Bladder cancer is a very common malignant tumor of the urinary tract. Patients with non-muscle invasive bladder cancer usually need bladder irrigation therapy after undergoing transurethral resection of bladder tumor. Now, some common questions about bladder perfusion therapy are answered one by one, hoping to help patients and friends.
1.Does every bladder cancer patient need irrigation therapy?
The preferred treatment for non-muscle invasive bladder cancer is transurethral resection of bladder tumor (TUR-BT), but about 40%-50% of patients will still have bladder tumor recurrence after complete resection of the tumor, but the recurrence is usually not at the site of the original tumor, which is due to the multicentric growth characteristics of uroepithelial tumors. Postoperative bladder perfusion therapy (chemotherapeutic drugs or BCG) can reduce the risk of recurrence, therefore most non-muscle invasive bladder cancers require perfusion therapy after electrodesiccation surgery.
2.How is perfusion chemotherapy performed and are there any side effects?
Intravesical irrigation therapy is performed on an outpatient basis and is very easy. A urethral tube is inserted and the drug is injected into the bladder along the urethral tube, after which the urethral tube is removed and the patient urinates and excretes the infused drug after an agreed time (usually half an hour-1 hour). Since the chemotherapy drug only acts on the bladder mucosa and is rarely absorbed systemically, serious systemic chemotherapy side effects such as bone marrow suppression, malignant vomiting and hair loss rarely occur.
3.Do I need to do perfusion for invasive bladder cancer?
Bladder irrigation therapy only works for non-muscle invasive bladder cancer, i.e. superficial bladder cancer, and can reduce its recurrence and progression. It has no effect on muscle-invasive bladder cancer. The standard treatment for muscle-invasive bladder cancer is radical total cystectomy, and even if bladder preservation therapy is chosen in special cases, it needs to be combined with intravenous systemic chemotherapy, not bladder infusion chemotherapy.
4.What are the perfusion drugs and how to choose them?
There are two types of perfusion drugs, one is chemotherapy and the other is immunotherapy, also known as BCG. Chemotherapy drugs are most commonly used, such as epirubicin, piribicin, mitomycin, etc. The overall efficiency 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 the course of treatment, it is common to consider switching to another drug to try, because the overall efficiency of each drug is basically the same, but the specific efficacy may still be different for each patient. The side effects of BCG are stronger than ordinary chemotherapy drugs, and there will be strong urinary frequency and urgency and even tuberculosis dissemination. For low and intermediate risk patients BCG is similar to the effect of ordinary chemotherapy drugs, but for high risk patients, the efficacy of BCG is better than chemotherapy drugs. Therefore, chemotherapeutic agents are preferred for low- and intermediate-risk patients, and BCG is preferred for high-risk patients. The specific risk stratification (low risk, intermediate risk, high risk) needs to be determined by the doctor according to the number, size, recurrence and pathology of the tumor.
5.When should the perfusion therapy be carried out and how long is the course of treatment?
The first postoperative perfusion chemotherapy should preferably be done within 24 hours after the electrosurgery, which is called immediate perfusion. This perfusion has the strongest effect on reducing bladder tumor recurrence. However, since the pathology is not particularly clear in some patients at the time of surgery, irrigation is not necessary if the tumor is considered benign, while if the tumor is very deep or extensively resected, irrigation is also not indicated due to concerns about wound healing and chemotherapy drug absorption.
For low-risk patients, one perfusion in the immediate postoperative period is sufficient and maintenance perfusion may not be needed. For most intermediate-risk patients, immediate perfusion during hospitalization is followed by one year of maintenance perfusion chemotherapy in the outpatient setting. The specific schedule is to come to the outpatient clinic 1-2 weeks after discharge for bladder irrigation once a week for 8 consecutive sessions, and once a month thereafter for 10 consecutive sessions, for a total of one year. If you come to Peking University Hospital for irrigation, you need to register for the urological bladder irrigation number (unlimited number) every Thursday morning, have on-site lab tests, prescribe medication and complete the irrigation, and go home at noon after the irrigation is completed. If you go back to the local perfusion, it is a simple operation as long as you go to a major hospital without any problems. For high-risk patients, BCG infusion is recommended and usually starts two weeks after surgery and also lasts for one year. The first phase is once a week for six consecutive weeks, which is the induction period; after that, the maintenance period is followed by a round of treatment every three months, and the treatment is perfusion once a week for three consecutive weeks, and such a round of treatment is repeated every three months.
6.Does perfusion treatment cause hematuria and painful urination? Does it always cause inflammation?
Bladder irrigation treatment requires the insertion of a urinary catheter, and sometimes hematuria and painful urination may occur, which usually resolves quickly on its own. The principle of bladder irrigation therapy is to induce an inflammatory immune response in the bladder and direct killing by chemotherapy drugs, and most patients experience one or more acute cystitis during the irrigation process. Therefore, it is necessary to use antibiotics in combination with perfusion therapy, and it is also necessary to check urinary routine before each perfusion to exclude infection.
7.Will the cancer come back during the perfusion period and how to check?
Active and strict review is still needed during perfusion treatment, because bladder perfusion treatment can only reduce the recurrence of bladder tumor by about one-third and cannot prevent the emergence of pelvic ureteral tumor. Therefore, strict postoperative review is very necessary. The specific items and time of postoperative review need to be arranged individually according to the patient’s specific condition.
8.What if perfusion therapy is delayed once or not tolerated?
In fact, most patients will experience one or more delays in perfusion treatment for various reasons (e.g. urinary tract infection), which in fact does not have a significant impact on the final therapeutic effect, and many patients even give up bladder perfusion treatment completely due to repeated urinary tract infections.
Because bladder perfusion treatment can only reduce about one-third of bladder tumor recurrence, I think regular and strict review and early detection and treatment if tumor recurrence occurs may be more significant than bladder perfusion.
9.What other precautions should be taken during perfusion therapy?
Before bladder irrigation, you should empty the urine and make sure that you have not drunk a lot of water or taken diuretics in the last 2 hours. Because 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 be explained to the outpatient physician in advance so that the appropriate size catheter can be changed. Drinking more water after urination is encouraged to expel residual medication and prevent urinary tract infection. Avoid tea, coffee, alcohol and colas to reduce bladder irritation.