12.64 Thiotepa or Mitromycin Bladder Installation - Urology Clinic
UWHC Departmental Policy
April 18, 2012 (extended expiration date to December 31, 2015)
Clinic Specific (Ambulatory)
To establish a process for Urology Clinic Registered Nurses (RNs) to perform bladder instillations of thiotepa or mitomycin
for patients with a history of recurrent bladder tumors as ordered by a Urologist.
This policy applies to Urology Clinic RNs who have been trained and demonstrated competence in performing bladder
A. The provider will order the bladder instillation, pre-procedure labs, and indicate the chemotherapy agent and the
number of instillations to be administered after benefit and risks are discussed with the patient. The orders will be
placed in HealthLink as a Consult to Urology or as a scheduler message in the follow-up section of the HealthLink
B. The Urology Clinic scheduler, in consultation with the Urology Procedure RN, will schedule the patient for the
C. The Urology Procedure RN will call the patient and provide teaching prior to the patient arriving for the appointment
and the teaching will be documented in a telephone encounter in the patient’s electronic medical record (EMR).
Teaching will include information that is covered in Health Facts for You (HFFY) 6939.
D. The appropriate medication will be requested from the pharmacy on UWH Form 300137 - Clinic and Procedure
Area Medication Order Form. Use one request form for each instillation in the series. The form will be completed by
the RN and signed by the ordering provider. The RN will fax the form to the pharmacy. The pharmacy will be
instructed to dispense 20ml of medication in a 30ml syringe when the RN calls for it on the day of the procedure.
IV. DAY OF PROCEDURE
A. All patients receiving thiotepa will be directed to the core lab for a hematology survey (if not done within the last
three days) prior to each treatment.
B. Patients receiving mitomycin will be directed to the core lab for a hematology survey (if not done within the last
three days) at the first, third, and sixth dose in the series.
C. If white blood cell count is not equal to or greater than 3.5K/u it or platelets not equal to or greater than 100k/u it
must be reviewed with the provider.
D. A same day urinalysis will be performed in the Urology lab for all patients (Ambulatory Policy 12.58 - Obtaining
Urine Specimens on Day of Visit – Adult Urology Clinic). If urinalysis result is abnormal it must be reviewed with the
provider prior to proceeding.
E. If the lab results are acceptable, the RN will call the pharmacy to dispense the medication that was previously
requested on UWH Form 300137 (see III.D. above).
F. The patient will receive teaching from the Urology RN which will include information covered in HFFY 6939. The
patient will be given HFFY 6939. The RN will document the teaching in the patient’s EMR.
G. If this is not the first bladder instillation, the RN will discuss with the patient any symptoms he/she may have
experienced since their last treatment. Any abnormal symptoms will be reviewed with the ordering provider prior to
proceeding with the bladder instillation.
H. Urology RN will have patient sign the Consent for Chemotherapy - UWH Form 4005826 at the first visit for the
series of instillations as ordered by the provider.
A. Assemble Equipment
1. Sterile catheter kit
2. 10 or 12 french clear straight catheter, coude catheter, or 14 french red rubber catheter for men and 14
french red rubber for women
3. 60ml catheter tip irrigation syringe
4. 2% lidocaine Urojet syringe
5. 10ml normal saline syringe
6. blue fluid impermeable gown with snug fitting knit or elastic cuff, nitrile gloves, mask, face shield, shoe
covers and sharps container
B. Thiotepa and/or mitomycin should be handled as a hazardous drug with appropriate precautions. (See Hospital
Administrative Policy 8.89 - Preventing Occupational Exposure to Hazardous Drugs.)
C. Using sterile technique instill 2% lidocaine Urojet in the male urethra. Wait for one to two minutes before
D. Catheterize the patient using sterile technique.
E. Drain the bladder of any urine.
F. Remove plunger from irrigation syringe.
G. Attach the irrigation syringe catheter tip to the urinary catheter.
H. Instill the chemotherapy agent into the open end of the irrigation syringe.
I. Allow the chemotherapy agent to drain via gravity to the patient’s comfort.
J. After the chemotherapy agent has completed draining, instill 10ml of normal saline into the irrigation syringe for
safety and to insure that all medication is instilled into the bladder.
K. Remove the catheter from the bladder.
L. Instruct the patient how and when to urinate per HFFY #6939. Review potential side effects and when and how to
call the clinic.
M. Document the instillation in the patient’s EMR including:
1. lab results reviewed
2. side effects of previous treatments
3. medication and dosage
4. how the patient tolerated the procedure
5. teaching performed
Administrative Policy 8.89 - Preventing Occupational Exposure to Hazardous Drugs
Ambulatory Policy 12.58 - Obtaining Urine Specimens on Day of Visit – Adult Urology Clinic
VII. REVIEWED AND APPROVED BY
Urology Clinic Manager
Urology Registered Nurses
David Jarrard, MD, Urology
Ambulatory Policy and Procedure Committee
Deborah D. Tinker, RN, MS, Director, Ambulatory Nursing