Post-operative intravesical chemotherapy for superficial bladder ...

Post-operative intravesical
chemotherapy for
superficial bladder cancer

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Table of Contents
1. Introduction ...........................................................................................................1
2. The problem...........................................................................................................1
3. GMCT objectives ...................................................................................................1
4. Tips for implementing a post-operative intravesical chemotherapy protocol .2
5. GMCT Model Protocol...........................................................................................7
6. Contact persons for assistance ...........................................................................7
7. References .............................................................................................................7
8. Appendices ............................................................................................................8


GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer
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1. Introduction

1. Introduction
Primary bladder cancer is the 5th most common cancer in men and accounts
for approximately 5% of new cancers in Australian men [1]. 75-85% will
present with superficial (non-muscle invasive) disease [2]. Within 5 years,
approximately 60% of patients will suffer a recurrence with conventional
transurethral resection of the bladder tumours alone [3].
Level 1 evidence exists for the routine single instillation of intravesical
chemotherapy immediately following transurethral resection of superficial
papillary bladder cancer to decrease recurrence rates by up to 50%
(Sylvester et al. JUrol2004).
Recommendations in authoritative international guidelines include this
treatment as standard of care for both single and multiple superficial
papillary bladder cancers (EAU guidelines 2001 & 2006).
2. The problem
Currently only 3 out of 14 Urology Units with Accredited training posts in
NSW have a protocol for the routine single instillation of intravesical
chemotherapy immediately following transurethral resection of superficial
papillary bladder cancer.
Whilst postoperative intravesical treatment is relatively simple to
administer, it requires the support and coordination of various
departments and committees. This is includes pharmacy, theatres,
recovery, ward and orderly (transport) staff as well as Occupational,
Health and Safety, and Drug & Therapeutics Committees. Several NSW
hospitals in the past have been obstructed and deterred by endless
logistical barriers [4].
3. GMCT objectives
GMCT (Urology) aims to simplify and assist in the implementation of
protocols for postoperative intravesical chemotherapy in NSW public
hospitals. Additional information including a current protocol, practical
tips and related documents are available at the end of this document and in
printable format on the GMCT website.
Nursing and medical contact details are also included for any specific
questions. The individual use of postoperative intravesical chemotherapy
will obviously be at the operating surgeon’s discretion.
GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer
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4. Tips for implementing a post-operative intravesical chemotherapy protocol

4. Tips for implementing a post-operative intravesical
chemotherapy protocol
Working Party
The safe and practical administration of intravesical chemotherapy
requires a user friendly, simple protocol that involves a multi disciplinary
approach. Successful implementation requires cooperation and
understanding of the objectives by all departments / committees involved.
Eg What are the risks/benefit to the patient? What are the safety issues for
all staff members and how will they be addressed?
Important persons/department heads need to be contacted BEFORE
drawing up any formal details to form a team or working party with
emphasis on encouraging ideas, flexibility and a coordinated effort.
This includes:
1. Policy writer/coordinator (Urology/Theatre CNC, Urology registrar) -
follows through all details and liaises with rest of party
2. Urology CNC
3. Theatre NUM
4. Recovery NUM
5. Day Surgery NUM (for day stays)
6. Surgical Ward NUM (for overnight admits)
7. Nurse educators (see later)
8. Pharmacy Head (or Oncology Pharmacist) involving Drug Committee
9. Medical Oncology CNC/CNS (will assist with spill guidelines etc)
10. Director of Medical Services (enthusiastic support is very useful)
11. Theatre Orderlies / Operation Assistant (their importance cannot be
under emphasized – transportation and positioning of patients, and
waste disposal issues)
12. VMO Urologists – treatment use is obviously at the surgeon’s
discretion but one must be a strong and vocal supporter of its use
13. Occupational, Health and Safety
14. (Cancer Care Services – Eg Director of Medical Oncology) ?required
15. (Other Medical and Nursing Directors) these will be specific to your
hospital
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GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer

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4. Tips for implementing a post-operative intravesical chemotherapy protocol

Choice of agent, dwell times and dosages
There is no general consensus on agent of choice as several have been
shown to be equally efficacious with similar adverse effects profile [5].
Similarly, there is no agreed optimal dose or dwell time although 30
minutes to 2 hours provides adequate dwell and complication rates are
minimal [6].
Mitomycin C, doxorubicin, and epirubicin are amongst commonly used
agents in various hospitals in Australia [7]. Epirubicin is a common agent
used due to its 3 month shelf life and acceptable cost. (Baxter $230 each
50mg in 50 ml normal saline)

Epirubicin instillation
Timing and Location of Administration
Currently available evidence does not give firm guidance on the optimal
timing of administration, but most authors recommend that it be no later
than 24 hours after operation.
Our experience is that the logistical issues are easiest managed if the
instillation is carried immediately after the bladder tumour resection, being
ordered and administered by the surgeon, before the patient has left the
operating room. The patient is transferred to the recovery room with the
catheter in situ and the chemotherapy indwelling.

Epirubicin syringe handed directly to surgeon from scout without contact with
scrub nurse or cystoscopy tray/setup
GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer
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4. Tips for implementing a post-operative intravesical chemotherapy protocol

Staff Education
Nurse educators should be thoroughly briefed directly by protocol
coordinator and repeated sessions held for all areas of staff on several
occasions just prior to commencing the use of the protocol. Include
education of night staff and ward orderlies who may be involved in
admitted patients. Educators and all key personnel should be present to
witness at least one entire procedure from instillation to catheter disposal.
Equipment (clamps and catheter adaptors):
These should be trialled and deemed safe and effective prior to
commencement. (details can be obtained from contacts below)

18F 2 way foleys urethral catheter with leur lock adaptor (3 way urethral catheter
if more extensive resection performed)

Urethral catheter with “G” clamps in position (NOT tightened), adaptor and
epirubicin syringe with 10ml of air
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GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer

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4. Tips for implementing a post-operative intravesical chemotherapy protocol


Post epirubicin instillation “G” clamps applied
Spill procedures / Incident reporting:
Spills will definitely occur at some time. It needs to be emphasized that it is
NOT a failure of the procedure nor the fault of any member of staff. These
things do happen. There just needs to be a spill procedure guidelines and
include recording of details (see attached documents) to ensure continued
and improved safety to staff and patients.

Cytotoxic equipment tub in theatre with surgeon in Personal Protective
Equipment (Sterile, disposable, impermeable gown, double gloves, particulate
respiratory mask and protective face shield)
GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer
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4. Tips for implementing a post-operative intravesical chemotherapy protocol


Following instillation surgeon disposes of epirubicin syringe, adaptor and
disposable patient drapes directly into cytotoxic “purple” waste bin
Consent/Patient information
All patients undergoing cystoscopic surveillance for bladder cancer should
be given informed consent of “+/- intravesical chemotherapy”. A simple
but detailed patient handout should be made available postoperatively to
the patients. (e.g Gosford Hospital Patient Information on “Intravesical
Epirubicin (included link).
Flexibility of procedure details
Once the process is up and running, small refinements may be required to
procedure guidelines to improve safety and efficiency. It is important that
a trial period (eg 3 months) further to which amendments to the protocol
can be made. Once again, all parties are consulted to address any of their
individual issues/concerns.

Patient transport from theatres with catheter clamped, cytotoxic nursing alert sign
and hazardous drugs spill kit on bed
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GMCT Guidelines for post-operative intravesical chemotherapy for superficial bladder cancer

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