Mitomycin Gel AEs and Administration in the Community Setting

Katie S. Murray, DO, NYU Grossman School of Medicine, and David Ambinder, MD, Urology Resident, New York Medical College/Westchester Medical Center, share the importance of detailing potential adverse events associated with mitomycin gel with their patients, as well as what advice they would give to private practice urologists who are considering offering mitomycin gel as a therapy option.

Dr. Ambinder: Obviously, there’s going to be some adverse effects that need to be monitored for. What are those and how do you monitor for them?

Dr. Murray: Anytime we’re treating patients with kidney sparing approaches for the upper urinary tract, we’re doing multiple ureterorenoscopy. We are doing manipulations of these patients and adding this chemotherapy or adding things on top of that. It doesn’t come, like you mentioned, free of side effects. And so there are incidents in reports of obviously ureteral stricture and upper urinary tract stricture.

It’s very important for us to talk about that with our patients, and probably also for myself, it gives me a reminder of how important it is to talk to my patients who are just undergoing ureteroscopy with laser ablations about that same thing because it’s definitely a risk there – discussing the incidents of flank pain or fevers, chills, anything that would make you lead towards thinking you could have an obstructive symptom that could be a sign of a stricture. Now, personally, I’ve treated a lot of patients with the nephrostomy tubes. I believe personally and in some retrospective personal data and multi-institutional data, that risk of stricture is much reduced with a nephrostomy tube versus urethral catheterization.

Dr. Ambinder: Are you doing the nephrostomy tube in outpatient setting?

Dr. Murray: I am. I do it in the office setting.

Dr. Ambinder: In terms of mitomycin C bladder installation at the time of nephron sparing surgery, what are your thoughts on that?

Dr. Murray: There’s no trial or anything to tell us that we should use an intravesical chemotherapy at the time of doing ureteroscopic ablations or anything like that. I do personally, oftentimes these patients have bladder as well, or lower urinary tract recurrences. When I do my bladder cancer, I actually use gemcitabine. Oftentimes, if patients have ureteroscopic ablations, I will use an immediate post-op course or immediate post-op dose of my gemcitabine in the recovery room. As a reminder to people, this mitomycin for propyl achilles solution is not an immediate adjuvant therapy that doesn’t happen in the operating room. It doesn’t happen in the recovery room. It is you find your patient, you discuss this with him as an outpatient, and then it’s done as a 6-week induction course therapy.

Dr. Ambinder: Last question, going back to the private practice urologist who’s considering implementing mitomycin C as a thermal gel, they’re nervous. They don’t know. They haven’t used it before. Maybe they’re not around a center that offers it, but they now know about it. What would you advise them? What are some things that should help them consider it further?

Dr. Murray: The biggest thing I would say is this is not something that is trying to take surgery away from surgeons. As surgeons at the gut of us, there’s always this fear that there’s going to be some sort of therapeutic that’s going to take surgery away. I make jokes about that to my patients. That’s not going to happen. There’s plenty of patients to operate on all the time. So, my first note to anybody out there considering it is you don’t have to change what you’re doing in your practice already. You just add this into it. You’re already seeing these patients. They’re not common. It’s a rare disease, but you’re seeing the patients. You’re finding them. You’re doing these big ureteroscopic ablations, yet the recurrence rate is high. It’s pushing 60% to 65% after these ablations. We’ve been waiting for something else.

Patients are begging for something else, and for that something else, I don’t mean a nephroureterectomy. This is just one extra thing to put into your armamentarium that you don’t have to change your practice. It instills very familiar to us as urologists. We are used to doing things once a week for 6 weeks. We’re used to letting people heal up for a couple of weeks after an operation, or an ablation, or resection before proceeding with those therapies. We’re used to having to take them back to the operating room to repeat, look up inside. It’s really not that different.

View their previous remarks on Effective Techniques for Nephron Sparing and Mitomycin Gel for UTUC.