Safety and feasibility of early single dose mitomycin-C bladder instillation post robot-assisted radical nephroureterectomy.

OBJECTIVES To assess the safety and feasibility of early single dose mitomycin-C (MMC) bladder instillation following robot-assisted radical nephroureterectomy (RANU) at a tertiary kidney cancer centre. Radical nephroureterectomy with bladder cuff excision and subsequent mitomycin-C (MMC) bladder instillation to reduce recurrence risk is the gold standard for high risk upper urinary tract urothelial carcinoma (UUTUC). We adapted a robot-assisted nephroureterectomy technique with precise distal ureteric dissection, bladder cuff excision and watertight bladder closure. MATERIALS AND METHODS We retrospectively reviewed all patients undergoing RANU for UUTUC at our centre performed as a standardised transperitoneal procedure comprising of: bladder cuff excision, 2-layer watertight closure and intra-operative bladder leak test; without re-docking/repositioning of the robotic surgical system. Patient demographics, the timing of MMC instillation, adverse events (surgical and potentially MMC-related) and length of stay (LOS) were assessed according to the Clavien-Dindo (CD) classification. RESULTS Sixty-nine patients underwent a RANU with instillation of MMC. The median age was 70 (interquartile range [IQR] 62-78) years. Median day of MMC instillation was 2 (IQR 1-3) days and median LOS was 2 (IQR 2-4) days, with urethral catheter removal on day of discharge in all cases. Only CD complications Grade 1 occurred (7 patients, 10%). Five patients had ileus, 1 wound infection and 1 self-limiting delirium; all managed conservatively. No adverse events potentially related to MMC instillation were noted within 30 days postoperatively. CONCLUSION The use of intravesical MMC instillation given in the immediate post-operative period appears feasible and safe in patients undergoing RANU with intraoperative confirmation of a water-tight closure ensuring early catheter free discharge, with no significant adverse events. The potential reduction in intravesical recurrence in patients receiving early MMC needs to be assessed with longitudinal follow up studies.