International Urology and Nephrology (2018) 50:1053–1059
UROLOGY - ORIGINAL PAPER
A care bundle to improve perioperative mitomycin use
in non‑muscle‑invasive bladder cancer
· Tumaj Hashemzehi
· Josie Colemeadow
Received: 4 March 2018 / Accepted: 30 March 2018 / Published online: 2 April 2018
© Springer Science+Business Media B.V., part of Springer Nature 2018
Purpose 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.
Methods 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 stake-
holders. 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.
Results 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.
Conclusion Compliance rates of intravesical chemotherapy in NMIBC can improve by devising care bundles to modify
Keywords Care bundle · Non-muscle-invasive bladder cancer · Chemotherapy · Mitomycin C · Intravesical instillation
Approximately 75–85% of transitional cell carcinomas
(TCC) of the bladder are non-muscle-invasive at the initial
presentation [1, 2]. Non-muscle-invasive bladder cancers
(NMIBC) comprise tumours staged as Ta, T1 or carcinoma
in situ (CIS). However, these tumours have high recurrence
rates with as many as 53% going on to develop a recurrence
within 2 years . A single dose of intravesical chemo-
therapy administered within 24 h of the ﬁrst resection of
NMIBC reduces recurrence rates and prolongs recurrence-
free intervals by approximately 40% [4–6]. Mitomycin C
(MMC), epirubicin, thiotepa, pirarubicin and doxorubicin
have all shown to be eﬃcacious in reducing recurrences .
Lately, drug combinations such as MMC and gemcitabine
have been shown to oﬀer durable recurrence-free survival
. Therefore, most guidelines recommend using intravesi-
cal chemotherapy after the ﬁrst resection in NMIBC [9, 10].
However, there is considerable variation in the practice of
intravesical chemotherapy use between medical institutions
and between surgeons [11, 12].
Like the majority of centres in the UK, this centre uses
MMC intravesical chemotherapy for NMIBC as the stand-
ard of care, both for its demonstrated eﬃcacy in reducing
recurrences and for its limited side eﬀects . We use the
“optimised” dose of 40 mg . Our initial analysis in 2013
revealed a low compliance rate with perioperative MMC
use. Therefore, we devised an intervention care bundle to
increase compliance as described below. The study describes
MMC compliance outcomes before and after the implemen-
tation of the new care bundle and our experience with the
implementation of these measures.
The primary endpoint of this study was to evaluate the
efficacy of a care bundle approach to improving MMC
usage. A secondary endpoint was to assess the causes of
underuse of MMC in our centre.
* Deepak Batura
Department of Urology, London North West University
Healthcare NHS Trust, Watford Road, Harrow,
London HA1 3UJ, UK