How the Procedure Is Performed
Before beginning the procedure, the patient is instructed to empty his bladder then place a condom with a small hole cut out at the tip over his penis. This provides a barrier to protect the penile skin from contact with the drug.
The patient lies on an examination table with his head elevated. The nurse inserts the Toomey syringe directly into the urethra through the hole in the condom and gently instills the mitomycin. After instillation of as much mitomycin as the patient is able to tolerate, a penile clamp is placed directly over the condom, and the Toomey syringe is withdrawn when the clamp is snug to the penis. This helps prevent any leakage of the mitomycin.
A condom catheter is then placed directly over the first condom to the level of the clamp and attached to a Foley drainage bag, which is used to collect the mitomycin as it drains from the urethra. After the recommended 15 minutes, the clamp is released and the remaining mitomycin, and any urine that may be present, is allowed to empty into the collection bag via gravity.
The patient usually sits up with the drainage bag in place for approximately 10 to 15 minutes to ensure as much of the medication is drained into the collection bag as possible. In this way the chemotherapy remains contained in a closed system. The condom is removed and the entire set is disposed of in the designated chemotherapy waste container. The patient then washes his genitals and hands with soap and water to rinse off any remaining trace of mitomycin.
An additional seventh treatment was ordered because the amount of mitomycin instilled and retained in the first treatment was less than the optimal 10 mL. The patient was able to adhere to the entire treatment regimen.
Our patient experienced few side effects from his treatment. He did report a minimal amount of hematuria that lasted 1 to 2 days after treatment. Any discomfort was rare and usually occurred when the Toomey syringe was introduced into the penis and during instillation of the mitomycin.
Addressing the Impact on Patient Sexuality
The patient was initially offered the option of sperm banking, but due to his age, he felt this was not necessary. He has a significant other and remained sexually active throughout the course of his treatment. However, he reported occasional increased discomfort and hematuria after intercourse. The importance of practicing safe sex following treatment was reinforced to both the patient and his partner.
Using the PLISSIT model, the patient was allowed to explore sexuality issues as they became relevant during the course of his treatment. After the fourth treatment, sexuality was determined to be a stressor during chemotherapy. The patient reported increased tension due to both pain with intercourse and the need to continue to be sexually intimate with his partner. As these issues were discussed with the patient, the need for a mental health consult became evident. The patient’s counseling is ongoing at the time this article went to press.
The patient was free of disease at his 3-month check. A single nodule was found at 6 months and was treated by surgical fulguration via cystourethroscopy. If further intervention is required, the urologist has determined that cystoprostatectomy with or without urethrectomy may be necessary. The patient will continue surveillance checks at 9, 12, and 18 months, as determined by his treating physician.
This study demonstrates the importance of involving the patient in the treatment plan. It recognizes that collaborative efforts by all members of the treatment team are necessary to provide care based on best practices. When usual standards of care are not available, a protocol must be established to achieve optimal benefit for the patient.
Tammy Litrico is a nurse with the US Department of Veterans Affairs.
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