Policies,Clinical,UWMF Clinical,UWMF-wide,Clinical Policies and Procedures,Urologic

Bladder Cancer Instillation-BCG or Thiotepa (102.135)

Bladder Cancer Instillation-BCG or Thiotepa (102.135) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Urologic




BCG or Thiotepa

Effective Date: January, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed November, 2007 April 2010 March 2012

PURPOSE: To provide guidelines for preparation and administration of BCG, Thiotepa, and Mitomycin C at UWMF

DEFINITION: BCG, Thiotepa, or Mitomycin C via bladder instillation is used to decrease recurrence of primary bladder

POLICY: The clinical staff will utilize the following guidelines to prepare and administer BCG, Thiotepa, and
Mitomycin C to a UWMF patient.

SUPPLIES: Provider’s order, Patient’s record
14 or 16 FR red rubber catheter (latex free if allergy)
Lidocaine 2% urojet (5cc female / 10cc male), Penile clamp (male)
Sterile cotton ball pack (cotton swab also if female)
Betadine prep solution, Lubricating jelly, Yellow chemo container
Goggles, Mask, Blue impervious gown
Non-sterile (nitrile) and sterile gloves, Prescribed antibiotics
BCG, Thiotepa, or Mitomycin C medication & administration kit (Pharmacy will deliver)

1. Verify provider order.

2. Patient to have stat WBC prior to Thiotepa.
NOTE: If WBC <4.0 treatment is held, and rescheduled to the following week.
NOTE: WBC prior to BCG will be provider preference.

3. Ask patient for urine specimen or obtain with catheterization.

4. Check urine for blood, leukocytes and nitrites.
NOTE: If positive inform provider. Treatment is held if urinary tract infection (UTI), gross hematuria.

5. Room patient using standard Urology Clinic procedure.

6. Answer any treatment questions.

7. Introduce yourself and identify the patient. Include date of birth and verify allergies (specifically to
Betadine, lubricating jelly, lidocaine, BCG, Thiotepa, Mitomycin C, or the prescribed antibiotic).

8. Verify that patient has not had fluids for 4 hours prior to treatment.
NOTE: This is not a reason to cancel the treatment, but an empty bladder will make it easier to retain drug
in bladder.

9. If patient has had prior BCC, Thiotepa, or Mitomycin C treatment, interview patient for gross hematuria, fever,
chills, aches, or flu like symptoms since last treatment.

10. Update provider of any positive findings from step 8.

11. If urine and WBC meet above guidelines, call pharmacy for medication.

12. Give prophylactic prescribed antibiotic.

13. Assist or ask patient to undress from waist down and assist them to exam table.

Male patients should lie supine on table.
Female patients should lie in dorsal lithotomy position with legs in stirrups.

14. Check for pharmacy delivery.

15. Ensure proper administration, adhering to the five rights of drug administration. (Right – drug, dose, time, route,

16. Wash hands and put on non-sterile (nitrile) gloves, gown, goggles and mask.

17. Open & prepare supplies.

18. Clean labial folds and meatus on female, or penis on male with betadine soaked cotton balls.
NOTE: If patient allergic to iodine, use 4% chlorhexidine gluconate solution for cleansing.
Clean entire penis, starting at the meatus and moving down the glans.
Clean labial folds and meatus from top to bottom

19. Inject Lidocaine jelly Wait time?
For females - inject 5cc into meatus and place cotton swab in meatus.
For males - inject 10cc into urethra and place penile clamp over shaft of penis, behind the glans.

20. Insert lubricated catheter and drain urine (obtain specimen if needed) leave catheter in place. For males, remove
penile clamp prior to inserting catheter.

21. Attach administration kit to catheter and instill medication by gravity.
NOTE: Medication will generally take a minute or less to instill.

22. After treatment is completed, crimp catheter to avoid spillage and then remove.

23. Discard catheter, medication vial and administration kit, gown, gloves and mask in yellow chemo container and
cover tightly.

24. Wash hands, then assist patient to sitting position and allow to or assist with dressing.

25. Perform patient education, give patient the following instructions:
a. Instruct patient to take any additional doses of antibiotic ordered.

b. BCG
Retain medication in bladder for 2 hours
Sit down on toilet to urinate and empty fully
After urinating, pour 2 cups of bleach into toilet and let sit 15-20 minutes before flushing
Repeat process with every void until 6 hours after treatment
May have mild dysuria, frequency


Call Clinic for the following
fever, chills, malaise, increased fatigue, flu like symptoms
gross hematuria, rash, urgency or frequency

c. Thiotepa & Mitomycin C
Retain medication in bladder for 1 hour
Do not need to use bleach after voiding
May have mild dysuria, frequency

Call Clinic for the following
fever, chills, malaise, increased fatigue, flu like symptoms
gross hematuria, rash, urgency or frequency

26. Documentation (in Progress Notes section of HealthLink) in the patient’s record:
Patient education
the procedure performed, date & time completed
name and amount of any medications given (using SmartPhrase: .medinclinic)
how patient tolerated procedure
discharge instructions
follow-up appointment (if any)

WRITTEN BY: Deb Brausen, R.N., Manager, Department of Urology
Donnette Deuser, R.N., Department of Urology
Gail Jahnke, R.N., N.P., Department of Urology

REVIEWED BY: Donnette Kelly, R.N., Department of Urology, 2012
Carol Decker, RN, MSN, Clinical Staff Educator, 2012


Department of Surgery, Urology Date

Medical Director Date