Safety and feasibility of early single‐dose mitomycin C bladder instillation after robot‐assisted radical nephroureterectomy

Abstract

Objectives To assess the safety and feasibility of early single‐dose mitomycin C (MMC) bladder instillation after robot‐assisted radical nephroureterectomy (RARNU) at a tertiary kidney cancer centre. RARNU with bladder cuff excision and subsequent MMC bladder instillation to reduce recurrence risk is the ‘gold standard’ for high‐risk upper urinary tract urothelial carcinoma (UUTUC). We adapted a RARNU technique with precise distal ureteric dissection, bladder cuff excision and watertight bladder closure. Patients and Methods We retrospectively reviewed all patients undergoing RARNU for UUTUC at our centre performed as a standardised transperitoneal procedure comprising of: bladder cuff excision, two‐layer watertight closure and intraoperative bladder leak test; without re‐docking/re‐positioning of the robotic surgical system. Patient demographics, the timing of MMC instillation, adverse events (surgical and potentially MMC‐related) and length of stay (LOS) were assessed according to the Clavien–Dindo classification. Results A total of 69 patients underwent a RARNU with instillation of MMC. The median (interquartile range [IQR]) age was 70 (62–78) years. The median (IQR) day of MMC instillation was 2 (1–3) days and the median (IQR) LOS was 2 (2–4) days, with urethral catheter removal on day of discharge in all cases. Only Grade I Clavien–Dindo complications occurred in seven patients (10%); five had ileus, one a wound infection and one a self‐limiting delirium, all managed conservatively. No adverse events potentially related to MMC instillation were noted within 30 days postoperatively. Conclusion The use of intravesical MMC instillation given in the immediate postoperative period appears feasible and safe in patients undergoing RARNU with intraoperative confirmation of a water‐tight closure ensuring early catheter‐free discharge, with no significant adverse events. The potential reduction in intravesical recurrence in patients receiving early MMC needs to be assessed with longitudinal follow‐up studies.

Risk Factors for Intravesical Recurrence after Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Cancer (ROBUUST Collaboration)

“…29 Gulamhusein et al recently found that intravesical mitomycin C can safely be given after robotic RNU in the postoperative period. 30 It is our hypothesis that a lack of standardization (ie nonhomogenous use, different regimens, selection bias etc) among intravesical chemotherapy may have accounted for the lack of significance as a protective factor against IVR. The authors of this study endorse the use of intravesical chemotherapy, either intraoperatively or postoperatively, to reduce IVR.…”

Ten‐year survival outcomes after radical nephroureterectomy with a risk‐stratified approach using prior diagnostic ureteroscopy: a single‐institution observational retrospective cohort study

“…It is therefore plausible that patients who undergo URS require earlier administration of MMC to achieve a clinically significant decrease in intravesical recurrence in the long term. Gulamhusein et al [13]recently reported the feasibility and safety of early MMC administration (median 2 days) in patients who undergo robot-assisted nephroureterectomy. Future studies evaluating the impact of early administration of MMC on intravesical recurrence, particularly in patients who undergo URS, will be of interest.…”

“…Gulamhusein et al. [13]recently reported the feasibility and safety of early MMC administration (median 2 days) in patients who undergo robot‐assisted nephroureterectomy. Future studies evaluating the impact of early administration of MMC on intravesical recurrence, particularly in patients who undergo URS, will be of interest.…”

Assessment of Therapeutic Benefit and Option Strategy on Intravesical Instillation for Preventing Bladder Cancer Recurrence after Radical Nephroureterectomy in Patients with Upper Urinary Tract Urothelial Carcinoma

“…A comprehensive literature search showed that single-dose intravesical chemotherapy may lower the risk of bladder cancer recurrence compared to no instillation; however, the effect of single-dose instillation on minor or serious adverse events was uncertain [ 49 ]. In the study of early single-dose mitomycin C intravesical instillation after robot-assisted radical nephroureterectomy, patients did not show adverse reactions potentially associated with mitomycin C instillation within 30 days [ 50 ]. Conversely, multiple mitomycin C instillation for high-risk nonmuscle-invasive bladder cancer may lead to adverse events, such as urinary frequency, incontinence, and urinary tract pain [ 51 ].…”