Ask the Doctor

Winter 2008

Our questions for this issue of Outlook were answered by Dr. Arthur Sagalowsky, Professor and Chief of Urologic Oncology at UT Southwestern Medical Center in Dallas, TX. We sincerely appreciate his sharing his opinions and impressions with us.

Q: Is it safe to have sexual intercourse while undergoing BCG treatments?

A: This is an excellent and very practical question about which there is embarrassingly little information. When introducing BCG, the catheter must be introduced without injuring or damaging the urethra, and recent biopsy sites must have healed to minimize the risk of infecting the patient with live BCG. Despite these precautions, some patients develop fever, rare systemic infection, and a small percentage of men may develop inflammatory conditions in their prostate or scrotum. In theory, men could shed BCG organisms in the urine, and possibly in the semen, in the first days after treatment. A barrier method such as a condom would confer protection against possible transfer of BCG to the sexual partner. However, I am not aware of any data that quantifies the presence of BCG in the urethra or the ejaculate after treatment. Nor have I ever heard of a case of the sexual partner becoming infected with BCG. Neither have several other bladder cancer experts to whom I posed the question. Clearly, we could all use better information on this point. Practically, I believe the risk, if any, must be small.

Q: What type of follow-up is recommended for patients following cystectomy?

A: The data on this topic is limited and individual practice patterns are somewhat arbitrary. In my own practice, I believe the follow-up needs to take into account two equally important issues: possible tumor recurrence (metastases from original bladder tumor; new onset upper tract urothelial tumor); and monitoring of urinary tract kidney function. In addition, every cystectomy patient has some type of urinary diversion and is at increased risk for urinary infection, stones and ureteral obstruction from fibrosis or tumor. I see every postop cystectomy patient every 3 months during the first year and obtain:

• CBC, lytes, creatinine
• Chest X-Ray
• Abdomen/pelvic CT
• Urinalysis
• Liver function tests every 6 mos

During years 2 and 3 following cycstectomy, the frequency of the above follow-up regimen remains:

• Every 3 months for patients who were stage T2,T3,T,4 or anyT,node positive
• Every 6 months for patients who were stage To,T1, node negative

After year 3 I follow patients annually. The frequency of long term follow-up imaging recently has been a subject of controversy. While statistics indicate that recurrence after 3 years is unlikely, and that many patients with metastases present with symptoms, my 30-year bladder cancer practice has shown that patients are not statistics, and that unusual recurrences can arise at any time. In addition, the increasing numbers of patients with neobladders require other long term follow-up concerns arising from the need to maintain adequate voiding and possible metabolic consequences of continent urinary diversion. In short, I believe every patient who undergoes cystectomy and urinary diversion for bladder cancer requires and deserves lifelong annual urologic follow-up.