Continuous saline bladder irrigation for two hours following transurethral resection of bladder tumors in patients with non-muscle invasive bladder cancer does not prevent recurrence or progression compared with intravesical Mitomycin-C

Abstract

BackgroundIntravesical Mitomycin-C (MMC) following transurethral resection of bladder tumor (TURBT), while efficacious, is associated with side effects and poor utilization. Continuous saline bladder irrigation (CSBI) has been examined as an alternative. In this study we sought to compare the rates of recurrence and/or progression in patients with NMIBC who were treated with either MMC or CSBI after TURBT.MethodsWe retrospectively reviewed records of patients with NMIBC at our institution in 2012–2015. Perioperative use of MMC (40 mg in 20 mL), CSBI (two hours), or neither were recorded. Primary outcome was time to recurrence or progression. Descriptive statistics, chi-squared analysis, Kaplan-Meier survival analysis, and Cox multivariable regression analyses were performed.Results205 patients met inclusion criteria. Forty-five (22.0%) patients received CSBI, 71 (34.6%) received MMC, and 89 (43.4%) received no perioperative therapy. On survival analysis, MMC was associated with improved DFS compared with CSBI (p = 0.001) and no treatment (p = 0.0009). On multivariable analysis, high risk disease was associated with increased risk of recurrence or progression (HR 2.77, 95% CI: 1.28–6.01), whereas adjuvant therapy (HR 0.35, 95% CI: 0.20–0.59) and MMC (HR 0.43, 95% CI: 0.25–0.75) were associated with decreased risk.ConclusionsPostoperative MMC was associated with improved DFS compared with CSBI and no treatment. The DFS benefit seen with CSBI in other studies may be limited to patients receiving prolonged irrigation. New intravesical agents being evaluated may consider saline as a control given our data demonstrating that short-term CSBI is not superior to TURBT alone.

Continuous bladder irrigation after transurethral resection of non‐muscle invasive bladder cancer for prevention of tumour recurrence: a systematic review

“…Retrospective studies utilizing a similar duration of CBI have also demonstrated similar findings 25,26 . Conversely, at least two retrospective studies of CBI over 2–3 h have shown no reduction in recurrence compared to no CBI 27,28 and a significantly shorter recurrence‐free survival compared to IC 27 …”

Comparison of Efficacy and Safety Between Postoperative Intravesical Instillation of Mitomycin-C and Continuous Saline Bladder Irrigation after TURBT in Non-muscle Invasive Bladder Cancers

“…15 In a study by Lenis et al, 205 patients were included in the study who met all the inclusion criteria and underwent TURBT for NMIBC. 16 About 82% of the patients were males with the mean age 71.9 (SD 11.4) with low-grade bladder cancer in 105(51.2%0) and high-grade bladder cancer in 100 (48.2%). Tumour sizes varied in different patients with <0.5 cm in 20 (9.8%), 0.…”

Lytic effects of water on cancer cells: Implications for post‐operative irrigation

“…Thus far, some clinical studies have attempted to assess the effects of irrigation as a method of reducing cancer recurrence in the context of urothelial cancer, gastric cancer and rectal cancer. [3][4][5][6][7][8][9][10][11][12][13][14] Bladder cancers were managed with continuous saline bladder irrigation (CSBI) via a catheter, gastric cancers underwent extensive intraoperative peritoneal lavages (EIPL), and rectal cancers were irrigated using an enema syringe. Studies either compared saline irrigation to no irrigation at all, or had saline irrigation serve as a control against chemotherapy.…”

“…13 Irrigation may provide additional benefit when appended to cytotoxic therapy, 5,6,9,15 but lengthier irrigation can add to surgical time or require overnight admission, negating the cost-benefit. 4,6 Alternatively, water can be used instead of saline for irrigation since, being hypo-osmolar, it is hypothesised that water would additionally cause osmotic cytolysis. 16 As yet, only four studies have observed the effects of saline exposure directly against water in the same trial, of which only one study was conducted in vivo.…”

“…Overall, results from these studies demonstrated that saline irrigation may provide some protection against recurrence, but only when used for extended periods of 18 or 24 h 3,4,9 where CSBI can be implemented, or with multiple serial dilutions in the context of peritoneal lavages. 13 Irrigation may provide additional benefit when appended to cytotoxic therapy, 5,6,9,15 but lengthier irrigation can add to surgical time or require overnight admission, negating the cost-benefit. 4,6 Alternatively, water can be used instead of saline for irrigation since, being hypo-osmolar, it is hypothesised that water would additionally cause osmotic cytolysis.…”