OBJECTIVES: Hexaminolevulinate (HAL) is an optical imaging agent used as an adjunct to white light cystoscopy (WLC) in the diagnosis and management of non-muscle invasive bladder cancer (NMIBC). The objective of this study was to model the cost-effectiveness of HAL-assisted blue light cystoscopy (HAL-BLC) compared to WLC alone when used at initial transurethral resection of bladder tumours (TURB) from the perspective of the National Health Service (NHS) in England and Wales using available clinical data. METHODS: A two-part model was developed to estimate the incremental cost-effectiveness of HAL-BLC at initial TURB for patients positively diagnosed in the outpatient setting with NMIBC over a lifetime horizon. This consisted of a short-term decision tree, which estimated the outcome of the outpatient diagnostic procedure and inpatient TURB, and a Markov cohort model, used to extrapolate long term outcomes. Clinical effectiveness evidence on recurrence was taken from a recent meta-analysis of NMIBC with HAL-BLC, costs were derived from NHS reference costs, and utilities and disease evolution were from the literature. RESULTS: Despite additional treatment and equipment costs, base case results suggest that HAL-BLC is a dominant strategy as an adjunct to WLC compared to WLC only, when used at initial TURB for patients diagnosed with NMIBC. HAL-BLC is expected to be associated with 0.060 incremental QALYs and cost-savings of £391 per patient resulting from fewer recurrences and fewer associated surgical procedures (33 avoided TURBs/149 positively-diagnosed patients), in turn due to improved completeness of lesion resection and better tumour staging. Probabilistic sensitivity analyses indicated that HAL-BLC was dominant in 91.9% of iterations. CONCLUSIONS: HAL-BLC as an adjunct to WLC was shown to be a dominant strategy over WLC alone when used at initial TURB for patients diagnosed with NMIBC in England and Wales, with improved patient outcomes and cost-savings expected to offset investment in HAL.