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    Immediate post-TURBT mitomycin instillation reduces recurrence risk

    Benefit observed even in patients receiving adjuvant instillations, data indicate

     

    Significantly lower recurrence risk seen

    The recurrence risk in the entire cohort was significantly lower at 27% in the immediate instillation group compared to 36% in the delayed instillation group (p<.001). Further, the difference in time to recurrence after 3 years of follow-up significantly favored an immediate instillation, with 34% reduction in the relative risk of recurrence (hazard ratio: 0.66) compared to delayed instillation. The 3-year cancer progression rate was lower with immediate instillation (2.7%) compared to delayed instillation (5.5%). However, the trial was not powered or designed to evaluate the risk of progression.

    When analyzing each risk group separately, no difference was noted in the risk of recurrence in the LR group from immediate versus delayed instillation (43% vs. 46%). However, immediate instillation significantly reduced the risk of recurrence in both the IR (20% vs. 32%) and HR group (28% vs. 35%).

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    Adverse effects were recorded in 258 of 1,048 patients (25%) in the immediate instillation group and 257 of 1,195 patients (22%) in the delayed instillation group (p=.08). Most common adverse effects were skin rash (5.4%) and irritative voiding symptoms (5.0%). In six patients (0.57%) in the immediate instillation group, MMC extravasation was reported, which was managed conservatively.

    For the entire study population, MMC instillation appears to be more effective when given immediately post-TURBT and appears to have a relatively favorable side effect profile. Because the protocol was devised in 1998, the risk categorization used in this report are somewhat different than the contemporary risk categories and the results of sub-group analysis may not be translatable. Also, a second TURBT or reporting muscle in the specimen (which are now quite standard) for high-risk cases was not required in this trial.

    It is postulated that the beneficial effect of post-TURBT MMC may be due to eradicating floating tumor cells, overlooked small tumors, or residual tumor at the resection site. Our clinical paradigm has shifted to bacillus Calmette-Guérin (not used in this trial) as the primary adjuvant therapy, and the increasing use of enhanced visualization technology (blue light cystoscopy, narrow band imaging) to allow more complete resection. One must question whether the benefits of MMC instillation will still be maintained in patients managed using these modalities.

    It appears that for all NMIBC patients, an immediate single instillation of MMC within 24 hours after TURBT reduces the recurrence rate and prolongs time to recurrence, regardless of whether adjuvant MMC instillations were given.

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    • Anonymous
      How long do you let the Mitomycin dwell in the bladder post TURBT?

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