title: Evaluating the safety of intraoperative instillation of intravesical chemotherapy at the time of nephroureterectomy.
abstract: BACKGROUND
  Urothelial carcinoma (UC) is a common cancer affecting many patients in the United States. Nephroureterectomy remains the gold standard for the treatment of high grade upper tract disease or low grade tumors that are not amenable to endoscopic management. Recent reports have shown a decrease in UC recurrence in patients who underwent nephroureterectomy and who had Mitomycin C (MMC) instilled into the bladder at the time of catheter removal. At our institution instillation of intravesical MMC at the time of nephroureterectomy has been common for more than 10 years. Given the recent data, we sought to formally describe our experience with and evaluate the safety of intravesical instillation of cytotoxic chemotherapy at the time of nephroureterectomy.
  
  
  METHODS
  We retrospectively reviewed 51 patients who underwent intraoperative intravesical instillation of cytotoxic chemotherapy (MMC (n = 48) or adriamycin (n = 3)) at the time of nephroureterectomy (2000-2012). The procedure was performed in a similar fashion by 8 different surgeons from the same institution, with drainage of the bladder prior to management of the bladder cuff. Patient characteristics and perioperative data including complications out to 90 days after surgery were collected. Perioperative complications for all patients were graded using the modified Clavien-Dindo classification.
  
  
  RESULTS
  Twenty-four men and 27 women underwent intraoperative intravesical instillation of cytotoxic chemotherapy at the time of nephroureterectomy. Median age at the time of operation was 74 years (range 48-88). Median dwell time was 60 min. Twenty three patients had a total of 45 perioperative complications. The majority (36/45) were Clavien grades I and II. No patients experienced any intraoperative or postoperative complications attributable to MMC or Adriamycin instillation.
  
  
  CONCLUSIONS
  Intraoperative intravesical instillation of cytotoxic chemotherapy at the time of nephroureterectomy is safe and feasible. Multicenter trials to study the efficacy of early cytotoxic chemotherapy administration to prevent recurrence of bladder urothelial carcinoma following nephroureterectomy are warranted.
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. mmoriarty@mcw.edu.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Moriarty
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. matthew-uhlman@uiowa.edu.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Uhlman
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. megan-bing@uiowa.edu.
authors.forename: Megan T
authors.initials: MT
authors.lastname: Bing
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. michael-odonnell@uiowa.edu.
authors.forename: Michael A
authors.initials: MA
authors.lastname: O'Donnell
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. james-brown-2@uiowa.edu.
authors.forename: James A
authors.initials: JA
authors.lastname: Brown
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. chad-tracy@uiowa.edu.
authors.forename: Chad R
authors.initials: CR
authors.lastname: Tracy
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. sundeep-deorah@uiowa.edu.
authors.forename: Sundeep
authors.initials: S
authors.lastname: Deorah
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. kenneth-nepple@uiowa.edu.
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Nepple
authors.affiliation: Department of Urology, University of Iowa, 200 Hawkins Drive, 3RCP, Iowa City, IA, 52242, USA. amit-gupta-1@uiowa.edu.
authors.forename: Amit
authors.initials: A
authors.lastname: Gupta
mesh_terms: D000283:Administration, Intravesical; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D004317:Doxorubicin / Q000008:administration & dosage*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D061214:Patient Safety; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*
chemical_list: D000970:Antineoplastic Agents; D004317:Doxorubicin