The administration of immediate instillation of intravesical chemotherapy (IVCT) following transurethral resection of bladder tumour (TURBT) has been shown to decrease the risk of recurrence and is recommended as standard practice following TURBT for new & recurrent tumours. Giving IVCT in this way ensures that the chemotherapy is given in a timely manner and in a safe environment with adequate protection for patients and staff.
The recommendation to give IVCT at the time of TURBT aligns with the NICE bladder cancer guidelines (recommendation 1.2.3).
Aims and objectives
The aim was to ensure that patients received IVCT in a timely manner in a safe environment for both patient and staff.
Reasons for implementing your project
Before we introduced IVCT in a theatre setting, immediately after TURBT, patients had to have IVCT given by a nurse on the ward after their return from surgery. The practice of providing intravesical chemotherapy later, when the patient returns to the ward, is fraught with problems of either obtaining the medication from pharmacy in time, the need for specialized nursing, or complying with safety measures associated with biohazardous chemical agents on the ward. This often leads to an unsatisfactory delay, with the instillation being given much later in the day or the next day after TURBT. In many cases the logistics of organising this meant that patients often did not get their IVCT or if they did it was given too late to be of benefit.
In addition the giving of IVCT on an open ward constituted a safety issue both for the staff giving it (in terms of training and wearing the right safety gear) as well as for other patients on the ward (in terms of the risk of spillage and the need for the patients to use a common toilet to empty their bladder of the IVCT afterwards).
How did you implement the project
A protocol was developed at the Trust to allow the safe administration of mitomycin C in theatre immediately after TURBT. The protocol was developed by the Consultant Urologist in collaboration with our theatre sister who was able to advise on the practicalities of what was then a new technique for theatres. We wrote an SOP, presented this to the theatre users committee which 'signed off' the process and then trained all the staff in our urology theatre to reconstitute and prepare the mitomycin as required in the protocol. Immediate instillation of mitomycin C in theatre after TURBT overcomes all the problems. The mitomycin C is stored in theatre and does not have to be ordered from the pharmacy. The agent is instilled after TURBT and therefore entails no additional specialized nursing time and biohazard precautions on the ward to administer it. Both the surgeon administering the mitomycin C and the scrub nurse preparing it are already wearing protective clothing in case of accidental spillage. The equipment is simple to use and requires no formal training. Finally, after TURBT the patient is under close nursing supervision in the recovery area, and any problems following intravesical instillation can be promptly managed. In total, 210 patients had TURBT over a 32-month period, of whom 177 received mitomycin C in theatre using the Mito-In delivery system. The changes were achieved with the support of our theatre sister and her team. Please refer to the supporting material in order to view the protocol.
In all, 177 mitomycin C instillations were administered in theatre immediately after TURBT. Adverse events occurred in two (1%) of these cases. In one patient the catheter balloon spontaneously deflated in the recovery ward, causing the catheter to fall out. This resulted in a minor leakage of mitomycin C onto the patient's skin that was washed with water and 8.4% sodium bicarbonate solution. The second patient complained of suprapubic pain after surgery, which was assumed to be due to extravasation of mitomycin C. This settled after immediate drainage of the mitomycin C from the bladder.
In conclusion, from 177 immediate instillations of mitomycin C in theatre after TURBT, there were only two adverse events. To our knowledge this has not been reported before. The immediate instillation of mitomycin C after TURBT is a feasible and safe method of administering intravesical chemotherapy, and may provide the earliest and most effective prophylaxis against tumour cell re-implantation at TURBT. The technique has additional practical and financial benefits by eliminating the need for ward-based chemotherapy instillation and bladder irrigation.
We have administered IVCT by this method now for 12 years. It has been widely but not universally adopted by many trusts throughout the UK. The method has been written up and most recently was reviewed and adopted by the NICE bladder cancer guidelines development group.
Key learning points
Engagement with your theatre team and pharmacy is required, in order to co-ordinate the delivery of the IVCT to theatre for administration at the time of surgery. Trust's have different procedures surrounding the availability of IVCT. If everyone (hospital pharmacy and theatre staff) are supportive, like they were at our Trust, the drug is always readily available in a locked cupboard in theatres, ready to be made up and used as appropriate.