoscopy for the investigation of pelvic pain is beneficial in finding additional areas of endometriosis if endometriosis is already suspected after white-light survey in a tertiary laparoscopic unit. Further research in nonspecialized units may show additional benefit and requires further research. NBI may also be useful as a diagnostic aid for trainees.

Techniques in minimally invasive surgery for advanced endometriosis

PURPOSE OF REVIEW

Surgery can be an important treatment option for women with symptomatic endometriosis. This review summarizes the recommended preoperative work up and techniques in minimally invasive surgery for treatment of deeply infiltrating endometriosis (DIE) involving the obliterated posterior cul-de-sac, bowel, urinary tract, and extrapelvic locations.

RECENT FINDINGS

Surgical management of DIE can pose a challenge to the gynecologic surgeon given that an extensive dissection is usually necessary. Given the high risk of recurrence, it is vital that an adequate excision is performed. With improved imaging modalities, preoperative counseling and surgical planning can be optimized. It is essential to execute meticulous surgical technique and include a multidisciplinary surgical team when indicated for optimal results.

SUMMARY

Advanced laparoscopic skills are often necessary to completely excise DIE. A thorough preoperative work up is essential to provide correct patient counseling and incorporation of the preferred surgical team to decrease complications and optimize surgical outcomes. Surgical management of endometriosis is aimed at ameliorating symptoms and preventing recurrence.

Laparoscopic Imaging Techniques in Endometriosis Therapy: A Systematic Review

Endometriosis is a common disease associated with pelvic pain and subfertility. Laparoscopic surgical treatment has proven effective in endometriosis, but is hampered by a high rate of recurrence. The aim of this systematic review was to evaluate the intraoperative identification of endometriosis by enhanced laparoscopic imaging techniques, focusing on sensitivity and specificity. A systematic review was conducted according to PRISMA guidelines in PubMed, Embase, Cochrane Library, and Web of Science. Published prospective studies reporting on enhanced laparoscopic imaging techniques during endometriosis surgery were included. General study characteristics and reported outcomes, including sensitivity and specificity, were extracted. Nine studies were eligible for inclusion. Three techniques were described: 5-ALA fluorescence (5-ALA), autofluorescence (AFI), and narrow-band imaging (NBI). The reported sensitivity of 5-ALA and AFI for identifying endometriosis ranged from 91% to 100%, compared with 48% to 69% for conventional white light laparoscopy (WL). A randomized controlled trial comparing NBI + WL with WL alone reported better sensitivity of NBI (100% vs 79%; p < .001). All 9 studies reported an enhanced detection rate of endometriotic lesions with enhanced imaging techniques. Enhanced imaging techniques are a promising additive for laparoscopic detection and treatment of endometriosis. The 5-ALA, AFI, and NBI intraoperative imaging techniques had a better detection rate for peritoneal endometriosis compared with conventional WL laparoscopy. None of the studies reported clinical data regarding outcomes. Future studies should address long-term results, such as quality of life, recurrence, and need for reoperation.

Narrow band imaging and bladder cancer: when and how

Narrow band imaging (NBI) is an optical enhancement technology for endoscopy. NBI works filtering the standard white light in two bandwidths of illumination of 415 nm, blue, and 540 nm, green. As a result, capillaries on mucosal surface appear brown and veins in connective subepithelial layer cyan, enhancing the contrast among epithelial, subepithelial tissue and its vascularisation. Given that it is a filter, it is safe, does not need any kind of instillation and the vision modality can be switched from NBI to white light and vice versa without any limitations of time. NBI-assisted cystoscopy increases the detection rate of urothelial lesions and enhances visibility of tumour margins with respect to standard white light modality, although it does not need a particular learning curve. NBI exploration of the bladder should be avoided during active bleeding because the light absorption would be excessive impeding an optimal vision. Moreover, it should always be employed in combination with standard white light modality to avoid an excess of false-positive findings, particularly during or immediately after topic treatments. It can be used in office to anticipate bladder recurrences and in the operating theatre to perform a complete tumour resection. As a matter of fact, it is able to reduce the recurrence rate and ameliorate bladder cancer management by identifying high-grade cancerous tissue, especially Cis, undetected by the standard white light modality.