Immediate intravesical chemotherapy after TURBT

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Why a single dose A resection scatters tumour cells into the irrigant and they implant on the resection bed and on any other raw patch of urothelium; many early recurrences are these implants rather than new tumours. A single dose of chemotherapy within 24 hours, and ideally within six hours, of the resection kills the floating cells before they attach, and reduces recurrence in low and intermediate-risk non-muscle-invasive disease by about a third relative, roughly fourteen per cent absolute at five years. It does not reduce progression, and it does little for the patient with frequent recurrences or high-risk disease, who needs a full course of BCG or chemotherapy instead. The dose is planned before the resection begins, not remembered afterwards.
2. Who does not get it Anyone in whom the bladder may not be intact. A perforation seen at resection, fat or a hole at the bed, or an irrigant deficit that suggests one; a deep or extensive resection where the wall is thin and a perforation is possible; and bleeding that needs continuous irrigation, because the dose cannot be held in a bladder that is being washed and the bleeding bed absorbs the drug. Mitomycin instilled into the perivesical tissue through a perforation causes chemical necrosis and there are reported deaths. A known allergy to the agent is the other bar. If there is doubt about the wall, the dose is omitted and the omission is written down with the reason.
   where it bites: a perforation, suspected or seen, cancels the dose; mitomycin outside the bladder is necrosis.
3. At the end of the TURBT The resection is finished, the bed and every other part of the bladder is inspected once more with the irrigation slowed, and the surgeon makes the decision aloud: the wall is intact, the bleeding is controlled, the dose is given. A two-way catheter of 16 to 20 French goes in, or a three-way if irrigation might be needed later, and the bladder is drained to empty so that 40 ml of drug is not diluted in a bladder full of irrigant. The catheter position is confirmed by drainage of clear irrigant, and the balloon is up and seated. The instillation is then given in theatre or in recovery, by whoever the local protocol names, from a prescription written before the case.
4. The dose Mitomycin C 40 mg in 40 ml of water or saline is the common UK dose, though some units use 40 mg in 20 ml; epirubicin and gemcitabine are alternatives with similar evidence and the local agent is used. The dose is prepared by pharmacy in a closed system and arrives labelled as cytotoxic. Whoever gives it wears gloves, a gown and eye protection, checks the patient, the drug and the dose against the prescription with a second person, and connects the syringe or bag to the catheter through a closed connector. Mitomycin on skin causes dermatitis and on the eye causes injury; a spill is contained with the cytotoxic spill kit, not wiped with a paper towel.
   where it bites: handled as cytotoxic from the syringe to the bag: gloves, gown, eye protection, a closed connector and the spill kit within reach.
5. Instilled and clamped for an hour The drug runs in slowly through the catheter into the empty bladder, followed by a small saline flush so that none is left in the catheter, and the catheter is clamped. The clamp is timed and written on the chart: one hour, occasionally up to two, but never left unclamped by default or forgotten. The patient is turned every fifteen minutes between prone, supine and each side so that the whole urothelium is bathed; in recovery this is the nurse turning a drowsy patient. Pain in the bladder or abdomen, a rising pulse or a distended abdomen during the dwell means the drug may be outside the bladder, and the clamp comes off at once.
   where it bites: abdominal pain or distension during the dwell is extravasation until proved otherwise; unclamp and drain immediately.
6. Drained, flushed, protected, disposed At the hour the clamp is released and the bladder drains into a closed bag. The catheter is flushed with saline so that the drug does not sit in the lumen against the urethra, and the bag is changed. The drained fluid, the bag, the syringe and the connector are cytotoxic waste in the purple-lidded bin, and the gloves and gown follow them. The perineal and genital skin is checked and washed if any drug has leaked around the catheter, because mitomycin causes a contact dermatitis and, rarely, a rash of the palms and genitals. For the next six hours the urine is treated as cytotoxic: gloves for any handling of the bag, and the toilet flushed twice with the lid down after a void.
7. The catheter and the ward The catheter stays until the urine is clear, usually overnight, and comes out in the morning for a day-case or short-stay patient; a resection that was small and bloodless can have the catheter removed a few hours after the drug is drained. The patient is warned about dysuria, frequency and urgency for a day or two, which is chemical cystitis and is treated with fluids and analgesia, and about mild haematuria. Fever, severe pain, a distended abdomen or a rash is reported. The note records the drug, dose and volume, the time in and out, the clamp time, the turning, the catheter, the skin check and any exception.
8. The recurrence pathway The histology arrives within a fortnight and decides the rest. Low-risk disease, a single small low-grade Ta tumour, has had its treatment with the resection and the single dose and goes to surveillance cystoscopy at three months and then twelve months, then yearly for five years. Intermediate-risk disease may have a course of intravesical chemotherapy or BCG for a year on top of the single dose. High-risk disease, high-grade or T1 or carcinoma in situ, was never going to be treated by a single dose: it needs a re-resection where indicated and induction and maintenance BCG, or cystectomy for the highest risk. The single dose is the beginning of the pathway, not a substitute for it.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance