Indications:
- Within 24 hours of TURBT for low or intermediate risk disease
- Course of 6 weekly treatments for intermediate risk disease
- Post-operative single dose after nephroureterectomy
Contra-indications:
- Suspected perforation or extensive resection
- Requiring bladder irrigation to control bleeding
No studies available comparing between agents for post operative dose.
BCG has better reduction of recurrence rates when given as adjuvant course, and chemotherapy does not reduce progression risk (cf. BCG course).
Mitomycin
Indications:
- Within 24 hours of TURBT for low or intermediate risk disease
- Course of 6 weekly treatments for intermediate risk disease
- Post-operative single dose after nephroureterectomy
Mitomycin C is an alkylating agent / anti-tumour antibiotic which causes DNA cross-linking, inhibiting DNA synthesis.
Dose is 40 mg in 40 mL of saline, placed intravesical.
39 % relative reduction in recurrence for post operative dose.
Subsequent meta-analysis – those who are most likely to benefit are those with 1 or less recurrence / year and with low risk. No effect on progression.
Can cause irritative LUTS, significant skin reactions and contact dermatitis, and horrible peritonitis if extravasation of chemotherapy.
May work better with alkalinised urine – sodium bicarbonate pre-instillation.
Other ways of optimising mitomycin:
- Heating the bladder to 42 degrees using either radiofrequency needles from tip of a catheter or bladder recirculating system – inflammatory reaction increases effectiveness
- Electromotive with transabdominal current
Epiriubicin or doxorubicin (Adriamycin)
Doxorubicin is an anthracycline agent and topoisomerase inhibitor.
Epirubicin is a derivative of doxorubicin.
Both are given as 50 mg in 50 mL and have side effects of chemical cystitis and occasional reports of reduced bladder volumes.
Similar efficacy to mitomycin.
Valrubicin
Semi-synthetic analogue of doxorubicin – used for BCG refractory CIS – 20 % response rate.
Gemcitabine
Gemcitabine is incorporated into DNA and inhibits DNA synthesis.
Adjuvant post-operative instillation of gemcitabine (2g in 100 mL) has been shown in RCT vs placebo to reduce recurrence rates (30 – 40 % reduction).
Excellent safety profile – comparable to placebo.
6 weekly course of intravesical gemcitabine has been used in BCG refractory disease, but without great success.
Docetaxel
75 mg in 100 mL – some evidence for reducing recurrence.