Options for delivering topical therapy to the upper tract include:
- Antegrade via nephrostomy tube
- Retrograde via ureteric catheter or Bander stent
- Retrograde via bladder refluxing up JJ stent
Systematic review and meta-analysis found no difference between different agents (BCG vs MMC) or instillation techniques in terms of recurrence, progression, or survival.
Recurrence rates in these small retrospective studies can be comparable to untreated patients, questioning efficacy in general.
No randomised data available.
Principles:
- Deliver via gravity feed rather than under pressure to avoid pyelovenous/pyelolymphatic reflux (+ extravasation if antegrade)
- Usual risks of BCG/MMC delivery + upper tract infection, stricture, obstruction etc
- Do not use in presence of UTI, obstruction
- May be used in select patients accepting poor evidence as an attempt to avoid nephroureterectomy
MitoGel
- Mitomycin C in gel form – liquid at low temperatures, forms solid gel at body temperature
- OLYMPUS study – 1/week instillation for 6 weeks in low grade Ta UTUC above PUJ
- 59 % complete response rate
- 44 % ureteric stenosis/stricture, UTI in 32 %