Intravesical Chemotherapy for NMIBC: A Patient's Guide

Polygon Health Team
May 13
10 min read

Updated: May 14

Non-Muscle Invasive Bladder Cancer (NMIBC) is a condition where cancerous cells are found in the inner lining of the bladder.1 A common approach to treating this type of cancer involves intravesical therapy, where medication is directly administered into the bladder.2 This method allows for a targeted treatment of the bladder lining. Within the realm of intravesical therapy, two primary categories exist: immunotherapy, which includes treatments like Bacillus Calmette-Guérin (BCG), and chemotherapy.2 This guide will specifically focus on intravesical chemotherapy as a treatment option for NMIBC.

Intravesical chemotherapy is a procedure where liquid chemotherapy drugs are placed directly into the bladder. This is achieved through the use of a thin, flexible tube called a catheter, which is gently inserted into the bladder.3 The term "intravesical" itself means "within the bladder".2 To help understand this process, one can think of the bladder as a balloon, and the medication is carefully placed inside this balloon directly targeting the cancer cells that reside on the surface of the bladder lining.2 This approach is distinct from systemic chemotherapy, where drugs are taken orally or injected into the bloodstream, traveling throughout the entire body.3

The primary objective of using intravesical chemotherapy is to eliminate any remaining cancer cells in the bladder following surgical removal of the tumor, a procedure known as Transurethral Resection of Bladder Tumor (TURBT). Additionally, this therapy aims to lower the likelihood of the cancer returning, a situation referred to as recurrence, in the lining of the bladder.3 Intravesical chemotherapy is predominantly used for bladder cancers that are in their early stages, specifically stage 0 and some stage 1 cancers, which are confined to or very close to the inner layer of the bladder.3

There are several benefits associated with this type of treatment. Firstly, it offers a targeted treatment, where the drugs primarily affect the cells lining the bladder and have a minimal impact on other parts of the body.3 This localized action leads to a significant advantage: reduced systemic side effects. Patients undergoing intravesical chemotherapy are less prone to experience common side effects associated with systemic chemotherapy, such as hair loss or nausea.3 Furthermore, it is effective after TURBT, with a single dose often administered within 24 hours of the surgery to address any remaining cancer cells.1 For cancers that carry a higher risk of recurrence, intravesical chemotherapy is also used in longer courses.3 Importantly, it serves as a valuable option when immunotherapy doesn't work, providing an alternative if intravesical immunotherapy, such as BCG, proves ineffective or is not a suitable option.2

The administration of intravesical chemotherapy typically takes place in a doctor's office or an outpatient clinic.1 The process involves several key steps. Initially, the patient will likely be asked to empty their bladder.16 Following this, a healthcare professional, such as a nurse or doctor, will gently insert a thin, flexible tube, known as a catheter, through the urethra – the tube that carries urine out of the body – and into the bladder.1 The chemotherapy drug, which is in a liquid form, is then instilled, or carefully put, into the bladder through this catheter.1 Once the medication is in the bladder, the catheter might be removed right away, or it could be temporarily clamped to ensure the drug remains within the bladder.16 The patient will then need to hold the medication in their bladder for a specific duration, typically around 1 to 2 hours.1 During this period, the medical team might instruct the patient to change their body position, such as lying on their back, stomach, and sides, to help the medication coat the entire inner lining of the bladder.2 It is worth noting that some medical opinions suggest that these positional changes might not be strictly necessary.16 After the designated time has passed, the patient will pass the urine that contains the chemotherapy drug, usually by urinating normally.1 If the catheter was left in place, a nurse will drain the bladder.7

During a typical treatment session, the instillation of the medication itself is usually a quick process, taking only a few minutes.23 The main part of the session involves holding the medication in the bladder for the prescribed 1 to 2 hours.1 Patients are often able to continue with their normal daily activities while the medicine is in their bladder and do not necessarily need to remain in bed.23 However, some medical centers might still recommend changing positions periodically to ensure the medication comes into contact with all areas of the bladder lining.2 It is important to follow any specific instructions provided by the healthcare team.2 Patients might experience a cool sensation as the chemotherapy liquid flows into the bladder.7 Some individuals might also feel mild discomfort, a burning sensation, or some cramping after the instillation.7

In the period immediately following the treatment, it is generally advised to drink plenty of fluids, around 2 to 3 liters or 8 or more glasses of water, for the next 24 to 48 hours. This helps to flush the chemotherapy drug out of the system.16 Patients need to exercise caution when passing urine, as it will contain some of the chemotherapy medication.16 Specific guidelines for handling urine should be followed for a period after treatment, which can range from approximately 6 hours to 48 hours, depending on the specific medication used and the protocols of the medical facility.16 These precautions typically include sitting down to urinate to minimize splashing 16, and in some cases, avoiding the use of public toilets.16 Some guidelines might also recommend adding bleach to the toilet after each urination and allowing it to sit for a short time before flushing.16 It is essential to wash hands and the genital area thoroughly with soap and water after each urination.16 Any clothing that becomes soiled with urine should be washed separately and immediately.16 Unless instructed otherwise, patients can usually resume their normal activities soon after the treatment.25

Several chemotherapy drugs are commonly used for intravesical treatment of NMIBC.2 These include Mitomycin C (MMC) 1, Gemcitabine 2, Epirubicin 2, Pirarubicin 2, Doxorubicin 10, Docetaxel 2, Valrubicin 3, and Thiotepa.28 The choice of drug or a combination of drugs is made by the doctor based on the specific type and risk level of the bladder cancer.2 Gemcitabine is often noted for being well-tolerated and having fewer systemic side effects compared to some other chemotherapy drugs.3 Valrubicin is sometimes specifically used when BCG immunotherapy has not been effective in treating carcinoma in situ.3

Because intravesical chemotherapy primarily acts within the bladder, the side effects experienced are generally less severe than those associated with systemic chemotherapy.3 Common side effects that can occur within 48 hours after treatment include a burning sensation or discomfort during urination, a frequent or urgent need to urinate, a feeling similar to a urinary tract infection (cystitis), and the presence of blood in the urine, which is usually light red or pink.2 Some patients might also notice small pieces of scabs or bladder lining in their urine.25 Other possible side effects include flu-like symptoms such as fatigue, mild fever, and aches, as well as muscle or joint aches.2 Nausea and a skin rash on the hands or feet are less common side effects.2

Strategies for managing these side effects include drinking plenty of fluids 9 and avoiding substances like caffeine, spicy foods, and alcohol that can irritate the bladder.7 Doctors might also prescribe medications such as sodium bicarbonate to help with bladder irritation 7 or over-the-counter pain relievers like acetaminophen or ibuprofen for fever and aches.16 In some cases, medications to alleviate urinary frequency and urgency might be prescribed.16 It is important for patients to contact their healthcare team if they experience more severe symptoms such as a high fever (above 100.5°F or 38°C) or chills, bright red blood or blood clots in the urine, severe pain when urinating or an inability to urinate, flu-like symptoms that last for more than 2 days, worsening fatigue, a skin rash, a cough, or any signs of infection like fever, chills, severe pain, or bad-smelling urine or discharge.16

The schedule and duration of intravesical chemotherapy treatment can vary based on the risk of the bladder cancer returning.3 Typically, the initial phase of treatment is called the induction phase, which usually involves weekly treatments for approximately 6 weeks.2 This initial intensive phase aims to destroy any remaining cancer cells.2 Following the induction phase, some patients may undergo a maintenance phase.2 During this phase, treatments are given less frequently, such as monthly or every few months, for a longer duration, ranging from several months up to a year or even three years in some instances.2 The purpose of maintenance therapy is to lower the risk of the cancer coming back (recurrence).2 For patients with low-risk NMIBC, often only a single instillation of chemotherapy is administered within 24 hours after the TURBT procedure.3 In cases of intermediate-risk NMIBC, a six-week induction course followed by maintenance therapy for up to one year is a common approach.3 For high-risk NMIBC, while BCG is frequently the first-line intravesical treatment, chemotherapy might be considered if BCG is not a viable option or has not been effective. The specific schedule in these situations can vary.2 The doctor will discuss the personalized treatment plan with the patient, taking into account their individual circumstances and the guidelines established by medical organizations such as the American Urological Association (AUA) 10 and the European Association of Urology (EAU).14

It is crucial for patients to openly communicate with their doctors and nurses about any questions or concerns they may have regarding their treatment.2 For additional reliable information, patients can consult reputable sources such as medical organizations like the American Cancer Society 3, the Urology Health Foundation 1, and the National Cancer Institute.20 Information can also be found at cancer centers like Memorial Sloan Kettering Cancer Center 21 and Cleveland Clinic 44, as well as patient advocacy groups such as Bladder Cancer Canada 2 and the Bladder Cancer Advocacy Network (BCAN).4 Patient guidebooks and online resources offered by these organizations can provide further support and encouragement.2

In conclusion, intravesical chemotherapy is a widely used and effective treatment for Non-Muscle Invasive Bladder Cancer. While patients may experience some side effects, these are typically manageable. Throughout the treatment journey, maintaining open communication with the healthcare team is essential for optimal care and outcomes.

Drug Name	Typical Use	Potential Common Side Effects (in the bladder area)
Mitomycin C	Often used as a single dose after TURBT and in induction and maintenance therapy.	Burning sensation during urination, frequent urination, urge to urinate, bladder irritation.
Gemcitabine	Used as a single dose after TURBT and in induction and maintenance therapy; often well-tolerated.	Frequent urination, urge to urinate, pain when urinating.
Epirubicin	Used in induction and sometimes maintenance therapy.	Burning sensation during urination, frequent urination, urge to urinate.
Pirarubicin	Used in some induction and maintenance protocols.	Similar to other intravesical chemotherapies, may include bladder irritation.
Doxorubicin	Used in induction therapy.	Burning sensation during urination, frequent urination, urge to urinate.
Docetaxel	Sometimes used, particularly in combination with gemcitabine or when other treatments have not worked.	Bladder irritation, frequent urination, painful urination.
Valrubicin	Primarily used for carcinoma in situ (CIS) that has not responded to BCG.	Frequent urination, urge to urinate, painful urination, blood in urine, abdominal pain, fatigue.
Thiotepa	Older agent, sometimes used for low-grade, low-stage bladder cancer.	Irritative voiding symptoms (frequent urination, urgency, pain), may have a higher risk of systemic side effects like low blood counts compared to other intravesical agents, so close monitoring is important.