Destruction of the bladder by single dose Mitomycin C for low-stage transitional cell carcinoma (TCC) – avoidance, recognition, management and consent (Lynch syndrome patients note)

Blogger's Note: of interest to Lynch Syndrome patients with upper tract urothelial carcinoma (UTUC) and prophylaxis MMC to reduce the risk of bladder cancer after radical nephroureterectomy; note this study included bladder cancer patients

abstract

 Keywords:

• bladder perforation;
• intravesical mitomycin;
• consent;
• extravasation

Objectives

• To identify a cohort of patients under our care who have had significant and in some cases irreparable damage to their bladders after Mitomycin C (MMC) instillation.
• To highlight the importance of avoidance and recognition of bladder perforations during transurethral resection of bladder tumour (TURBT) and explore the issue of consent regarding MMC given the serious complications that may occur after its instillation.

Patients and Methods

• Patients referred to our tertiary centre for a second opinion to manage their complications after a suspected MMC leak was identified from the departmental database between January 2000 and December 2010.
• After collection of all the records, we established a cohort of six patients.
• All patients had their initial tumour resection elsewhere and were referred for specialist management thereafter. Details of the operating surgeon and cystoscopic findings were known only in half of the cases.
• Retrospective analysis of their notes including documentation from the referring centre was undertaken. This included a review of all the histology and imaging.

Results

• All patients had immediate severe pelvic pain on instillation of the MMC. Four of the six continue to have chronic pelvic pain.
• Two patients had urinary retention and three had severe lower urinary tract symptoms. One patient developed a frozen pelvis.
• Initial treatment was with an indwelling catheter for a period of 2–52 weeks to aid healing.
• Two patients had reconstructive surgery, one with success and the other with failure, as an intestinal patch failed to close the fistula and he continues with a catheter. One patient had an ileal conduit.
• No patient was warned of such complications.

Conclusions

• Although rare, prophylactic MMC can have devastating consequences.
• Patients should be aware of such major risks.
• Strong emphasis should be placed on the quality of the initial TURBT coupled with the judgement of an experienced surgeon before to MMC instillation. The real clinical benefit could be reviewed and intravesical MMC offered only to patients who have a good chance of benefit.