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Effects of fluorescent light-guided transurethral resection on non-muscle-invasive bladder cancer: a systematic review and meta-analysis |
Shen P, Yang J, Wei W, Li Y, Li D, Zeng H, Wang J |
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CRD summary This review concluded that fluorescent light-guided transurethral resection of non-muscle-invasive bladder cancer was not superior to white light-guided resection, in diagnostic accuracy, but it did reduce the residual tumour rate. Given the limitations of the review, acknowledged by the authors, and the poor quality of the included trials, the conclusions should be treated with caution. Authors' objectives To assess the diagnostic accuracy and therapeutic outcomes of fluorescent light-guided transurethral resection, for non-muscle-invasive bladder cancer. Searching PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched for studies, published in English, up to April 2011; search terms were reported. Reference lists of retrieved articles were searched. Study selection Randomised controlled trials comparing the diagnostic accuracy, safety and cost-effectiveness of fluorescent light and white light-guided transurethral resection of bladder tumours, in patients who had suspected or proven, primary or recurrent, non-muscle-invasive bladder cancer, were eligible for inclusion. The primary outcomes were residual tumour rate, recurrence-free survival, and progression-free survival. Abstracts without full articles and unpublished studies were excluded. In the included trials, where reported, across the trial arms, the mean age of participants ranged from 59 to 70 years; no further population characteristics were presented. Patients in the fluorescent light-guided transurethral resection group received five-aminolevulinic acid or hexyl aminolevulinate instillation before resection. Two authors independently selected studies for the review. Assessment of study quality Trial quality was assessed for the generation of randomisation sequences, allocation concealment, blinding method, description of withdrawals and dropouts, and the use of intention-to-treat analysis. The authors did not state how many reviewers assessed quality. Data extraction Two authors independently extracted the data to calculate relative risks, with 95% confidence intervals; disagreements were resolved by discussion or consultation with a third reviewer. Authors were contacted to obtain missing data. Methods of synthesis Summary relative risks and 95% confidence intervals were produced using a random-effects or fixed-effect model, depending on the presence or absence of statistical heterogeneity. Heterogeneity was assessed using Χ² and Ι², with a probability of less than 0.05 indicating significant heterogeneity. Sensitivity analyses were planned to investigate the impact of trial quality. Results of the review Fourteen trials were included in the meta-analysis, with 4,078 patients (range 57 to 749); 1,951 patients received white light and 2,127 received fluorescent light. Of the 14 trials, randomisation sequence was adequate in four, allocation concealment in one, blinding in three, and seven used an intention-to-treat analysis. There was no statistically significant difference, between groups, in the tumour detection rate (RR 0.99, 95% CI 0.96 to 1.03; Ι²=68%; nine trials) and the false-positive bladder tumour diagnosis rate (RR 0.69, 95% CI 0.49 to 0.97; Ι²=19%; three trials). The rate of residual tumour was statistically significantly higher with white light, than with fluorescent light (RR 2.77, 95% CI 1.47 to 5.20; Ι²=85%; nine trials). There was no significant difference, between the two groups, in carcinomasin situ, recurrence-free survival at three and 12 months, and progression-free survival at one and 24 months. Two studies reported that no patient was given adjuvant therapy after their procedure. Most adverse events (four trials) were related to bladder tumour resection and no phototoxicity was observed. The results of the cost-effectiveness analysis were not reported. Authors' conclusions Fluorescent light guidance for transurethral resection of bladder tumours was not superior to conventional white light guidance, in diagnostic accuracy. It reduced the residual tumour rate, but had no significant effect on short-term recurrence-free or progression-free survival. CRD commentary The authors addressed a clear review question supported by reproducible inclusion criteria. Several relevant sources were searched, but unpublished trials and those not in English were excluded. The selection of studies and data extraction were conducted by two people independently, but it was unclear whether similar methods, to reduce error and bias, were used for quality assessment. Trial quality was assessed, using appropriate criteria, and the results were published in full. Only one of the included trials seemed to be of reasonable quality; all the others appeared to be at a high risk of bias. The analyses had high levels of heterogeneity, which were not explored. The authors acknowledged the potential for the presence of language, publication, and selection bias in their review. Given the limitations of the review, and the poor quality of the included trials, the conclusions should be treated with caution. Implications of the review for practice and research Practice: The authors did not state any implications for practice. Research: The authors stated that more high-quality, multicentre, randomised controlled trials were needed to investigate the advantage of fluorescent light-guided transurethral resection in reducing the residual tumour rate. Funding Supported by the Natural Science Foundation China. Bibliographic details Shen P, Yang J, Wei W, Li Y, Li D, Zeng H, Wang J. Effects of fluorescent light-guided transurethral resection on non-muscle-invasive bladder cancer: a systematic review and meta-analysis. BJU International 2012; 110(6b): E209-E215 Indexing Status Subject indexing assigned by NLM MeSH Fluorescence; Humans; Neoplasm Invasiveness; Urinary Bladder Neoplasms /pathology /surgery AccessionNumber 12012042530 Date bibliographic record published 10/10/2012 Date abstract record published 11/03/2013 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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