International Urology and Nephrology

, Volume 50, Issue 6, pp 1053–1059 | Cite as

A care bundle to improve perioperative mitomycin use in non-muscle-invasive bladder cancer

  • Deepak Batura
  • Tumaj Hashemzehi
  • Josie Colemeadow
Urology - Original Paper



Intravesical chemotherapy administered within 24 h of the first resection of non-muscle-invasive bladder cancer (NMIBC) reduces recurrence rates and prolongs recurrence-free intervals. However, there is considerable variation in the use of intravesical chemotherapy amongst urologists. In our hospital, we use mitomycin C (MMC), and our usage was inconsistent. Therefore, we devised a care bundle to improve MMC usage. The objective of this study was to evaluate the effectiveness of the care bundle on postoperative MMC use.


We measured baseline postoperative MMC use during the first quarter of 2013. In 2014, we implemented a care bundle by changing MMC delivery, through computer-based clinical information systems and repeated training of key stakeholders. We studied the performance of the bundle through snapshot audits in the last quarter of 2014, a 6-month period in the middle of 2015 and again in the final quarter of 2016.


We observed an increase in intravesical chemotherapy usage after implementing the care bundle. Instillation rates in our samples increased from 46% (6/13), in 2013 to 89% (8/9), in 2014, 90% (9/10), in 2015 and 100% (12/12), in 2016.


Compliance rates of intravesical chemotherapy in NMIBC can improve by devising care bundles to modify team behaviour.


Care bundle Non-muscle-invasive bladder cancer Chemotherapy Mitomycin C Intravesical instillation 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed on human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

This was a retrospective study with anonymised data, not requiring informed consent.


  1. 1.
    Nargund VH, Tanabalan CK, Kabir MN (2012) Management of non-muscle-invasive (superficial) bladder cancer. Semin Oncol 39:559–572CrossRefPubMedGoogle Scholar
  2. 2.
    Tanaka T, Miyazawa K, Tsukamoto T, Kuno T, Suzuki K (2011) Pathobiology and chemoprevention of bladder cancer. J Oncol. Google Scholar
  3. 3.
    Tolley DA, Parmar MK, Grigor KM, Lallemand G, Benyon LL, Fellows J, Freedman LS, Grigor KM, Hall RR, Hargreave TB, Munson K, Newling DW, Richards B, Robinson MR, Rose MB, Smith PH, Williams JL, Whelan P (1996) The effect of intravesical mitomycin C on recurrence of newly diagnosed superficial bladder cancer: a further report with 7 years of follow up. J Urol 155:1233–1238CrossRefPubMedGoogle Scholar
  4. 4.
    Perlis N, Zlotta AR, Beyene J, Finelli A, Fleshner NE, Kulkarni GS (2013) Immediate post-transurethral resection of bladder tumor intravesical chemotherapy prevents non-muscle-invasive bladder cancer recurrences: an updated meta-analysis on 2548 patients and quality-of-evidence review. Eur Urol 64(3):421–430. CrossRefPubMedGoogle Scholar
  5. 5.
    Lykke MR, Nielsen TK, Ebbensgaard NA, Zieger K (2015) Reducing recurrence in non-muscle-invasive bladder cancer using photodynamic diagnosis and immediate posttransurethral resection of the bladder chemoprophylaxis. Scand J Urol 49(3):230–236CrossRefPubMedGoogle Scholar
  6. 6.
    De Nunzio C, Carbone A, Albisinni S, Alpi G, Cantiani A, Liberti M, Tubaro A, Iori F (2011) Long-term experience with early single mitomycin C instillations in patients with low-risk non-muscle-invasive bladder cancer: prospective, single-centre randomised trial. World J Urol 29:517–521CrossRefPubMedGoogle Scholar
  7. 7.
    Sylvester RJ, Oosterlinck W, van der Meijden AP (2004) A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer: a meta-analysis of published results of randomized clinical trials. J Urol 171:2186–2190CrossRefPubMedGoogle Scholar
  8. 8.
    Cockerill PA, Knoedler JJ, Frank I, Tarrell R, Karnes RJ (2016) Intravesical gemcitabine in combination with mitomycin C as salvage treatment in recurrent non-muscle-invasive bladder cancer. BJU Int 117:456–462CrossRefPubMedGoogle Scholar
  9. 9.
    Babjuk M, Burger M, Zigeuner R, Shariat SF, van Rhijn BW, Compérat E, Sylvester RJ, Kaasinen E, Böhle A, Palou Redorta J, Rouprêt M, European Association of Urology (2013) EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2013. Eur Urol 64:639–653CrossRefPubMedGoogle Scholar
  10. 10.
    Brausi M, Witjes JA, Lamm D, Persad R, Palou J, Colombel M, Buckley R, Soloway M, Akaza H, Böhle A (2011) A review of current guidelines and best practice recommendations for the management of nonmuscle invasive bladder cancer by the International Bladder Cancer Group. J Urol 186:2158–2167CrossRefPubMedGoogle Scholar
  11. 11.
    Madeb R, Golijanin D, Noyes K, Fisher S, Stephenson JJ, Long SR, Knopf J, Lyman GH, Messing EM (2009) Treatment of nonmuscle invading bladder cancer: do physicians in the United States practice evidence based medicine? The use and economic implications of intravesical chemotherapy after transurethral resection of bladder tumors. Cancer 115:2660–2670. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Chamie K, Saigal CS, Lai J, Hanley JM, Setodji CM, Konety BR, Litwin MS, Urologic Diseases in America Project (2011) Compliance with guidelines for patients with bladder cancer: variation in the delivery of care. Cancer 117:5392–5401CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Volpe A, Racioppi M, D’Agostino D, Cappa E, Filianoti A, Bassi PF (2010) Mitomycin C for the treatment of bladder cancer. Minerva Urol Nefrol 62:133–144PubMedGoogle Scholar
  14. 14.
    Au JL, Badalament RA, Wientjes MG et al (2001) Methods to improve efficacy of intravesical mitomycin C: results of a randomised phase III trial. J Natl Cancer Inst 93:597–604CrossRefPubMedGoogle Scholar
  15. 15.
    Resar R, Griffin FA, Haraden C, Nolan TW (2012) Using care bundles to improve health care quality. IHI Innovation Series white paper. Institute for Healthcare Improvement, Cambridge.
  16. 16.
    Nolan T, Berwick DM (2006) All-or-none measurement raises the bar on performance. JAMA 295:1168–1170CrossRefPubMedGoogle Scholar
  17. 17.
    Stroman L, Tschobotko B, Abboudi H, Ellis D, Mensah E, Kaneshayogan H, Mazaris E (2016) Improving compliance with a single post-operative dose of intravesical chemotherapy after transurethral resection of bladder tumour. Nephrourol Mon 8:e29967. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Seo GH, Kim JH, Ku JH (2016) Clinical practice pattern of immediate intravesical chemotherapy following transurethral resection of a bladder tumor in Korea: National Health Insurance Database Study. Sci Rep 15(6):22716. CrossRefGoogle Scholar
  19. 19.
    Gan C, Patel A, Fowler S, Catto J, Rosario D, O’Brien T (2013) Snapshot of transurethral resection of bladder tumours in the United Kingdom Audit (STUKA). BJU Int 112:930–935. CrossRefPubMedGoogle Scholar
  20. 20.
    Neuzillet Y, Colin P, Comperat E, Dubosq F, Houede N, Larre S, Masson-Lecomte A, Pignot G, Puech P, Roumiguie M, Xylinas E, Mejean A, Roupret M (2016) Observational survey of the French Urological Association Oncology Committee (CCAFU) evaluating the practice of immediate postoperative instillation (IPOP) using mitomycin C for non-muscle-invasive bladder cancer (NMIBC) treatment. Prog Urol 26:181–190CrossRefPubMedGoogle Scholar
  21. 21.
    Nielsen ME, Smith AB, Pruthi RS, Guzzo TJ, Amiel G, Shore N, Lotan Y (2012) Reported use of intravesical therapy for non-muscle-invasive bladder cancer (NMIBC): results from the Bladder Cancer Advocacy Network (BCAN) survey. BJU Int 110:967–972CrossRefPubMedGoogle Scholar
  22. 22.
    Smith A, Nielsen ME, Manvar A, Ferguson J, Pruthi R, Wallen E, Lotan Y (2011) Reported patterns of utilization of intravesical therapy in non-muscle-invasive bladder cancer: results from the BCAN/SUO/AUA/LUGPA electronic survey. J Clin Oncol Mar 29(Suppl):267CrossRefGoogle Scholar
  23. 23.
    Cookson MS, Chang SS, Oefelein MG, Gallagher JR, Schwartz B, Heap K (2012) National practice patterns for immediate postoperative instillation of chemotherapy in nonmuscle invasive bladder cancer. J Urol 187:1571–1576. CrossRefPubMedGoogle Scholar
  24. 24.
    Chang SS, Boorjian SA, Chou R, Clark PE, Daneshmand S, Konety BR, Pruthi R, Quale DZ, Ritch CR, Seigne JD, Skinner EC, Smith ND, McKiernan JM (2016) Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. J Urol 196(4):1021–1029. CrossRefPubMedGoogle Scholar
  25. 25.
    Babjuk M, Burger M, Comperat E, Gontero P, Mostafid AH, Palou J, van Rhijn BWG, Roupret M, Shariat SF, Sylvester R, Zigeuner R (2017) Non-muscle-invasive Bladder Cancer. European Association of Urology Guidelines. Accessed 04 March 2018
  26. 26.
    Sylvester RJ, Oosterlinek W, Holmang S, Sydes MR, Birtle A, Gudjonsson S, De Nunzio C, Okamura K, Kaasinen E, Solsona E, Ali-El-Dein B, Tatar CA, Inman BA, N’Dow J, Oddens JR, Babjuk M (2016) Systematic review and individual patient data meta-analysis of randomised trials comparing a single immediate instillation of chemotherapy after transurethral resection with transurethral resection alone in patients with stage pTa-pT1 urothelial carcinoma of the bladder: which patients benefit from the instillation? Eur Urol 69:23–244CrossRefGoogle Scholar
  27. 27.
    Bosschieter J, Nieuwenhuijzen JA, van Ginkel T, Vis AN, Witte B, Newling D, Beckers GMA, van Moorselaar RJA (2018) Value of an immediate intravesical instillation of mitomycin C in patients with non-muscle-invasive bladder cancer: a prospective multicentre randomised study in 2243 patients. Eur Urol 73:226–232CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of UrologyLondon North West University Healthcare NHS TrustLondonUK

Personalised recommendations