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Urology Update

Illuminating a Path to Enhanced Bladder Cancer Detection

With its acquisition of Blue Light Cystoscopy with Cysview in December 2018, the urological team at Penn State Health Milton S. Hershey Medical Center is able to look into the bladder with pinpoint accuracy and immediately remove cancerous lesions that are invisible to the naked eye. More thorough eradication of tumors may reduce recurrence rates and the likelihood that missed cells will develop into more aggressive malignancies.

As the only healthcare provider in the region with this new technology, the Milton S. Hershey Medical Center offers bladder cancer patients and referring physicians better diagnostics, along with the expectation of fewer procedures in the future — improving quality of life and underscoring the organization’s commitment to provide leading-edge technology in central Pennsylvania.

How It Works

One hour before the cystoscopy procedure, the indicator fluid, Cysview, is instilled in the bladder via catheter. From the patient’s perspective, this is the only difference in preparation between Blue Light Cystoscopy and conventional white light cystoscopy, , assistant professor of surgery – urologic oncology, and associate program director of the urology residency program at Hershey Medical Center.

Once the patient is under anesthesia, the urologist inserts a scope that is similar to the white light scope, but shines a blue light, causing the bladder to fluoresce — the cancer lights up pink against a blue background. While the procedure can be used simply for surveillance, physicians most often proceed directly to resection of cancer cells.

“We can toggle back and forth between the blue and white light, which is what we use as we perform the removal,” says Matthew Kaag, MD, associate professor of surgery – urologic oncology, and clinical program co-leader in genitourinary oncology. “That enables us to see the anatomy more clearly.”

There is a marked difference in what can be observed — and therefore removed — with blue light. A study in The Journal of Urology showed that one or more additional Ta or T1 tumors were detected in approximately a quarter of patients using Blue Light Cystoscopy with Cysview versus white light alone.


The image shows two views of the bladder. The image on the left is of the bladder using white light cystoscopy alone. It does not show any visible abnormality. The image on the right is the same image using Blue Light Cystoscopy with Cysview. The blue light causes the bladder to fluoresce, revealing a lesion near the center.

The image on the left is of a bladder using white light cystoscopy alone. The image on the right is the same image using Blue Light Cystoscopy with Cysview, which reveals a lesion in pink against the blue light. Images courtesy of Dr. Ashish Kamat, MD Anderson Cancer Center.

A More Complete View

That sharper view is key, Dr. Kaag explains, because it illuminates lesions that the most cautious examination might otherwise fail to detect.

“Even an experienced surgeon is going to miss things that are not yet three-dimensional within the bladder,” he says. “The large tumors that protrude into the lumen of the bladder are easily identified, but things that are still flat are very tough to see.”

In particular, Dr. Merrill adds, carcinoma in situ is easily missed under white light.

“So many times, these have satellite lesions,” she says. “The blue light can help you ensure the margins are negative.”

Catching as many cancerous cells as possible decreases the chance of the cancer growing back and/or progressing, she adds. If not removed, cancer may also become more aggressive.

Greater Precision

One other difficulty in using only a white light scope is that scar tissue from previous resections can be hard to differentiate from new cancer lesions. Dr. Merrill describes a patient in his 50s who had multiple bladder cancer recurrences.

During regular white light surveillance, Dr. Merrill had detected a lesion that appeared to be growing. However, Blue Light Cystoscopy with Cysview illuminated the area only slightly, leading her to believe it likely was not cancer. That enabled her to perform only a small biopsy of the tissue, which reduced the impact on the patient of a potentially more significant resection and showed that the tissue was normal.

“He had become very sensitive to resection over the years,” she says. “The less involved procedure minimized his symptoms afterward.”

“Everyone, from the physicians and surgeons to the nursing assistants and operating room technicians, is proud of our commitment to innovation. That’s definitely the culture at Penn State.”
— Suzanne B. Merrill, MD, assistant professor of surgery – urologic oncology, and associate program director of the urology residency program at Milton S. Hershey Medical Center

Fewer Visits

Repeated transurethral resection of bladder tumors can be stressful for bladder cancer patients, most of whom are elderly — the average age at diagnosis is 73, according to the American Cancer Society. With more accurate identification of tumors because of Cysview and more extensive removal of cells, patients can have longer breaks between procedures. That is a key advantage because patients with bladder cancer may have more frequent recurrences than those with other cancers.

Decreasing the number of operations has other benefits as well. Some bladder cancer patients are on blood thinners, for example, which have to be stopped more frequently as more resections become necessary. Blue Light Cystoscopy with Cysview may even reduce healthcare costs.

“If we can eliminate one cystoscopy under anesthesia, Blue Light Cystoscopy has basically paid for itself,” Dr. Kaag says.

Commitment to Innovation

In addition to bladder cancer, Dr. Merrill, Dr. Kaag and their experienced colleagues provide the full spectrum of care in urology and urologic oncology, including treating kidney, penile and testicular cancers, as well as genitourinary sarcoma and a range of other conditions. That care is significantly more effective because of Hershey Medical Center’s early adoption, not only of Blue Light Cystoscopy with Cysview, but of other state-of-the-art technologies. For instance, the urology team recently added MRI fusion-guided prostate biopsy.

“Typical biopsies are performed under ultrasound guidance,” Dr. Merrill says. “We’re now able to fuse the MRI image with the real-time active ultrasound image to enhance our ability to biopsy the area to detect the cancer.”

Hershey Medical Center embraces new technologies and procedures, Dr. Kaag says, and follows through by facilitating their effective utilization. He cites as one example the innovation team for the Department of Surgery. The team develops new techniques and devices and holds several patents —, but, crucially, also helps surgeons optimize use of those advanced technologies in patient care.

“There’s always someone available who knows about the engineering, the chemistry or the biochemistry or whatever new technology you’re implementing,” Dr. Kaag says. “It’s one of the reasons I went into academics: to have the kind of infrastructure behind me that allows me to stay on the cutting edge of what we do.”

A head-and-shoulders photo of Matthew G. Kaag, MD

Matthew G. Kaag, MD

Associate Professor, Department of Urology, Penn State Cancer Institute
Clinical Program Co-Leader in Genitourinary Oncology
Phone: 717-531-4475
Fellowship: Urologic Oncology/Surgery, Memorial Sloan Kettering Cancer Center, New York
Residency: Urology, Penn State Health Milton S. Hershey Medical Center, Hershey
Medical School: Penn State College of Medicine, Hershey
Internship: General surgery, Milton S. Hershey Medical Center, Hershey, Pa.
Connect with Matthew G. Kaag, MD, on Doximity

A head-and-shoulders photo of Suzanne B. Merrill, MD

Suzanne B. Merrill, MD

Assistant Professor of Urology
Associate Program Director of the Urology Residency Program
Phone: 717-531-8887
Fellowship: Urologic oncology, Mayo Clinic, Rochester, Minn.
Residency: Duke University Medical Center, Durham, N.C.
Medical School: University of North Carolina School of Medicine, Chapel Hill, N.C.
Internship: General surgery, Duke University Medical Center, Durham, N.C.
Connect with Suzanne B. Merrill, MD, on Doximity


Levisay, Sheri. Illuminating a Path to Enhanced Bladder Cancer Detection. MD News Central Pennsylvania Edition. May 2019. Accessed Nov. 27, 2019.

The Department of Urology at Penn State Milton S. Hershey Medical Center offers expert diagnosis and treatment of diseases and conditions involving the urinary tract. Our fellowship-trained surgeons and skilled advanced practice providers offer individualized care for cancer, kidney stones, infertility, impotence and other complex urologic concerns.

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