"We thought, from a nursing standpoint, 'What is our goal for doing this?' What we wanted was first, education of the patient. Can we successfully educate the patient to prepare them? Can we alleviate as much anxiety as possible so that they feel comfortable coming in and having this done? The second goal is to preserve kidney function throughout the treatment. To date, we've been successful with that. And the third goal is to complete treatment without infection," ONS member Chris Amoroso, BSN, RN, OCN®, registered nurse at Fox Chase Cancer Center in Philadelphia, PA, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a conversation about intrarenal administration for upper urothelial tract disease. Music Credit: "Fireflies and Stardust" by Kevin MacLeod Licensed under Creative Commons by Attribution 3.0 Earn 0.75 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at courses.ons.org by May 1, 2027. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. Learning outcome: Nurses caring for people with cancer require knowledge of the different routes for drug administration, including intrarenal administration via a percutaneous nephrostomy. Episode Notes Complete this evaluation for free NCPD. ONS Podcast™ episodes: Episode 141: Care Coordination for Urothelial Cancer Episode 133: Treatment Advancements for Advanced or Metastatic Urothelial Cancer ONS Voice articles: A Primer on Urothelial Cancer Chemo Combo May Be a Bladder Cancer Treatment Alternative During BCG Shortage Nurses Are Key to Patients Navigating Genitourinary Cancers Clinical Journal of Oncology Nursing articles: Avelumab First-Line Maintenance Therapy: Managing Patients With Advanced Urothelial Carcinoma Percutaneous Nephrostomy Infusion: Nursing Considerations for Treatment of Upper Urinary Tract Urothelial Carcinoma ONS Learning Libraries: Cancer of the Genitourinary Tract Safe Handling of Hazardous Drugs To discuss the information in this episode with other oncology nurses, visit the ONS Communities. To find resources for creating an ONS Podcast club in your chapter or nursing community, visit the ONS Podcast Library. To provide feedback or otherwise reach ONS about the podcast, email pubONSVoice@ons.org. Highlights From This Episode "In an office setting, it's not something we can really visualize. Patients will present with hematuria or flank pain, obstructions in the ureter, some hydronephrosis, they may be having a lot of urinary tract infections. And a routine cystoscopy in the office is not going to visualize the ureters. We can do biopsies like a ureteroscopy, a computerized tomography urogram, or a urine cytology. And those are usually the main ways of diagnosing upper tract disease—again, because it's rare." TS 2:33 "We ask patients to get into a comfortable position where they can sit or lay for an hour without too much movement. The movement of their body position can interfere with the flow of the medication going in. ... When we're ready to start, we're cleaning the ends of the nephrostomy tube and the IV tubing with a chlorhexidine solution. We're instilling this using micro drip tubing. The tubing has to be microchipped so we can accurately control the flow. The IV bag with medication is hung about 10 inches above kidney level. And the reason we do that is because we do not want to increase the intrarenal pressure. ... We want a slow infusion via gravity over about an hour. We're watching throughout the procedure to make sure that there's no leakage, no discomfort, really just watching the patient and having that communication with the patient. Are they feeling anything different? Do we notice a difference in the flow rate? Is it slowing down? And if so, why is it? Did the patient change position? If we have any [instance] where the patient says, 'I can feel something there,' or we see leakage, we stop that infusion immediately, emphasizing that it has to be gravity, never on a pump." TS 7:30 "We go over all the bacillus Calmette-Guérin (BCG) precautions because this is the drug that we're giving. As if we were doing traditional intravesical therapy such as placing a catheter up into the bladder, we're still giving patients BCG. So, we need them to follow the special precautions. We ask every patient, regardless of the drug we're giving them, to sit down to urinate, pour two cups of bleach in the toilet, let it sit for about 15 minutes, then close the lid and flush twice. Even though we're giving this for upper tract disease, it's still being excreted into the urine. So, precautions need to be followed. Sitting down to urinate to avoid splashing of the drug, putting the two cups of bleach in every time they urinate for a duration of six hours, closing the lid, and then flushing that toilet twice. The same precautions, whether it's traditional intravesical or intrarenal." TS 14:20 "The induction phase is the first six installations. So, the first time we give this drug, we're doing it once a week for six weeks. And during those six weeks, we're communicating with the patient. We'll do a follow-up phone call and ask, 'How are you feeling? Any issues?' And we do get to know our patients really well. ... If they call, we're going to send them for a urine culture and make sure there's nothing there. ... After those six weeks, we make sure the patient understands that this is not one course and done. We want to continue to do this to give them the best chance at preventing recurrence. After we've done those six, we'll wait about four to six weeks, and then we'll do a cystoscopy and ureteroscopy in the operating room to make sure we have the response we're looking for. Again, letting the patients know because sometimes they don't understand that this is going to continue—it's not six treatments and done." TS 23:08 "You can't think of this as the same as bladder cancer. This is in the upper tract. We can't approach it as if it was non-muscular invasive bladder cancer. The diagnosis is different. It's harder to diagnose. Again, we're not visualizing the ureters in a routine office cystoscopy. ... You can't resect it out. When I was talking to our surgeon, he said, 'You can't resect the urothelial disease in the ureters like you would in a bladder tumor.' You can't go and just pick it apart. It's a little bit more complex than that. You can't go in and resect out lesions in the ureter itself." TS 36:20
