Percutaneous drainage should be part of the initial management strategy for emphysematous pyelonephritis. This strategy is associated with a lower mortality than medical management or emergency nephrectomy. Delayed elective nephrectomy may be required in some patients.

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ObjectivesThe aim of this study was to assess the test performance and clinical effectiveness of photodynamic diagnosis (PDD) compared with white light cystoscopy (WLC) in people suspected of new or recurrent bladder cancer. MethodsA systematic review of randomised controlled trials (RCTs), non-randomised comparative studies or diagnostic cross-sectional studies comparing PDD with WLC. Fifteen electronic databases and websites were searched (last searches April 2008).For clinical effectiveness only RCTs were considered. ResultsTwenty-seven studies (2949 participants) assessed test performance. PDD had higher sensitivity than WLC (92%, 95% CI 80 to 100% versus 71%, 95% CI 49 to 93%) but lower specificity (57%, 95% CI 36 to 79% versus 72%, 95% CI 47 to 96%). For detecting higher risk tumours, median sensitivity of PDD (89% (6 to 100%)) was higher than WLC (56% (0 to 100%)) whereas for lower risk tumours it was broadly similar (92% (20 to 95%) versus 95% (8 to 100%)). Four RCTs (709 participants) using 5-aminolaevulinic acid (5-ALA) as the photosensitising agent reported clinical effectiveness. Using PDD at transurethral resection of bladder tumour (TURBT) resulted in fewer residual tumours at check cystoscopy (relative risk (RR) 0.37, 95% CI 0.20 to 0.69) and longer recurrence-free survival (RR 1.37, 95% CI 1.18 to 1.59), compared with WLC. 4 ConclusionsPDD detects more bladder tumours than WLC, including more high risk tumours.Based on four RCTs reporting clinical effectiveness, 5-ALA mediated PDD at TURBT facilitates a more complete resection and prolongs recurrence-free survival.

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