2 UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE The Safety of Hyperthermic Intravesical Chemotherapy Part 3 Dr S Cornish Urologist “Is it safe?” This was the question that Laurence Olivier asked of Dustin Hoffman in the great movie Marathon Man. Unfortunately for Dustin he could not answer the question and Laurence took great delight in drilling holes in his healthy teeth with the panache born of years spent as a Gestapo dentist. I hope in this article that I will convince the reader that Hyperthermic chemotherapy of the bladder is not only safe but is better tolerated than the gold standard of BCG therapy. This is a dry subject at best, but I hope to make the subject less painful to digest than a freshly drilled dental nerve. I have added some pearls to this article which I hope the reader will nd of some use when treating patients with hyperthermic bladder therapy. In this article I am going to look at the safety of hyperthermic therapy and review the various papers on this subject that have been published in the last twenty years. I will rst deal with the drugs that have been used for intravesical therapy other than BCG in the room temperature setting. Just about every urologist is familiar with BCG immunotherapy, but for many entering the arena of chemotherapy is a new experience and challenge. Different protocols need to be understood when working with these drugs. For a long time mitomycin C was the only drug used for thermal intravesical therapy. The drug had a long track record of use in the cold setting (room temperature) when BCG had failed, or it was not available, or when adverse reactions accompanied its use. Urologists have had a relatively long experience of using this drug in either the post cystoscopy setting for prophylaxis or using it to treat non-muscle invasive disease. Its use was rst described in the 1970's. I am not sure if everyone is aware of how toxic this substance can be. In terms of handling, the drug is not very nice. It is classied as a hazardous substance because it is a mutagen. It can affect the kidney of handlers of the drug. It is important to wear protective clothes and gloves when handling the drug. A pregnant person should not handle the drug. Getting it on your skin or in your eyes requires immediate washing of the affected surface. The crystals when mixed, give off fumes which can be inhaled. Therefore, one should make sure to mix the drug in its ampoule and not spill any of the uid. Patients should be instructed to void urine sitting down, for six hours after treatment so as not to splash, and the toilet bowel should be ushed twice with the lid down. Oddly enough according to OSHA, an organisation that quanties drug hazards, drinking mitomycin C is not too dangerous and there has been a study looking at its absorption across the GIT in 1976. Patients may experience no symptoms from the use of mitomycin C in their bladders. The urine may turn blue green for up to forty-eight hours; dysuria can occur as well as abdominal cramps and diarrhoea. Mitomycin C can produce a skin rash on the palms of the hands, soles of the feet, and genitals. If this side effect occurs, the mitomycin C management should be abandoned. Sometimes steroids are needed to resolve the rash. A very rare side effect is reduction in bladder capacity. Some people may develop a urinary infection after mitomycin C therapy and this needs to be managed appropriately. Rarely the drug can cause a pancytopaenia. The overall incidence of adverse events has been reported at between 22 and 25% with dysuria making up 5.5%, or about a quarter of the total cases. Gemcitabine has been used in an intravesical setting from around 2010. When handling the drug, His urological interests lie in cancer therapies and diagnosis, urinary incontinence, prostate enlargement therapy and fertility management.
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