Bladder cancer is a common malignancy of the urinary tract. Patients with non-muscle invasive bladder cancer usually require bladder irrigation therapy after undergoing transurethral resection of the bladder tumor. Some common questions about bladder irrigation therapy are answered here in the hope of helping patients.

1.Does every patient with electrosurgery for bladder cancer need perfusion therapy?

The treatment of choice for non-muscle invasive bladder cancer is transurethral resection of bladder tumors (TUR-BT), but bladder tumors still recur in approximately 40-50% of patients after complete resection of the tumor, but the recurrence is usually not at the site of the original tumor, which is determined by the multicentric growth characteristics of uroepithelial tumors.Postoperative bladder perfusion therapy (chemotherapeutic agents or BCG) reduces the risk of recurrence, so the vast majority of non-muscle invasive bladder cancers require perfusion therapy after electrosurgery.

2.How is infusion chemotherapy given and are there any side effects?

Intravesical irrigation therapy is performed on an outpatient basis and is very simple. A urinary catheter is inserted and the medication is injected along the catheter into the bladder, then the catheter is removed and the patient urinates and drains the instilled medication on their own after an agreed time (usually half an hour – 1 hour).Because chemotherapy drugs act only on the bladder lining and are rarely absorbed systemically, serious systemic chemotherapy side effects such as bone marrow suppression, malignant vomiting, and hair loss are rare, except for urinary tract infections, which are more common and cause discomfort such as urinary frequency and pain.

3.If I have invasive bladder cancer, should I still have perfusion?

Bladder perfusion therapy works only for non-muscle invasive bladder cancer, i.e. superficial bladder cancer, reducing its recurrence and progression, but not for muscle invasive bladder cancer.The standard of care for muscle-invasive bladder cancer is radical total cystectomy, although in special cases bladder-preserving therapy is an option, which must be combined with intravenous systemic chemotherapy rather than bladder infusion chemotherapy.

4.What are perfusion medications and how do I select them?

There are two types of drugs for infusion, one is chemotherapy and the other is immunotherapy, also known as BCG. The most commonly used chemotherapy drugs are epirubicin, piribicin, mitomycin, etc. And the overall efficacy of these drugs is basically the same, so there is not much difference in drug selection at the beginning.However, if a relapse occurs during treatment, a switch to another drug is usually considered, since the overall efficacy of each drug is basically the same, but the specific efficacy may still differ for each patient.The side effects of BCG vaccine are stronger than normal chemotherapy drugs, and there will be strong urinary frequency and urgency and even TB spread. For low and intermediate risk patients, BCG vaccine has similar effect to normal chemotherapy drugs, but for high risk patients, BCG vaccine is more effective than chemotherapy drugs. Therefore, chemotherapy drugs are preferred for low and medium risk patients, and BCG vaccine is preferred for high risk patients.The specific risk stratification (low risk, intermediate risk, high risk) must be determined by the physician based on the number, size, recurrence, and pathology of the tumors.

5.When is the perfusion treatment performed and how long is the treatment?

The first instillation of chemotherapy after surgery is best done within 24 hours of electrosurgery, called immediate instillation. This perfusion has the strongest effect on reducing bladder tumor recurrence. However, since the pathology of some patients is not very clear at the time of surgery, perfusion is not necessary if the tumor is considered benign, while if the tumor is very deep or extensively resected, perfusion is not possible due to concerns about wound healing and chemotherapy drug absorption.

For low-risk patients, immediate postoperative perfusion is sufficient and maintenance perfusion may not be required. In contrast, for most intermediate-risk patients, immediate perfusion during hospitalization is followed by one year of outpatient maintenance perfusion chemotherapy.The specific arrangement is to come to the outpatient clinic for bladder irrigation 1-2 weeks after discharge, once a week for 8 consecutive times, and then once a month for 10 consecutive times for a total of one year.BCG infusion is recommended for high-risk patients, usually starting two weeks after surgery and continuing for one year. The first phase is once a week for six consecutive weeks, which is the induction period, followed by the maintenance phase, which is a round of treatment every three months, with treatment being infused once a week for three consecutive weeks and repeating such a round every three months.

6.Does infusion therapy cause hematuria and painful urination? Does it cause inflammation?

Bladder irrigation therapy requires the insertion of a urinary catheter and sometimes results in hematuria and dysuria, which usually resolve quickly on their own. The principle of bladder irrigation therapy is to induce an inflammatory immune response in the bladder and direct killing by chemotherapeutic agents, and most patients experience one or more acute cystitis episodes during the irrigation process. Therefore, antibiotics must be used in conjunction with irrigation therapy and urinalysis must be performed prior to each irrigation to rule out infection.

7.Will the cancer come back during perfusion and how should I be monitored?

Active and rigorous monitoring is still required during perfusion therapy because bladder perfusion therapy only reduces bladder tumor recurrence by about one third and does not prevent the occurrence of pelvic ureteral tumors. Therefore, strict postoperative control is very necessary. The specific points and the time of postoperative check-up must be arranged individually according to the patient’s specific condition.

8.What if perfusion therapy is delayed or not tolerated?

In fact, most patients experience one or more delayed instillations during instillation therapy for various reasons (e.g., urinary tract infection), which actually does not have much impact on the final outcome, and many patients even abandon bladder instillation therapy altogether due to recurrent urinary tract infections and other reasons.

Since bladder perfusion therapy can only reduce bladder tumor recurrence by about one-third, I think regular and rigorous surveillance and early detection and treatment of tumor recurrence may be more useful than bladder perfusion.

9.What other precautions should I take during perfusion therapy?

The bladder should be emptied prior to bladder irrigation and it should be confirmed that large amounts of water or diuretics have not been consumed within the last 2 hours. Since drug concentration and duration of action are very important for efficacy, it is necessary to avoid diluting the drug with urine or not holding it long enough.Keep your body relaxed during instillation so that the muscles around the urethra are relaxed to facilitate smooth entry of the catheter into the bladder. Patients with conditions such as urethral strictures can inform the outpatient physician in advance so that the appropriate size catheter can be changed.Avoid tea, coffee, alcohol, and cola to reduce bladder irritation.

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