4 safety precautions should be similar to mitomycin C. It is not quite as toxic and is more likely to target the lungs. As with mitomycin C it should be washed off the skin or the eyes immediately. Pregnant staff should not handle the drug. Gemcitabine is currently becoming the most commonly used chemotherapeutic drug in intravesical therapy because of a shortage of mitomycin C. The difculty in accessing mitomycin C started in 2019 and was attributed to manufacturing problems. Gemcitabine is an antimetabolite that targets components of the cell division process. In 2011 Cao et al reported that gemcitabine's adverse event rate was similar to Mitomycin C. In 2020 Li et al published work comparing gemcitabine to mitomycin C. The researchers looked at chemical cystitis; haematuria; rash and hepatorenal toxicity. There was a clear advantage in terms of side effects visually demonstrated on forest plots in favour of gemcitabine. A meta-analysis by Zigi Ye et al published in 2018 looked at the adverse rates of gemcitabine versus BCG and they concluded that there was a signicant difference in favour of gemcitabine for the categories of dysuria, fever, haematuria, and miscellaneous adverse events. However, a study published in 2021 by J. Kuperus showed that gemcitabine had a greater incidence of fatigue and chills compared with BCG, although duration of symptoms was longer with BCG and haematuria was a lot worse. Very rarely gemcitabine, as with mitomycin C can cause a reduction in bladder volume. A study published in 2014 looked at the safety and efcacy of valrubicin. A drug that had been reintroduced to the medical world after having been withdrawn at the beginning of the century because of concerns over manufacturing procedures. Valrubicin is a anthracycline antibiotic. Simplistically this group of antibiotics damages DNA in cancer cells. In handling the drug, the usual rules will apply concerning protective clothing when drawing up this red coloured solution. It should not be used with PVC products because a component of the drug leaches PVC. Instead, administration sets using polypropylene or polyolen should be used. The commonest side effects were the usual suspects of haematuria and pollakiuria. Four percent dropped off the study because of serious adverse events. A rash on the palms and genitalia from voiding urine containing the drug is common. It is important to wash one's hands and genitalia carefully for the rst forty-eight hours after the drug administration. Valrubicin can also cause a generalised rash, but treatment can be continued on topical steroids. A noteworthy side effect is red urine, not to be confused with haematuria. It can be ignored unless it continues for more than a day. Other side effects include nausea, vomiting, abdominal pain, diarrhoea, backache, and headache. Overall, more than 90% of patients will have some form of symptoms during the six-week induction phase. The largest study to date, reported 60% of patients having irritable bladder symptoms. The rate for urinary tract infections is 15%. Pirarubicin and epirubicin are other red anthracycline drugs with very similar side effects to valrubicin. Similar precautions and safety aspects apply to these drugs. Docetaxel has been used successfully in sequential combination with gemcitabine for nearly fteen years. Until recently, both drugs have been administered in the room temperature setting. However, in 2020 a paper appeared by Rao et al who had reported on their experience of thermal gemcitabine and docetaxel that began in 2007. They had sixty patients in the study, all who had refused radical cystectomy. Thirty-one patients had some local symptoms, and all patients completed their treatment course. The commonest symptoms reported were mild fatigue (20%), haematuria (20%), mild urinary frequency/urgency (13%), dysuria (10%), and nocturia (7%). Gemcitabine is given before docetaxel because gemcitabine induces cell cycle arrest and docetaxel provides the coup de gras by promoting cell death. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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