Intravesical Mitomycin Therapy
Intravesical = in the urinary bladder
Mitomycin-C (mitomycin) = agent instilled into the bladder to kill bladder cancer
Mitomycin is an antibiotic that also kills tumor (cancer) cells. In order to treat a patient, the mitomycin is instilled directly into the bladder through a catheter. There are many theories as to why mitomycin is effective against bladder cancer. Although the mechanism is not completely understood, it is known that mitomycin activates the production of oxygen-free radicals. These are molecules that interfere with the production of DNA; the genetic material making up all cells. Because cancer cells develop at a much more rapid rate than do normal cells, the drug is more toxic to the cancer than to normal cells.
Mitomycin may be used for three different reasons in the bladder. While the intended outcome is not guaranteed, a huge body of literature supports its use in an attempt to:
- kill remaining tumor cells that may still exist after the primary tumor has been surgically removed
- prevent new tumors after all known tumor cells have been eradicated
- decrease the incidence of progression (advancement to a higher stage of cancer)
There is no particular preparation for mitomycin therapy. If you are currently sick (i.e. a severe cold or flu) or have gross hematuria (blood in the urine that you can actually see), you must tell your urologist as mitomycin might not be administered under those conditions until you are evaluated. It will also not be given if a bladder infection is present.
To review the basics of what we discussed in the office: The actual procedure typically takes just a few minutes. The initial treatment of mitomycin is once a week for eight consecutive weeks. Maintenance treatments for prevention of future tumor recurrences vary and you will be given a very specific schedule if you are going to be enrolled in a maintenance program.
You will lie down on your back on a table. Under sterile conditions, a small soft catheter will be gently advanced into your urethra and into your bladder. All of the urine in your bladder will be emptied. Once your bladder is empty, the mitomycin medicine will be slowly poured into the catheter through a large syringe or funnel attached to the catheter. The medicine is allowed to slowly run into the catheter until it is all administered. The amount is small and is usually far less than the volume capacity of your bladder. The catheter is then removed. You are then ready to go home.
It is important for you to hold the medicine in your bladder for two hours so that the medicine can remain in contact with the inner lining of the bladder for that amount of time.
If you typically have a problem holding urine for that long, you may want to limit fluid consumption for a few hours prior to the treatment. Certainly, caffeine beverages (coffee, sodas, tea, etc.) should be avoided that day prior to your appointment. These drinks will make you have to urinate more frequently.
You might have a little stinging in the urethra the first time you urinate. This is usually due to the catheterization and is not a cause for concern. Each week, the stinging may last a bit longer than the prior week. This is due to cystitis (inflammation of the bladder wall) and/or urethritis (inflammation of the urethra). Although the sensation can last for two or three urinations after several weeks of treatment, it is rare for it to persist beyond the day of the treatment. In 25% of patients, there may be a little blood in the urine with the first few urinations after each treatment. It will typically resolve in one to two days. If the urine is not clear to the eye by the next week, the following treatment might be delayed for a few days more.
Expectations of Outcome
The urologic literature contains many articles discussing the optimum use of mitomycin in bladder cancer. While we administer the medicine for an eight week course initially, there are articles supporting extended regimens or repeat regimens at various intervals. Overall, the data support its use in certain grades (aggressiveness of the cell type) and stages (degree of depth of invasion into the bladder wall) of TCC. Mitomycin has been shown to effectively eradicate residual tumor (small areas of cancer left behind after the "scraping" procedure), delay or prevent new tumors from growing, and in many studies, delay progression (advancement of the tumor to a higher stage). In that regard, its benefits typically outweigh its potential side effects. After your initial eight week course, your urologist will discuss the pros and cons of maintenance therapy or repeat courses.
Possible Complications of the Procedure
ALL procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
Urinary Tract Infection or Urosepsis (Bloodstream Infection): Even from a minor and sterile procedure, it is possible for you to get an infection with bacteria that typically cause urinary tract infections (UTIs). It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.
If you have high temperatures or any symptoms of severe illness (fevers, shaking chills, weakness or dizziness, nausea and vomiting, confusion) let your doctor know immediately and proceed to the nearest emergency room.
- Blood or Blood Clots in the Urine: As previously mentioned, mitomycin can cause cystitis (inflammation in the bladder). Severe inflammatory changes in the bladder can result in hematuria (blood in the urine). In almost all instances, the urine clears on its own over the next day or so. If severe, the blood can form clots and block the flow of urine. This is more common in men who may already have partially obstructing prostates. the treatment may be placement of a catheter to drain the urine from the bladder and/or irrigating the clots out of the bladder.
- Urinary Retention: Even in the absence of bleeding in men, the prostate can become inflamed secondary to delayed infection. As a result, the flow or urine can be blocked. In this instance, a catheter is placed and your doctor would discuss the next step. Patients at greater risk are those who already have difficulty urinating before the procedure due to BPH (benign prostatic hyperplasia).
- Urethral Strictures: Strictures are narrow, scarred tissue areas. Although uncommon, any patient who is catheterized often can develop scar tissue months or years later. Strictures are typically treated with minor, minimally invasive procedures.
- Palmar, Genital and/or Facial Skin Rashes: Mitomycin can sometimes cause skin irritations or rashes on the hands, genital area, and even on the face where direct contact with the drug does not occur. One should be cautious with the first urination soas to minimize splashing. Afterward, it is important to carefully wash your hands.
- Myelosuppression: In very rare instances, mitomycin can affect the bone marrow's ability to produce certain types of cells. Once recognized, the treatment would be discontinued. Typically the problem is reversible as new bone marrow cells develop.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.