Standard bladder cancer surveillance utilizes WLC; however, bladder tumors can display various gross morphological features, and CIS in particular can appear as normal urothelium under WLC. Use of fluorescent cystoscopy improves the detection of urothelial carcinoma, especially CIS.78, 303 A recent meta-analysis of 13 trials concluded that the risk of bladder cancer recurrence is decreased with fluorescent cystoscopy versus WLC at short-term (<3 months; 9 trials; RR: 0.58; 95% CI: 0.36 to 0.94; I2=75%), intermediate-term (3 months to <1 year; 6 trials; RR: 0.70; 95% CI: 0.56 to 0.88; I2=19%), and long-term follow-up (≥1 year; 12 trials; RR: 0.81; 95% CI: 0.70 to 0.93; I2=49%).114 Although 5‑aminolevulinic acid (5-ALA) was used in some of the aforementioned clinical studies, it is not approved by the FDA, and hexaminolevulinate (HAL) is currently the only agent approved in the U.S. and Europe for use with BLC. Focusing on studies that used HAL only, fluorescent cystoscopy was associated with a decreased risk in bladder cancer recurrence at long-term follow-up (≥1 year; 7 trials; RR: 0.75; 95% CI: 0.62 to 0.92; I2=41%). In a large RCT of HAL–BLC performed in patients with NMIBC, there was a statistically significant reduction in recurrence rates at 9 months (47% for patients who received HAL–BLC and WLC compared with 56% for those who underwent WLC alone; p=0.026), and a non-significant reduction in the rate of recurrent “worrisome” tumors (defined as CIS, recurrent T1, or muscle-invasive disease; 16% versus 24%; p=0.17).304 With a median follow-up of 53 months for patients who underwent WLC alone and 55 months for those who received HAL–BLC in addition to WLC, a large international RCT reported that the HAL–BLC group experienced a significant delay in median time to recurrence (16.4 months) compared with the WLC group (9.4 months; p=0.04). A meta-analysis using pooled data from 9 prospective trials that included only HAL using actual raw data demonstrated that HAL–BLC was associated with lower recurrence rates at 12 months compared to WLC (35% versus 45%; RR: 0.761; p=0.006). The benefits were independent of the baseline risk of recurrence and were demonstrated in patients with primary or recurrent Ta, T1, or CIS lesions.305 In contrast, the PHOTO trial, a randomized prospective trial, did not find a difference in recurrence or progression rates over 44 months in intermediate- and high-risk NMIBC patients undergoing initial TURBT with BLC versus WLC.306 538 patients with initial clinical diagnosis of intermediate-/high-risk NMIBC were randomized to undergo either white-light or blue-light resection at several U.K. centers. At 44 months, the HR for recurrence was 0.94 (95% CI: 0.69 to 1.28; P=0.70). There was no difference in progression detected between groups (HR: 1.41; 95% CI: 0.67 to 2.96). CIS was present in only 13% of the resection specimens of patients enrolled in the trial; thus, a key group in which blue light detects the most “missed” tumors was under-represented in the study. Additionally, the trial was published prior to enrolling the full number of patients for adequate power to detect a difference between groups. Five other systematic reviews have shown decreased recurrence rates with the use of BLC compared to WLC.307-311 Importantly, however, researchers have reported higher false-positive results for HAL–BLC compared to WLC, particularly in patients who have undergone recent TURBT, who have concurrent UTI or inflammation, or who have recently received intravesical BCG or chemotherapy. This over-detection may be improved if BLC is delayed for greater than or equal to three months after intravesical therapy.304 The reported false-positive rates of BLC also seem to decrease over time with experience.312