Clinical Practice Recommendations for the Prevention and Management of Intravesical Therapy-Associated Adverse Events

Context: Although intravesical therapy is an integral part of the management of non-muscle invasive bladder cancer (NMIBC), both intravesical chemotherapy and bacillus Calmette-Guérin (BCG) have potential side effects that may lead to treatment cessation and incomplete treatment courses. Objective: To provide evidence-based strategies for the prevention and management of intravesical therapy-associated adverse events. Evidence acquisition: A committee of international leaders in bladder cancer management, known as the International Bladder Cancer Group (IBCG), was convened in October 2006 to review current literature surrounding adverse events associated with intravesical therapy. Following the inaugural meeting in October 2006, the IBCG met on three subsequent occasions to exchange ideas and to develop practical recommendations for the prevention and management of these adverse events. Evidence synthesis: The IBCG provided an overview of adverse events associated with BCG and intravesical chemotherapy as well as practical recommendations for the prevention and management of these side effects based on current evidence. Conclusions: Cystitis and hematuria are side effects common to both chemotherapy and BCG. Other rare complications common to both intravesical therapies include contracted bladder and ureteral obstructions. BCG-specific adverse events include granulomatous prostatitis, epididymo-orchitis, systemic BCG reactions, and allergic reactions, while side effects specific to intravesical chemotherapy include contact dermatitis, bladder calcifications, and myelosuppression. The keys to management of these adverse events are education, prevention, and awareness. Preventive strategies include instructing health care professionals about proper catheterisation techniques and instilling BCG at least 2 wk following a TURBT; if catheterisation is traumatic or the patient has a urinary tract infection, BCG instillations should be deferred for 1 wk. Furthermore, the use of prophylactic ofloxacin 200 mg given twice after BCG instillations appears to be a simple and practical method of improving BCG tolerability while maintaining its efficacy. BCG dose reduction may also be a reasonable option, particularly for those patients known to be intolerant to standard-dose BCG. © 2008 European Association of Urology.