The dilemma with treatment for urethral cancer lies in the difficulty of exposing the urethra to topical chemotherapeutic agents to achieve the optimal response. Unlike conventional systemic therapy, optimal response is related to the concentration of the drug and duration of exposure.
Prognosis for patients with urethral cancer is determined by the following factors:
• Anatomical location: Distal tumors are usually considered more curable than proximal, and this appears to be true for both men and women. In males, a less favorable response occurs with proximal (bulbomembranous) and prostatic urethral tumors.
• Tumor size
• Tumor stage: The more advanced the tumor, the less likely a cure will be achieved, regardless of treatment.
• Depth of invasion: Prognosis is less favorable for deeply invasive tumors.
Developing Our Protocol
Mitomycin gel was another potential option, but it is not available at our facility due to cost and unwanted side effects, such as pain and possible stricture of the urethra.
We contacted a neighboring facility to collaborate over the proper administration of mitomycin but found they had no previous cases to follow, and most of the available research we found on using mitomycin was conducted in the United Kingdom and Australia. Therefore, this patient became our first patient treated with this method. In addition, with no documented standard for this treatment option, we had to develop our own protocol.
Intraurethral mitomycin should not be confused with intravesical mitomycin. Intraurethral administration is to instill the medication directly into the urethra whereas intravesical administration is accomplished via instillation into the patient’s bladder.
The original order was to “administer 40 mg of mitomycin reconstituted in 60 mL of normal saline” to be “directly instilled into the urethra using a Toomey syringe.” The regimen is 6 treatments delivered once weekly.
The patient was actively involved in his treatment from the beginning. We created a log to document each treatment, and the patient completed it by recording any symptoms he experienced after the prior treatment. For example, his notes in the log indicated that after the sixth treatment he experienced increased burning, hematuria, and a rash on his hands. He also reported increased stress with his significant other.
The patient even helped us calculate the optimal medication dose. Applying his engineering background to our documented research, the patient determined the volume of a cylinder the size of an average male urethra: 8 inches in length, with a diameter of 0.2 inches. Using these numbers, he determined that the amount of mitomycin he could comfortably hold in his urethra was 15 mL .
Despite the physician’s order specifying a Toomey syringe, the pharmacy prepared the medication in a Luer Lock syringe. We tried to attach the Luer Lock onto a Foley catheter to instill the medication into the urethra. This was unsuccessful due to the lack of control; subsequently, less than 10 mL of the drug was actually instilled and retained. We needed to make a change to ensure optimal and safe drug administration.
Working with the attending physician, the order was rewritten so the mitomycin would be prepared in “20 mL of saline using a Toomey syringe.” This improved ease of administration for the nursing staff and was better tolerated by the patient.
Mitomycin must be handled carefully to ensure it does not come into contact with unprotected skin. Continued exposure to unprotected skin could lead to urethral sloughing and possible necrosis of the skin.5,6 Therefore, both the administering nurse and the patient wore full chemotherapy personal protective equipment, including gowns, gloves, and face shields, according to Oncology Nursing Society (ONS) guidelines.