Single postoperative instillation for non-muscle invasive bladder cancer: are there still any indication?

Intravesical chemotherapeutical agents after transurethral resection have shown to be effective in reducing the risk of recurrence and progression during the follow up. Specifically, an early single chemotherapeutical instillation (SI) might play an important role but the efficacy of this treatment has been questioned. For these reasons, we sought to review and summarize the current evidence with a non-systematic Medline/PubMed literature search. Level 1a evidence strongly supports the utility of SI in reducing recurrence in low-intermediate risk non-muscle invasive bladder cancer (NMIBC) patients, with about 35% of relative reduction rates in patients with single, <3 cm and low-intermediate stage and grade tumors. The efficacy of this procedure is particularly evident when epirubicin or mitomycin C is administered. However, no randomized controlled trials compared the effect of the different types of drugs for SI. Only few trials have analyzed the effect of timing in SI, therefore, the optimal delivery timeframe is not yet completely clear with some series suggesting that a delivery within the first 2 hours after surgery might have an impact on recurrence rates and others that show no differences with those treated within 24 hours. None of the patients included in the randomized controlled trials analyzed in this review suffered from systemic toxicity. On the other hand, other side effects were recorded, including: chemical cystitis and skin reaction. Although it is a safe procedure, rare severe complications have been reported in the literature, mostly due to extravasation of drugs in patients who underwent extended resection or bladder perforation. To avoid potential deadly complications, SI should not be administered in these patients.